1. Bariatric Procedures, Complications and Follow up
Bariatric surgery holds out the promise of a healthier and a better quality life to those who have failed to maintain a healthy weight through diet, exercise and medication! Patients will generally live longer and have better health. However, these operations are also associated with risks and complications!
Spire Bushey Hospital
Mr Pratik Sufi
Consultant Bariatric & Upper GI Surgeon

2. Balancing Activity Levels with Food
Physical Activity
Calories Burnt / 30 minutes
Walking 2mph 85
Walking 4mph
170
Gardening
135
Raking leaves
145
Dancing
190
Bicycling 10mph
205
Swimming laps, medium level
240
5mph
275
One small chocolate chip cookie (50 calories) is equivalent to walking briskly for 10 minutes.
The difference between a large gourmet chocolate chip cookie and a small chocolate chip cookie could be about 40 minutes of raking leaves (200 calories).
One hour of walking at a moderate pace (20 min/mile) uses about the same amount of energy that is in one jelly filled doughnut (300 calories).
A fast food "meal" containing a double patty cheeseburger, extra-large fries and a 24 oz. soft drink is equal to running 2½ hours at a 10 min/mile pace (1500 calories).
One tsp sugar (20cal) ≈ 4 min walk
One can coke (160cal) ≈ 30 min walk

3. Dietary Change

4. Obesity Associated Co-morbidities
Pulmonary Disease
Abnormal Function
Obstructive Sleep Apnea
Hypoventilation Syndrome
Asthma
Cerebral
Idiopathic Intracranial Hypertension
Stroke
Cataracts
Hepato-pancreato-biliary Disease
Steatosis (NALD)
Steatohepatitis (NASH)
Cirrhosis
Gall Bladder Disease
Pancreatitis
Coronary Heart Disease
Diabetes
Dyslipidemia
Hypertension
CCF
Herniae
Umbilical
Ventral
Inguinal GI
GORD & Hiatus Hernia
Cancer
Breast, Uterus, Cervix,
Colon, Esophagus, Pancreas,
Kidney, Prostate
Gynecologic Abnormalities
Abnormal Menses
Infertility
Polycystic Ovarian Syndrome
Vascular
Phlebitis / DVT
Venous stasis
Leg ulcers
Obesity OnLine Slide Presentation. Accessed May 17, Accessible as slide #5 at
Musculoskeletal
Osteoarthritis
Gout
Skin
Dermatitis
Leg ulcers 4

5. Impact of Obesity on GP Consultations
BMI
Percentage 20 25 30 35 40 15 10
Brown WJ et al. Int J Obes 1998;22:
Low BMI was associated with fewer physical health problems than mid-level or higher BMI.
Indicators of health care use showed a J-shaped relationship with BMI for general practitioners (>5 GP Consultations).
Prevalence of medical problems (for example, hypertension OR 6x and diabetes OR 6x), surgical procedures (cholecystectomy OR 7x and hysterectomy OR 2x) and symptoms (for example, back pain OR 40% and constant tiredness OR 70%) increased monotonically with BMI.

6. Effect of Diet and Surgery on Weight & Mortality
Diet & exercise effective up to 6m
60% failure at 1 yr.
80% failure at 2 yrs.
100% failure at 5 yrs.
Surgery effective long-term (80%)
Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects N Engl J Med 2007;357:

7. Primary Obesity Options Today
Low Risk
Less Effective
More Effective
Diet/ Drugs
EndolumenalObesity
Gastric
Balloon
POSE
Endosheath
20-60%
Low efficacy – less durable weight loss
Moderate risk / efficacy – intermediate durability
Effective but unacceptable risk
High efficacy – durable weight loss
Surgery
Abandoned Surgery
40-95%
Lap
Band
Sleeve
Gastrectomy
Gastric
Bypass
BPD/DS
VBG
Jejuno-Ileal
Bypass
High Risk

