ESTES PARK, COLO. — Batten down the hatches. It's time for primary care physicians to prepare for a rising tide of patients with health issues related to prior bariatric surgery.

Demand for bariatric surgery has skyrocketed because of the convergence of the obesity epidemic, safer surgery through improved techniques, and persuasive evidence of dramatic health benefits. In 2003 there were just over 100,000 bariatric procedures performed in the United States. In 2007 there were 205,000. Even if the volume were to plateau at the 2007 level, there would be an additional 2 million–plus patients with a history of bariatric surgery 10 years from now, he noted.

“Aftercare is critical. These surgeons do a good job with the surgery, but a year later it's your problem,” Dr. Daniel Bessesen said at a conference on internal medicine sponsored by the University of Colorado.

“These patients have a tendency to drift,” he said. They have life-changing surgery and then they “start exercising, get a new job, move, and they get a new primary care physician. … You say, 'Nice to meet you. Tell me about your health history,' and they say, 'Well, I used to weigh 400 pounds.' It's almost like a distant memory for them. But the reality is that if they had gastric bypass surgery, it's something that needs to be dealt with for the rest of their life. And you're the one they're going to see about it,” explained Dr. Bessesen, professor of medicine at the university and chief of endocrinology at Denver Health Medical Center.

Help in managing health issues related to bariatric surgery is available in the form of an outstanding set of guidelines, he said.

The guidelines, created by the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic and Bariatric Surgery, are comprehensive: 83 pages long, with 164 evidence-graded recommendations (www.aace.com/pub/guidelines

“If you're seeing one of these people and you're going, 'Holy cow, what do I do about calcium, and—oh no—she's vomiting,' you can go to this site and find the answers,” Dr. Bessesen said.

The primary goal in aftercare is to maintain good nutrition. The key dietary guidance is to eat small amounts—2–3 ounces of food, or a cup or less, at a sitting; eat it slowly, over the course of about 30 minutes; and focus on protein-containing foods.

“After the surgery, a lot of these folks don't have much of a taste for meat, so it's hard for them to get 60 g of protein per day. It's especially important to emphasis getting that 60 g per day in the first 6–8 months, when they're dropping weight quickly,” according to Dr. Bessesen.

Micronutrient deficiencies are a big concern after gastric bypass surgery. Deficiencies in thiamine and other water-soluble vitamins occur rapidly in the absence of supplementation. Dr. Bessesen recommended that all patients who've had a gastric bypass take a daily prenatal vitamin or another high-quality multi-vitamin containing iron.

Vitamin B₁₂ deficiency is so common in these patients that he has them preemptively take oral crystalline B₁₂ at 500–1,000 mcg/day, sublingual B₁₂ at 500 mcg/day, intramuscular B₁₂ at 100 mcg once monthly, or B₁₂ nasal spray at 500 mcg once weekly.

Supplementation with 1,200–1,500 mg/day of calcium citrate is also important because gastric bypass surgery recipients typically eat a lot less calcium and vitamin D–containing foods than before their surgery.

Eighty percent of bariatric surgery patients are women. Many believe they are infertile, but their fertility may increase following large weight loss. If they become pregnant while they're losing a lot of weight, there may not be enough food for fetal growth and development, he said.

“I strongly encourage women not to get pregnant in the first year after surgery by using some effective form of birth control. The case series suggest the pregnancy outcomes are okay with good monitoring, but it's not a situation you want to be in,” Dr. Bessesen advised.

If primary care physicians are going to refer patients for bariatric surgery, they ought to be sending them to American Society for Metabolic and Bariatric Surgery centers of excellence, in his view. The society's online search will locate accredited centers by physician or practice name, city, or state (www.surgicalreview.org/locate.aspx

“The day of any old general surgeon doing five of these a year is over. People who don't do a lot of these procedures have a high morbidity and mortality. There are now clear requirements for center-of-excellence status. There's an organization that goes out and looks at the surgeons' site—how many cases they do, their complications, their nutritional and psychiatric support. I think you can, with some confidence, refer people to the centers of excellence,” the endocrinologist said.

70720_fx1.sml

'Aftercare is critical. These surgeons do a good job with the surgery, but a year later it's your problem.'

Source DR. BESSESEN

Primary Care Likely to See More Bariatric Patients