A physician’s perspective Too lean a service? A review of the care of patients who underwent bariatric surgery A physician’s perspective Jonathan Pinkney Professor of Medicine Plymouth and Peninsula Schools of Medicine and Dentistry Plymouth Hospitals NHs Trust Jonathan.Pinkney@pms.ac.uk 1

Pre-surgery and referral Appropriate referrals? Role of MDT Role of dietitian Psychological support Medical evaluation

Appropriate referrals for bariatric surgery?

before bariatric surgery? Who assesses patients before bariatric surgery?

Not a surgeon’s responsibility? 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

The MDT in UK bariatric surgery

The role of bariatric dietitians

Adequacy of psychological assessment

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

Early readmissions after bariatric surgery

90-Day readmissions and reoperations after gastric bypass 252 Total number of readmissions, ED visits, and/or reoperations Indication for readmission, ED Visit, and/or reoperation 1222 RYGB 173 14.1% Number of patients Nausea, Vomiting, dehydration 65 25.8% Wound problems 21 8.3% Abdominal pain 50 19.8% Modified from: Kellogg TA, et al. Surg Obes Relat Dis. 2009;5(4):416-423.

Early postoperative surgical follow-up

Impact of follow-up frequency on weight loss following LAGB Dixon JB, et al. Obesity (Silver Spring). 2009;17(4):698-705. ANOVA P<0.05

Adequacy of follow-up

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.

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

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

Registers and audits

What does the NCEPOD report tell us? Suboptimal patient preparation Follow-up: Whose responsibility? Poor professional training Lack of long term aftercare framework Suboptimal results Inconsistent preoperative MDT process Bariatric surgery Safety concerns Suboptimal medical preparation

Where now with bariatric surgery?

Improving pre and post-operative pathways in bariatric surgery 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