8. Procedure Comparison Procedure Mechanism of action EBWL (2 year)
Invasiveness / Durability
Follow-up
Gastric balloon
Restrictive
10-20%
Minimal/Short-term
Intensive/6-24m
POSE
20-40%
Minimal/Long-term
Minimal/12-24m
Endosheath
Diversion
30-50%
Intensive/12-24m
Gastric band
Restrictive + Neurostimulation
50-60%
Moderate/Long-term
Intensive/Life-long
Gastric plication
40-60%
High/Unknown
Modest/Life-long
Sleeve
Restrictive + Endocrine
60-80%
High/Long-term
Gastric bypass
Restrictive +
Bypass-Diversion +
Malabsorption
70-90%
Duodenal switch
90-100%
Very high/Long-term

9. Referral - Minimal Dataset
Age
Weight & BMI
Co-morbidity esp.
cardiovascular
respiratory
endocrine
GI and
musculo-skeletal
Medication
Previous attempts at weight loss
Other concerns like
Untreated eating disorders
Psychiatric history
NICE: BMI≥35
ASMBS: BMI≥30
Asians: BMI 2 points lower

10. Pre-operative Liver Shrinkage Diet
Slimfast –900 kcal/d approximately
Food-based – 900 kcal/d approx.
Meal/Snack
Product
Amount
Calories
Protein (g)
Breakfast
Slimfast shake
1 serving
220 / 230
14 / 15
Morning snack
Slimfast shake or Slimfast meal replacement bar
Lunch
Dinner
Totals
56-60
Food group
No of servings
Fruit 2 
Vegetables 3 
Carbohydrates
Dairy
Protein
Fats
Two (2) weeks
Four (4) weeks

11. Pre-operative Special Considerations
Hypertension control
ACE Inhibitors
AT2 receptor antagonists
Glycaemic control
Oral hyperglycaemic agents
Insulin
Anticoagulation
Warfarin
Clopidogrel
Aspirin
OSA
CPAP
GORD
PPI
NAFLD / NASH
Liver shrinkage diet

12. Post-operative Regime
Liquids only for 2-3 weeks
Soft blended food for 2-3 weeks
Resume solids after 4-6 weeks
Small mouthfuls
Chew well
Eat slowly
Separate eating and drinking by ½ hour
Avoid fizzy / sugary drinks or sugary food
Medication – liquid / soluble (crushed)
Supplements
Iron
Calcium and vitamin D
Vitamin B12
Folic acid
Vitamin B1
Recommended Multivitamin and minerals:
Chewable versions:
Bassett’s Adult Chewable multivitamins with prebiotics & minerals
Wellkid Smart / Sanatogen A-Z Kids Chewable
Haliborange Chewable multivitamins
Whole tablet:
Sanatogen Gold or Centrum (after 3 months)
Plus
Chewable Calcium – 1000mg calcium /day
Liquid iron or iron drops - 50mg of iron/day 

13. Post-operative – Suitable Fluids D0-W2
Milk - Aim for at least two pints (1.2L) of milk or a milk alternative a day
Milk can be flavoured with Nesquick or low calorie hot chocolate
Slimming drinks e.g. Slimfast or chemist/supermarket own brand
Complan or Build-up shakes or soups
Yogurt drinks and smoothies
Still mineral water, if taking the flavoured types make sure they are low sugar
Still low-sugar squashes
Smooth soups e.g. cream of tomato or chicken; or oxtail
Tea and coffee without sugar
Unsweetened pure fruit juice

14. Post-operative Special Considerations
Diet
Not allowed to eat and drink together
Eat slowly, chew well – at least minutes
Liquids for 24-48hours after band adjustment
Return to work
Change in medications
Restrictions on tablets – soluble, liquids or crushed tablets
Change in co-morbidity
Antihypertensive
Oral hyperglycaemic agents
Insulin
Change in absorption
Warfarin
Oral contraceptives
Avoid pregnancy for 18 months
Risk to mother
Risk to foetus

