The GP and bariatric surgery: Part 2

In most cases the bariatric centre will provide the follow-up consultations for the first two years postoperatively before discharging back to the care of the general practitioner.¹ Immediately post-operatively, patients start on a liquid diet before progressing slowly onto more solid textured food. The average length of hospital stay is 2.7 days.² Patients should expect to return to a normal solid diet between three and six weeks, although in smaller portions.

Patients are recommended to have a balanced diet in combination with nutritional supplementation appropriate to both the procedure and subsequent deficiencies which may develop.³

This is part two of a two part series.

Common consultations

Post-operative complications

The recently published United Kingdom National Bariatric Surgery Registry (NBSR 2014) data confirms that bariatric surgery in the UK has a low overall mortality (0.07%) and surgical complication rate (2.7%). A high proportion of primary bariatric operations are carried out and completed laparoscopically (95.4%).² These figures demonstrate bariatric surgery is as safe as most elective major operations. When patients do suffer from complications they may present with a variety of complaints, including abdominal pain, dysphagia, nausea, vomiting, reflux, infection and weight regain. Depending on the surgery carried out these may indicate development of a post-operative complications (Table 3). The British Obesity and Metabolic Surgery Society (BOMSS) has produced a traffic light system to guide GP referral back to bariatric services.

Pregnancy and bariatric surgery

Patients are currently advised to avoid pregnancy in the immediate 24 months following surgery. There is some evidence to suggest that women are at increased risk of preterm births and small for gestational age births in comparison to controls. This is thought to be a result of the rapid weight loss which occurs in the initial postoperative period, which can result in maternal and fetal malnutrition. Pregnancy post-bariatric surgery should be regarded as high risk and requires specialist input.¹⁰

Plastic surgery post bariatric surgery

Currently, plastic surgery to remove excess skin following weight loss is not funded as part of bariatric surgery. Patients are counselled to this effect preoperatively, although individual funding requests to commissioning bodies can be made for patients who experience severe complications of excess skin.

Nutritional deficiencies

All bariatric surgical procedures may impact to some degree upon nutritional status. The BOMSS strongly recommends postoperative biochemical monitoring for patients who have undergone bariatric surgery with the aim of identifying post-operative complications/micronutrient deficiencies.³ Most bariatric units will perform the relevant blood tests on their patients for the first two years postoperatively. Following this, it is recommended that the GP performs surveillance blood tests annually (Tables 1 and 2).³
The financial viability of bariatric surgery in the current NHS There can be little argument that bariatric surgery achieves effective weight loss in obese patients.¹¹

Perhaps, even more importantly, obesity surgery has also been demonstrated in a large systematic review and meta-analysis of 22,094 patients to be effective in improving, or completely resolving significant chronic medical conditions such as: diabetes; hyperlipidaemia; hypertension; and obstructive sleep apnoea.¹²

The Office of Health Economics estimates that up to 140,000 people in England are eligible for bariatric surgery. It is projected that, if 5% of eligible patients were to undergo bariatric surgery, the total economic gain would be £382 million after three years, rising to £1,295 million if 25% of eligible patients underwent surgery. These figures do not include £35-£150 million per year in benefits that would be saved.¹³ Rising rates of obesity, demonstrated safety of laparoscopic surgery for obesity, robust evidence to support the efficacy of surgery and a strong financial incentive mean there is a strong case for bariatric surgery, even in these times of austerity.

Discussion

Bariatric surgery is here to stay. The NHS health gurus have increasingly realised the importance of bariatric surgery. Over the past few years, the trend has been to make obesity surgery accessible to people with lower BMIs and those with recent onset of diabetes mellitus.

GPs have become increasingly aware of, and ready to refer patients to, weight management and bariatric services. As per the recent NBSR report, the morbidity and mortality rates of UK bariatric surgery are generally lower than any other national registry worldwide, demonstrating surgery to be a safe intervention.

However, it remains to be seen if there is political drive to increase funding for bariatric surgery. Currently, the service is underutilised with only an estimated 1-5% of eligible patients receiving the opportunity to undergo obesity surgery. This figure can only improve and in doing so, will provide improved quality of life for thousands of patients alongside huge potential financial benefits to the health service and economy.

NICE guidance on bariatric surgery⁸

Bariatric surgery should be considered in the management of obesity in adults if the following criteria are met:

• BMI over or equal to 40kg/m2 or between 35-40 kg/m2 with co-existing significant disease including type 2 diabetes mellitus or hypertension that may be improved with weight loss
• BMI of 35kg/m2 or over who have recent-onset type 2 diabetes
• BMI of 30-34.9 who have recent-onset type 2 diabetes that is very poorly controlled
• People of Asian family origin who have recent-onset type 2 diabetes at a lower BMI than other populations
• Appropriate non-surgical options have been explored and utilised however have failed to achieve or sustain clinically significant reduction in weight for greater than 6 months
• Patient has been managed or awaiting management by the local specialist obesity service
• Patient is fit enough to tolerate a general anaesthetic and surgery.

The first part of this article can be found here

Nicola Maguire, Milind Rao, Bussa Rao Gopinath, The University Hospital of North Tees

References

1.  O’Kane M, Pinkney J, Assheim E, Barth J, Batterham R, Welbourn R. GP Guidance: Management of nutrition following bariatric surgery. 2014.
2.  National bariatric surgery data committee. The United Kingdom National Bariatric Surgery Registry: Second Registry Report. 2014.
3.  O’Kane M, Pinkney J, Aasheim E, Barth J, Batterham R, Welbourn R. BOMSS Guidelines on perioperative biochemical monitoring and micronutrient replacement for patients undergoing bariatric surgery.
4.  Brown JJS, Boyle M, Mahawar K, Balupuri S, Small PK. Br J Surg. 2013;100:1614–8.
5.  Frezza E, Reddy S, Gee L, Wachtel M. Obes Surg. 2009;19:684–7.
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8.  Sarkhosh K, Birch D, Sharma A, Karmal S. Can J Surg. 2013;56(5):347–52.
9.  Woodcock S. Post op primary care management [Internet]. Available from: http://www.bomss.org.uk/primary-care-management-of-post-operative-patients/
10.  Roos N, Neovius M, Cnattingius S, Trolle LY, Sääf M, Granath F, et al. BMJ. 2013;347(f6460).
11.  Colquitt J, Pickett K, Loveman E, Frampton G. Surgery for weight loss in adults ( Review ). Cochrane database. 2014;(8).
12.  Buchwald H, Avidor Y, Braunwald E, Jensen M, Pories W, Fahrbach K, et al. JAMA. 2004;292(14).
13.  Office of health economics. Shedding the pounds: Obesity management, NICE guidance and bariatric surgery in England. 2010.