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
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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