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Post-Bariatric Surgery Care

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Summary: This page is to inform the effective monitoring of patients post-bariatric surgery.
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Who’s it for: GPs
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Disclaimer The information in this page is based on NICE guidelines from July 2023.

Background

There are several types of weight loss surgery, the most common being:

  • gastric band – a band is placed around the stomach
  • gastric bypass (Roux-en-Y) – the top part of the stomach is joined to the small intestine
  • sleeve gastrectomy – some of the stomach is removed

Patients who have bariatric surgery tend to have obesity related co-morbidities pre-surgery, which will need continuous monitoring following surgery.

In addition, despite its significant benefits, bariatric surgery can result in multiple issues, including serious and/or long-term nutritional deficiencies (e.g., Wernicke's encephalopathy, anaemia, osteoporosis, etc.), psychological issues and complications from surgery.

Therefore, bariatric surgery patients require lifelong monitoring and appropriate treatment as part of a shared-care model of management.

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BOMSS

The British Obesity and Metabolic Surgery Society (BOMSS) maintains an up-to-date and in-depth GP Hub for post-bariatric surgery management guidance in primary care.

Possible nutritional issues post-bariatric surgery

  • Protein malnutrition → can be caused by vomiting from an overtight gastric band, anastomotic stricture, chronic diarrhoea/malabsorption, insufficient dietary protein, or non-adherence with dietary advice.
  • Vitamin deficiency → in iron, vitamin D, and B vitamins, especially thiamine and B12, in patients having gastric bypass, sleeve gastrectomy or duodenal switch.
  • Fat soluble vitamins → Patients undergoing malabsorptive operations (e.g., duodenal switch, single anastomosis duodenal ileal bypass (SADI), long limb gastric bypass) are at additional risk for deficiencies in fat soluble vitamins and require long term specialist care.
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Our responsibilities

For the first two years after surgery, most patients are actively supervised and supported by bariatric service follow-ups.

After discharge from the bariatric service, GPs continue to monitor according to the discharge care plan provided. This should involve collaboration between named tier 3 specialists, primary care and the patient, as well as locally agreed monitoring arrangements and responsibilities.

There may be situations where the patient or hospital prefers the GP surgery to arrange post-operative blood tests in the first 2 years following surgery. Below are local guidelines as to the tests usually required in this situation:

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Pregnancy

If a patient is planning pregnancy or becomes pregnant → refer them to a bariatric specialist as soon as possible, and refer them urgently for consultant-led obstetric care.

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Blood tests up to 24 months post-surgery

Cosmetic Surgery for Excess Skin

As patients lose weight after surgery, they may be left with excess folds and rolls of skin. Surgery to remove the excess skin (e.g., tummy tuck) is usually considered cosmetic surgery, so it's not necessarily available on the NHS.

If a patient is not willing to pay privately for excess skin removal, you can make and an Individual Funding Request on their behalf. See IFR page for further information: NHS England » Individual funding requests for specialised services: a guide for patients

Monitoring of nutritional status

Bariatric surgery impacts nutritional intake. Hence, after surgery, specific dietary changes are recommended, including:

  • small portions
  • more frequent meals
  • adequate protein intake
  • daily multivitamin and mineral supplements.
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If patients have one deficiency, they often have others, so it is recommended that if one is identified, full screening bloods should be requested.
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If a patient’s discharge letter includes recommended supplementation or blood tests details, they should be followed in preference to local guidance.
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Local supplementation guidance

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Safety Netting

Ensure patients who require it are getting B12 injections every 3 months. Use the ‘B12 injection reminder’ template on Accurx to inform patient of injection due date.

Annual review appointments

Annual review of post-bariatric patients involves identifying any nutritional deficiencies and providing appropriate nutritional supplements or referral. Also screen for complications of bariatric surgery, make a brief dietary assessment, and consider psychological issues as appropriate.

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Appointment overview

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Review medications

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The annual review appointment should focus on the whole person and their experience, not just their weight.
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Annual blood tests

Resources for patient info/referral