Medical follow up after bariatric surgery: nutritional and drug issues General recommendations for the prevention and treatment of nutritional deficienciesPrise en charge médicale après chirurgie bariatrique: prescriptions diététiques, médicamenteuses et suivi. Mesures générales indispensables

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Abstract

This review is an update of the long-term follow-up of nutritional and metabolic issues following bariatric surgery, and also discusses the most recent guidelines for the three most common procedures: adjustable gastric bands (AGB); sleeve gastrectomy (SG); and roux-en-Y gastric bypass (GBP). The risk of nutritional deficiencies depends on the percentage of weight loss and the type of surgical procedure performed. Purely restrictive procedures (AGB, SG), for example, can induce digestive symptoms, food intolerance or maladaptative eating behaviours due to pre- or postsurgical eating disorders. GBP also has a minor malabsorptive component. Iron deficiency is common with the three types of bariatric surgery, especially in menstruating women, and GBP is also associated with an increased risk of calcium, vitamin D and vitamin B12 deficiencies. Rare deficiencies can lead to serious complications such as encephalopathy or protein-energy malnutrition. Long-term problems such as changes in bone metabolism or neurological complications need to be carefully monitored. In addition, routine nutritional screening, recommendations for appropriate supplements and monitoring compliance are imperative, whatever the bariatric procedure. Key points are: (1) virtually routine mineral and multivitamin supplementation; (2) prevention of gallstone formation with the use of ursodeoxycholic acid during the first 6 months; and (3) regular, life-long, follow-up of all patients. Pre- and postoperative therapeutic patient education (TPE) programmes, involving a new multidisciplinary approach based on patient-centred education, may be useful for increasing patients’long-term compliance, which is often poor. The role of the general practitioner has also to be emphasized: clinical visits and follow-ups should be monitored and coordinated with the bariatric team, including the surgeon, the obesity specialist, the dietitian and mental health professionals.

Résumé

Dans cette revue sont présentés les principaux problèmes nutritionnels et métaboliques que pose le suivi à long terme des patients ayant bénéficié d’une chirurgie bariatrique et discutées les recommandations récemment publiées concernant l’anneau gastrique ajustable (AGA), la gastrectomie longitudinale (GL) et le court circuit gastrique (CCG). Le risque de carence nutritionnelle dépend de l’importance de la perte de poids et du type de chirurgie; les techniques purement restrictives (AGA, GL), peuvent induire des troubles digestifs, une intolérance pour certains aliments et des comportements alimentaires mal adaptés en rapport avec des troubles du comportement alimentaire pré ou post opératoires. Le CCG entraîne de plus une malabsorption intestinale modérée. La carence en fer est fréquente dans les 3 cas et concernent particulièrement les femmes non ménopausées. Le CCG augmente le risque de carences en fer, calcium-vitamine D et vitamine B12. Certaines carences rares conduisent à des complications sérieuses comme l’encéphalopathie ou la malnutrition protéino-énergétique.

Le risque à long terme de maladies osseuses ou de complications neurologiques doit être connu et prévenu. Quelle que soit la technique chirurgicale, la surveillance nutritionnelle, la prescription de suppléments appropriés et la surveillance de l’adhésion des patients à ces mesures s’imposent. Les trois points clefs sont (1) la prise quasi systématique de minéraux et de multivitamines; (2) la prévention de la lithiase biliaire par l’acide ursodésoxycholique pendant les 6 premiers mois; (3) le suivi à vie des patients. L’éducation thérapeutique du patient (ETP) est une nouvelle approche, par nature multidisciplinaire, centrée sur la personne. Des programmes d’ETP doivent être mis en place avant et après la chirurgie pour améliorer l’adhésion et la compliance à long terme des patients, qui est souvent médiocre. Le rôle du médecin traitant est à valoriser car c’est lui qui peut coordonner et contrôler le suivi, en collaboration avec l’équipe médicochirurgicale qui comporte le chirurgien, le spécialiste de l’obésité, la diététicienne, le psychologue et le psychiatre.

Introduction

Current bariatric surgery includes solely restrictive gastric procedures—adjustable gastric bands (AGB), vertical banded gastroplasty (VBG) and sleeve gastrectomy (SG)—and a combined procedure, the roux-en-Y gastric bypass (GBP) [1]. GBP, characterized by a restrictive component and a minor malabsorptive state, is believed to affect the hormones [such as ghrelin, glucagon-like peptide-1 (GLP-1) and peptide YY (PYY)] that control eating behaviours and body weight [2]. Indeed, changes in gut peptide concentrations can cause a profound loss of appetite. SG also affects ghrelin secretion.

This is a review of the standard of practice for long-term nutritional management, mainly in relation to the most common bariatric procedures (AGB, GBP and SG). VBG is no longer performed in France, and biliopancreatic diversion (BPD), with or without duodenal switch (DS), is a complex procedure that is reserved for only very specific situations. The perioperative management of the obese patient and of any surgical complications are beyond the scope of this review.