15. Long-term Follow-up Pins and needles (B12, B1)
Frequent falls (B12, B1, Fe)
Tiredness (anaemia, hypoglycaemia)
Generalised pain (PTH)
Abdominal pain (ulcer, gallstones / hernia / kidney stones)
Reflux / regurgitation/ N&V / persistent cough (band slippage, over-tight band, ulcer, hiatus hernia)
Calcium supplements- 1000mg calcium / day. Liquid or effervescent tablets
Ferrous Sulphate/ ferrous fumarate or sodium feredetate – drops, syrup or sugar free elixir. 50mg of iron/day
Hydroxocobalamin Vitamin B12 injections – 1mg every 3 months

16. Nutritional Deficiencies
Mechanism
Prevalence
Clinical
Protein
Intake, absorption,
Distal RYGB 6-13%
Standard RYGB 0%
Peak 1-2 yrs
Loss of muscle, weakness, oedema, etc.
Iron
Intake, Acid exposure, absorption
2 yr: 33%
Anaemia, tinnitus, hair loss
Vitamin B12 (cobalamin)
Reduced acid,
?IF link
1 yr: 12 – 70%
Within 2yrs: 25%
Anaemia, macrocytosis
Calcium & Vitamin D
Intake, absorption, HyperPTH
Distal RYGB:
2yr Ca 10%, Vit D 51%
BPD
Ca 25-50%, Vit D 17 – 50%
MBD –
Osteomalacia, osteoporosis
Liposoluble Vitamins (A, E, K)
Reduced fat breakdown
RYGB: very low
BPD (4yr): A-69%, K-68%, E-4%
A: night blindness
Zinc
Absorption – dependent on lipids
Surgical stress
RYGB: rare
BPD: 10 – 50%
Hair loss

17. Diagnosis and Treatment of Nutritional Deficiencies
 Deficiency
Symptoms
and signs
 Confirmation
Treatment
first phase
second phase
Protein malnutrition
Weakness, decreased muscle mass, brittle hair, generalized oedema
Serum albumin and prealbumin levels, serum creatinine
Protein supplements
Enteral or parenteral
nutrition; reversal of
surgical procedure
Calcium/
Vitamin D
Hypocalcaemia, tetany, tingling, cramping, metabolic bone disease
Total and ionized calcium levels, intact PTH, 25-D, urinary N-telopeptide, bone densitometry
Calcium citrate 1,200–2,000 mg,
oral vitamin D
50,000 IU/d
Calcitriol oral vitamin D 1,000 IU/d
Vitamin B12
Pernicious anaemia, tingling in fingers and toes, depression,
dementia
Blood cell count,
vitamin B12 levels
 Oral crystalline B12
350 mg/d
1,000 –2,000
mg/2–3 months im
Folic acid
Macrocytic anaemia,
palpitations, fatigue,
neural tube defects
Cell blood count,
folic acid levels,
homocysteine
Oral folate, 400 mg/d
(included in
multivitamin)
Oral folate, 1,000
mg/d
Iron
Decreased work ability,
koilonychia, pica,
brittle hair, anaemia
Blood cell count, serum
iron, iron binding
capacity, ferritin
Ferrous sulphate 300 mg 2–3 times/d, taken with vitamin C
Parenteral iron
administration
Vitamin A
Xerophthalmia, loss
of nocturnal vision,
decreased immunity
Vitamin A levels
Oral vitamin A,
5,000–10,000 IU/d
An Endocrine Society Clinical Practice Guideline

18. Schedule for Clinical and Biochemical Monitoring
TESTS
Pre-operative
1 month
3 months
6 months
12 months
18 months
24 months
Annually
Complete blood count X
LFTs
Glucose
Creatinine
Electrolytes
Iron/ferritin Xa
Vitamin B12
Folate
Calcium
Intact PTH
25-D
Albumin/prealbumin
Vitamin A
Optional
Zinc
Bone mineral density and body composition
Vitamin B1
Xa – Tests should only be performed after RYGB, BPD, or BPD/DS.
X – Tests suggested for patients submitted to restrictive surgery where frank deficiencies are less common.
An Endocrine Society Clinical Practice Guideline

