Too lean a service ? A review of the care of patients who underwent bariatric surgery A physician’s perspective Jonathan Pinkney Professor of Medicine Plymouth and Peninsula Schools of Medicine and Dentistry Plymouth Hospitals NHs Trust Jonathan.Pinkney@pms.ac.uk
Pre-surgery and referra l Appropriate referrals? Role of MDT Role of dietitian Psychological support Medical evaluation
Appropriate referrals for bariatric surgery?
Who assesses patients before bariatric surgery?
Not a surgeon’s responsibility? Identify poor food choice and eating behaviours Educate on dietary adaptation Identify emotional eating Diagnose eating disorders Manage preoperative micronutrient deficiencies Correctly identify all medical comorbidities Ensure realistic expectations of medical impact Postoperative medical management plan Postoperative dietary plan Postoperative micronutrition plan Responsibility for long term follow-up / support
The MDT in UK bariatric surgery
The role of bariatric dietitians
Adequacy of psychological assessment
Follow-up Surgical issues Non-surgical issues Getting the best results Patient safety Follow-up – whose responsibility?
Early readmissions after bariatric surgery
90-Day readmissions and reoperations after gastric bypass Total number of Indication for readmission, ED Visit, and/or readmissions, Number reoperation RYGB ED visits, of and/or Nausea, patients Wound Abdominal reoperations Vomiting, problems pain dehydration 252 21 173 1222 65 50 8.3% 14.1% 25.8% 19.8% Modified from: Kellogg TA, et al. Surg Obes Relat Dis. 2009;5(4):416-423.
Early postoperative surgical follow-up
Impact of follow-up frequency on weight loss following LAGB 30 % Weight Loss at 1 year 25 20 15 10 5 0 <5 5-6 7-8 9-11 12-14 15-18 19+ Visits in the first year (N=227) Dixon JB, et al. Obesity (Silver Spring). 2009;17(4):698-705. ANOVA P <0.05
Adequacy of follow-up
Non-surgical issues during follow-up Dietary adaptation: Food choices, weight relapse etc. Psychological adaptation. Management of medical comorbidity eg diabetes. Nutritional monitoring and replacement. Investigation and treatment of side effects.
Nutritional deficiencies reported after malabsorptive bariatric surgery Problem Mechanisms Anemia Poor diet; malabsorption of iron, folic acid, vitamin B12, and ascorbate; non- adherence and lost to follow-up Neurological syndromes Neuropathy Deficiencies of thiamin, B12, copper and Wernicke encephalopathy zinc; Guillain-Barre syndrome Osteomalacia Vitamin D deficiency Visual problems Vitamin A deficiency Pellagra Niacin deficiency Cardiomyopathy Selenium deficiency Acrodermatitis Zinc deficiency Neural tube defects Maternal deficiencies of folic acid and vitamins Fetal brain hemorrhage
Pinkney et al. Diabetologia 2010; 53: 1815-1822.
Registers and audits
What does the NCEPOD report tell us? Suboptimal patient Follow-up: preparation Whose responsibility? Suboptimal results Inconsistent Poor professional Bariatric preoperative training surgery MDT process Lack of long term Safety concerns aftercare framework Suboptimal medical preparation
Where now with bariatric surgery?
Improving pre and post-operative pathways in bariatric surgery MDT should include surgeon, dietitian, physician, nurse specialist, coordinator, anaesthetist ± psychologist. Written record. Commission surgery with explicit pathways and protocols for aftercare Define responsibility for follow-up Enforced data registration for accreditation purposes
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