1. 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 1

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

3. Appropriate referrals for bariatric surgery?

4. before bariatric surgery?
Who assesses patients
before bariatric surgery?

5. 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

6. The MDT in UK bariatric surgery

7. The role of bariatric dietitians

8. Adequacy of psychological assessment

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

10. Early readmissions after bariatric surgery

11. 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 %
Wound
problems 21
8.3%
Abdominal pain %
Modified from: Kellogg TA, et al. Surg Obes Relat Dis. 2009;5(4):

12. Early postoperative surgical follow-up

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

14. Adequacy of follow-up

15. 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.

16. 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

17. Pinkney et al.
Diabetologia 2010;
53:

18. Registers and audits

19. 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

20. Where now with bariatric surgery?

21. 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