Assessment of the metabolic and nutritional consequences of bariatric surgery is best guided by the type of surgical procedure involved. Both AGB and VBG have minor effects on normal physiological digestive processes and, as a result, selective nutritional deficiencies are presumed to be unusual. However, caloric or nutritional restriction, maladaptive eating behaviours and digestive symptoms can lead to nutritional deficiencies. This is particularly true when weight loss is rapid and significant. On the other hand, it is well established that the anatomical changes imposed by malabsorptive surgical procedures can also increase the risk of nutrient deficiencies.

The major issues summarized here are based on the recently published French, European and US guidelines [3], [4], [5], [6] [all recommendations (R) are shown in italics], along with the few published expert recommendations [7], [8], [9], [10], [11], [12], [13], [14] and our own accumulated experience. However, consensus is still lacking on many critical issues, probably because the long-term nutritional outcome data are scanty. Also, there are no evidence-based guidelines for an optimal postoperative supplementation strategy.

Section snippets

Preoperative management

Many patients have preoperative eating disorders or nutritional deficiencies that may persist after undergoing a bariatric procedure. There is now evidence to support the need for routine assessments of the patient's protein and micronutrient status prior to bariatric surgery [15,16]. An appropriate nutritional evaluation, including selective micronutrient measurements, is absolutely necessary for all patients before any bariatric surgical procedure [5].

Early postoperative nutritional management (< 5 days)

In general, the following guidelines are

Late postoperative nutritional management (≥ 5 days)

Follow-up of the morbidly obese patient who has been surgically treated can be divided into three periods: (1) the weightloss phase (0–18 months, with the vast majority of weight loss accomplished by around 1 year); (2) the weight-regain phase [2–6 years after surgery, according to the Swedish Obese Subjects (SOS) study [17], in which about one-third of the initial weight loss was regained within 5 years]; and (3) the weight-stability phase (6–15 years, according to the SOS study).

Physical activity

The importance of regular physical activity for weight maintenance in conventional weight-loss treatment is well known [25]. Exercise limits the proportion of lean tissue lost in low-calorie regimens, limits the weight regained and has a favourable effect on health status (cardiovascular disease, diabetes, hypertension, cancer). The US National Weight Control Registry (of individuals successful at long-term weight maintenance) shows that those who lost weight by surgical means reported

Nutritional deficiencies: metabolic and nutritional surveillance

Which vitamins and/or minerals should be measured for which bariatric procedures, and which supplements should be given? It should be emphasized that the frequency of and recommended nutritional surveillance, as well as vitamin and mineral supplementation, remain empirical for surgically treated patients [5,[7], [8], [9], [10], [11], [12], [13]. Such schedules have not been precisely delineated in the French guidelines [3], most likely because of the lack of evidence-based data. Moreover, such

Osteoporosis

The impact of obesity surgery on bone metabolism has been reviewed by Wucher et al. [45]. Bone loss frequently occurs after bariatric surgery and particularly after GBP. Early bone loss due to bone resorption has been described, as suggested by an increase in bone markers. The mechanisms may involve adipokines such as leptin and adiponectin [45].

As long-term studies of the risk of osteoporosis are lacking [3, 5, 7, 9], it is difficult to view the future with confidence for young women who do

Pregnant women

Pregnancy is not recommended in the 12–18 months after surgery, as various deficiencies of vitamins and micronutrients could play a role in causing fetal malformations or complications. Assessing nutritional status and the supplements to be prescribed have been reported by Poitou et al. [12]. Iron, vitamin D/calcium and folate are the three priorities in terms of nutritional deficiencies that require careful monitoring (before conception, if possible) [12]. It is also important to look out for

Specific management and frequency of follow-up visits by surgical procedure

The frequency of follow-up visits should be modified according to the patients’weight loss over time, occurrence of clinical symptoms or complications and type of procedure performed [3], [4], [5], [6]. Closer clinical follow-up is more necessary after AGB than after GBP, whereas the reverse is true for perioperative nutritional evaluations [3], [4], [5], [6].

Multidisciplinary team

The pre- and postoperative management of bariatric surgery patients is clearly multidisciplinary [3], [4], [5], [6]. The treating physician (in our experience, the nutritionist, who, in France, is a physician) and surgeon are responsible for the treatment of co-morbidities before the operation and for the follow-up after the operation [4]. Complementary follow-up pathways (surgical and medical) should be provided to all patients [4]. The surgeon is responsible for all possible short- and

Therapeutic patient education and patient responsibility

Behavioural treatments, generally considered a necessary component of any adequate obesity-treatment programme, are paradoxically rarely proposed after bariatric surgery. According to the guidelines, it is recognized that: (1) the patient takes lifelong responsibility for adhering to the follow-up rules [4]; and (2) treatment outcome is significantly dependent, among other factors, on patients’compliance with long-term follow-up [4]. All patients should be encouraged to participate in ongoing

Conclusion

Severe obesity is a serious chronic clinical condition that requires the application of long-term strategies for its effective management and prevention. Bariatric surgery has a major impact on obesity-related co-morbidity [52], and decreased mortality rates in surgically treated obese patients are now relatively well documented [47,53,54]. Yet, bariatric surgery is not a ‘magic bullet’. Intensive preoperative nutritional and psychosocial counselling is believed to be important not only in the

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