19. Post-Bariatric Surgery Complications
Pulmonary Disease
Pneumonia / Atelectasis
Cerebrovascular Disease
Wernicke’s Encephalopathy (Beriberi)
Stroke / TIA
Malnutrition
Glossitis, stomatitis
Hair loss
CV Disease MI
DVT / PE
Beriberi
HPB Disease
Hepatitis (trauma)
Pancreatitis (trauma)
Cholecystitis
GI Disease
Bleeding
GORD & Hiatus Hernia
Ulcer
Bloating / Obstruction
Diarrhoea / Constipation
Malabsorption
Renal Disease
Kidney stones
Gynecologic Abnormalities
Amenorrhoea
Fertility – failure of contraception
Bone Disease
Osteomalacia
Malnutrition
Dermatitis
Neuropathy
Ataxia 19

20. General complications
Immediate post-operative – infection, bleed, thromboembolism
Tiredness, pain, ulcers, dry skin, pins and needles, hair loss etc. (Nutritional deficiency – Iron, Calcium, Vitamin D, Folate, Vitamin B12, Vitamin B1, Zinc)
Nausea, vomiting (Slipped band, over-restriction, hiatus hernia, gallstones, anastomotic ulcer, GLP-1 excess, internal /port-site hernia etc.)
Hernia – port-site, incisional

21. Band Complications Slippage (Pain, N&V)
Erosion (Pain, N&V, loss of restriction)
Oesophageal dilation (Regurgitation, N&V, persistent cough)
Infection (Pain, local inflammation, systemic sepsis)
Nutritional deficiency (tiredness, hair loss)
Gallstones (Pain, N&V, Jaundice)
Hiatus hernia / GORD (Regurgitation, heartburn, dysphagia)

22. Sleeve Gastrectomy Complications
Staple line leak (pain, N&V, sepsis)
Staple line bleed
Reflux (regurgitation, heartburn, dysphagia)
Sleeve dilation (weight regain)
Nutritional deficiency (tiredness, hair loss, pain)
Gallstones (pain, dyspepsia, N&V, jaundice)

23. Gastric Bypass Complications
Staple line leak (pain, N&V, sepsis)
Staple line bleed
Ulcer (pain, N&V, dysphagia)
Stenosis (dysphagia, pain, N&V, regurgitation, excessive weight loss)
Dumping (giddiness, tiredness, tachycardia, cramps)
Internal hernia (cramps, bloating, constipation)
Gallstones (pain, N&V, Jaundice)
Nutritional deficiency (tiredness, hair loss, pins and needles, pain, ulcers)

24. Balloon Complications
Intolerance (nausea & vomiting, cramps)
Ulcer (epigastric pain)
Deflation and migration (bowel obstruction)

25. POSE Complications Perforation Bleeding
Intolerance (nausea & vomiting, cramps)
Ulcer (epigastric pain)

26. Pain Gallstones Pancreatitis Anastomotic ulcer
Perforation / Anastomotic leak
Gastric band erosion
Slipped gastric band
Dumping syndrome
Anastomotic stricture
Small bowel obstruction
Gastro-gastric fistula

27. Nausea & Vomiting Pregnancy! Gastroenteritis
Gastric balloon intolerance
Over-restricted gastric band
Anastomotic ulcer
Anastomotic / Sleeve gastrectomy stricture
Gallstones / Pancreatitis
Hiatus hernia
Internal hernia / Small bowel obstruction

28. Diarrhoea Gastroenteritis Bacterial overgrowth Clostridium difficile
Fat malabsorption
Dumping syndrome
Lactose intolerance

