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Oct 31, 2023 275 likes •509 views

Too lean a service ? A review of the care of patients who underwent bariatric surgery A physicians perspective Jonathan Pinkney Professor of Medicine Plymouth and Peninsula Schools of Medicine and Dentistry Plymouth Hospitals NHs Trust

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Too lean a service?

A review of the care of patients who underwent bariatric surgery

Jonathan Pinkney Professor of Medicine Plymouth and Peninsula Schools of Medicine and Dentistry Plymouth Hospitals NHs Trust Jonathan.Pinkney@pms.ac.uk

A physician’s perspective

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Pre-surgery and referral

Appropriate referrals? Role of MDT Role of dietitian Psychological support Medical evaluation

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Appropriate referrals for bariatric surgery?

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Who assesses patients before bariatric surgery?

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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

Not a surgeon’s responsibility?

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The MDT in UK bariatric surgery

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The role of bariatric dietitians

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Adequacy of psychological assessment

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Follow-up

Surgical issues Non-surgical issues Getting the best results Patient safety Follow-up – whose responsibility?

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Early readmissions after bariatric surgery

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Modified from: Kellogg TA, et al. Surg Obes Relat Dis. 2009;5(4):416-423.

1222 RYGB 252

Total number of readmissions, ED visits, and/or reoperations

173 14.1%

Number

patients

90-Day readmissions and reoperations after gastric bypass

Nausea, Vomiting, dehydration

65 25.8%

Abdominal pain

50 19.8%

Wound problems

21 8.3%

Indication for readmission, ED Visit, and/or reoperation

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Early postoperative surgical follow-up

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5 10 15 20 25 30 <5 5-6 7-8 9-11 12-14 15-18 19+ % Weight Loss at 1 year Visits in the first year

(N=227) ANOVA P<0.05

Dixon JB, et al. Obesity (Silver Spring). 2009;17(4):698-705.

Impact of follow-up frequency on weight loss following LAGB

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Adequacy of follow-up

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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.

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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 zinc; Guillain-Barre syndrome Wernicke encephalopathy 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

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Pinkney et al. Diabetologia 2010; 53: 1815-1822.

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Registers and audits

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Suboptimal patient preparation Suboptimal medical preparation Suboptimal results Safety concerns Inconsistent preoperative MDT process Follow-up: Whose responsibility? Poor professional training Lack of long term aftercare framework

What does the NCEPOD report tell us?

Bariatric surgery

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Where now with bariatric surgery?

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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