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Bariatric Surgery

Bariatric Surgery: Information for Health Care Professionals

HCPs play a crucial role in guiding patients towards optimal health outcomes, including the management of obesity. Bariatric surgery is an effective but complex intervention that requires multidisciplinary input before and after surgery. The following is a guide to essential information about bariatric surgery to help HCP better support and advise their patients.

Indications for Bariatric Surgery

Bariatric surgery is typically recommended for individuals with a Body Mass Index (BMI) ≥ 40 or ≥ 35 with obesity-related health conditions such as type 2 diabetes, hypertension, obstructive sleep apnoea, or osteoarthritis.

Benefits of Bariatric Surgery

  • Significant and sustainable weight loss which often results in improvements in obesity-related health conditions and overall quality of life.
  • Many patients experience remission or significant improvement in conditions such as type 2 diabetes, hypertension, and sleep apnoea following bariatric surgery.
  • Bariatric surgery can positively impact metabolic parameters such as insulin sensitivity, lipid profiles, and blood pressure.
  • There can be significant improvements in important patient-reported outcomes, such as self-esteem, physical health/functioning, mental/psychological health, social health, stigma, and body image.

Pre-Bariatric Surgery

Patients are referred to the Level 3 Centre for Obesity Management (COM) service by a HCP and assessed by a multidisciplinary team, who work with the patient to assess desire and suitability for surgery. Even when a patient is referred directly for bariatric surgery, all patients are first seen in the Level 3 service. Not all patients who attend Level 3 COM will choose to go on to have bariatric surgery. If the patient wishes to proceed with surgery the MDT engage the patient on important preparatory work to try and increase the likelihood of successful short and long term outcomes following bariatric surgery. The MDT focus on healthy eating patterns, movement and participation, mental health and social support.

Some patients may initiate obesity medications such as GLP-1 agonists prior to surgery.

If you have referred a patient to COM there are some helpful things that can be done while they wait on an initial assessment:

  • Psychological readiness forms an important part of the work done with patients in COM. Addressing underlying psychological factors, particularly trauma, is crucial for the success of bariatric surgery and the patient’s overall well-being. The National Counselling Service (NCS) provides free counselling to those who have experienced childhood abuse or neglect or who have been a resident of a mother and baby home. This is separate to the Counselling in Primary Care (CIPC) which requires a medical card. Patients can self-refer https://www2.hse.ie/mental-health/services-support/ncs/about/
  • Screen for obstructive sleep apnoea (OSA) using the STOP-BANG scoring system and refer for a sleep study as appropriate http://www.stopbang.ca/osa/screening.php. All patients should be referred for a sleep study if BMI >50kg/m2, as prevalence of OSA can be as high as 90% in this population, and some patients will not have typical symptoms.
  • Consider if the patient meets criteria for Saxenda (Liraglutide) reimbursement, and discuss a trial of this medication with the patient. Ozempic (Semaglutide) is also used for obesity treatment and can be prescribed off licence for patients without type 2 diabetes. There are other licenced medications, such as naltrexone/bupropion and orlistat. Further information is available in the Pharmacotherapy in Obesity Management chapter of the CPG for Management of Obesity in Adults in Ireland – https://asoi.info/guidelines/pharmacotherapy/
  • Review list of medications. Common obesogenic medications include SSRIs/ SNRIs, anti-psychotics, anti-convulsants, steroids, insulin and contraceptives. Table 9 of the following CPG chapter lists medications with higher or lower risk for weight gain – https://asoi.info/wp-content/uploads/2022/11/06-IR-ObesityAssessment-FINAL.pdf
  • Refer to a CORU registered dietitian. Some people living with obesity may not be eating adequately for nutritional health, and/or may have disordered eating pattern. Collaboration between doctors and dietitians can help to address misconceptions around diet culture and promote a healthy relationship with food.
  • It is important to encourage movement but to meet suggestions at the patient’s current baseline. It may be helpful to refer to a program such as Exwell that caters for all levels and those living with chronic diseases https://www.exwell.ie/
  • Patients must not be consuming any nicotine products including vapes before bariatric surgery. It is never too early to address smoking cessation https://www2.hse.ie/living-well/quit-smoking/ and it should be maintained lifelong.

The Surgical Assessment

If after collaborating with the multidisciplinary team a patient wishes to proceed to bariatric surgery, they will meet with the Surgical Team to further review suitability and discuss surgical options. The type of surgery performed is individualised, but the main surgeries performed are:

  • Roux en Y Gastric Bypass (RYGB)
  • One stage Anastomosis Gastric Bypass (OAGB)
  • Sleeve Gastrectomy (SG)

Post Bariatric Surgery

Follow up will usually occur at the following intervals post operatively – 6-8 weeks, 3 months, 6 months, 12 months then annually thereafter as required. Patients may be reviewed at more frequent intervals if indicated.

Medications prescribed short-term post bariatric surgery

  • Cubitan x 4 weeks
  • Clexane x 21 days
  • PPI x 3 months
  • Ursofalk 500mg x 6 months
  • Analgesia (not NSAIDS) prn x 2 weeks
  • Laxative prn

 

The following medications are recommended life-long post bariatric surgery:

  • Multivitamin (Centrum complete/ Boots A-Z) x 2 tablets daily
  • Calcichew D3 Forte Double Strength 1000mg/800 iu daily
  • Ferrograd C x 1 daily
  • Vit B12 injection 1000mcg, to be initiated 3 months post-surgery and every 3 months thereafter. If levels are normal B12 injections should be continued every 3 months to maintain. If levels are running high B12 injections can be extended to every 4-6 months.

 

As the numbers of people accessing bariatric surgery in Ireland rises, patients who are doing well will be discharged back to the care of their GP. In the UK, NICE recommend specialist follow up for 2 years post bariatric surgery and once stable, discharge to the GP for lifelong annual reviews.

Key resources for HCPs involved in care of patients who have undergone bariatric surgery:

Prof Helen Heneghan speaking about Bariatric Surgery: Not Exactly "a quick fix". Obesity and Bariatric medicine study day. St Columcille's Hospital. October 2022