29. Case Study 1 Thiamine Deficiency
Mr A, 32 year old publican, gastric bypass 3 year ago, lost 85% excess body weight
Tripping over repeatedly – 4 months. Nausea and vomiting, pins and needles in hands and feet
Investigate / Treat / Refer to hospital – Emergency / Urgent / Routine?
GP referred patient to neurologist
Differential diagnosis: Thiamine / Vitamin B12 deficiency
Investigation: RBC thiamine / Serum Vit B12 + ECHO + MRI brain
Treatment: Thiamine 100mg bd for 12 weeks
Thiamine Deficiency
Beriberi
Wernicke’s encephalopathy
Confusion, irritability, memory loss, nervousness, speech difficulties
SoB, orthopnoea, tachycardia
Constipation, digestive problems, loss of appetite
Numbness of hands and feet, pain sensitivity, poor coordination, weakness, absent knee and tendon reflexes, paralysis

30. Case Study 2 Band slippage Epigastric pain Dysphagia Weight regain
Mrs B, 42 year old housewife, gastric band 2 years ago, lost 64% excess body weight
Sudden onset epigastric pain and dysphagia
Investigate / Treat / Refer to hospital – Emergency / Urgent / Routine?
Differential diagnosis:
Band slippage
Band erosion
Investigate:
Contrast swallow
CT abdomen
OGD
Band slippage – Emergency band deflation + reposition / removal
Band slippage
Epigastric pain
Dysphagia
Weight regain
Band erosion
Loss of restriction
Band infection

31. Case Study 3 Anastomotic ulcer Epigastric pain, heartburn Gallstones
Mrs X, 37 year old writer, gastric bypass 6 months ago, lost 45% excess body weight
Intermittent epigastric pain and nausea
Investigate / Treat / Refer to hospital – Emergency / Urgent / Routine?
Differential diagnosis:
Anastomotic ulcer
Gallstones
Internal hernia
Investigate:
USS, Contrast swallow, CT abdomen, OGD
Diagnosis: Gallstone cholecystitis
Treatment: Laparoscopic cholecystectomy
Anastomotic ulcer
Epigastric pain, heartburn
Gallstones
Epigastric / RUQ pain, N&V, Pancreatitis
Internal hernia
Abdominal cramps after eating, constipation, bloating, acute abdomen

32. Case Study 4 Bacterial overgrowth
Mr Y, 27 year old computer analyst, gastric bypass 3 years ago, lost 75% excess body weight
Abdominal pain, bloating, nausea and diarrhoea
Refer to hospital – Emergency / Urgent / Routine?
Differential diagnosis:
Bacterial overgrowth
Malabsorption
Internal hernia
Investigate:
Bloods, ABG, CT abdomen, D-Xylose test, Hydrogen breath test, Stool culture, Faecal fat
Diagnosis: Bacterial overgrowth
Treatment: Correct nutritional deficiencies and Metronidazole + Live yogurt / Neomycin + Rifampicin
Bacterial overgrowth
Abdominal cramps, diarrhoea, borborygmi
Malabsorption
SoB, orthopnoea, tachycardia
Internal hernia
Abdominal cramps after eating, constipation, bloating

33. Case Study 5 Over-restricted band Cough, reflux and water brash
Ms Q, 42 year old teacher, gastric band 2004, lost 60% excess body weight
Cough, reflux and water brash for the last 3 weeks.
Investigate / Treat / Refer to hospital – Emergency / Urgent / Routine?
GP started her on Amoxicillin and referred for an OGD
Differential diagnosis: RTI, band slippage, over-restricted band
Investigation: Gastrograffin swallow + OGD
Treatment: Band volume reduction - defill
Over-restricted band
Cough, reflux and water brash
Unable to tolerate solids
Unable to lie down without coughing
Band slippage
Epigastric pain
Intolerant to solids / liquids
Weight regain

34. Take Home Message
Bariatric surgery is a cost-effective treatment for obesity which leads to resolution of co-morbidities, improved quality of life and increased life expectancy
However, patients need lifelong follow-up after surgery in order to avoid harm – this can be performed by their surgical team and by the primary care.
Patients can present with nausea, vomiting, dysphagia, reflux, abdominal pain and neurological symptoms.
Common things are common!
Nutritional deficiencies are common and easily preventable.

35. Thank you!