Ascertaining Areas for Long-Term Follow-Up of Bariatric Surgical Patients for Primary Care: A Narrative Review

Abstract

Introduction:

Bariatric surgery is unique in terms of anatomical changes imposing a resetting of the physiological milieu. Although many changes are beneficial, adverse effects, complications, and impact on psychological well-being may occur. Health care professionals need to be aware of the impact of these changes and respond appropriately. The aim of the review was to analyze the existing corpus of literature and identify areas to inform a future long-term follow-up strategy for postsurgical patients.

Methods:

A narrative review was carried out, allowing a wide range of inclusion criteria across a broad range of topics. Two independent literature searches were carried out using PubMed.

Results:

Searches returned 49 results. Critical analysis of the literature was carried out, with consensus reached on topics of relevance and importance to postbariatric surgery long-term follow-up.

Conclusions:

This review highlights 12 common issues that bariatric patients may face after surgery, to facilitate prompt diagnosis and treatment, to inform Primary Care professionals to deal with presenting symptoms, and to ensure appropriate action to inform best possible treatment and outcomes. We recommend that these areas are discussed further with the responsibility of follow-up, frequency of follow-up, and patient education taken into consideration when planning postbariatric care and support.

Introduction

Patients undergoing bariatric surgery experience a complex range of anatomical, physiological, psychological, and social changes, many of which are the subjects of ongoing research to gain a more in-depth understanding. These changes have a far-reaching consequence on patients' physical and mental health, which may extend throughout a patients' life. Although most of the adjustments and complications occur within the first few years following surgery, other issues can manifest in the longer term, which require long-term monitoring, follow-up, and support.

Although bariatric surgery is associated with a reduction in the long-term all-cause, cardiovascular, and cancer-related mortality,¹ this cohort of patients appear to be at higher risk of mortality due to liver failure and suicides.² Moreover, patients can develop nutritional complications³ or surgical complications like an internal hernia⁴ several years after surgery. It is therefore widely recognized that lifelong follow-up should form an essential part of the aftercare of these patients.⁵

The current guidelines on follow-up of bariatric surgery patients by the American Society for Metabolic and Bariatric Surgery (ASMBS)⁶ and the British Obesity and Metabolic Surgery Society (BOMSS)⁷ are useful, but do not cover all aspects of long-term follow-up of these patients, and are based on varying levels of available evidence. Despite published guidance, ensuring adequate long-term follow-up of bariatric surgery patients is a challenge for health care professionals involved in providing care for these patients.⁸ This suggests a need to develop more robust strategies for follow-up of these patients. There is further a need to address the knowledge gap in primary care on issues concerning bariatric surgery.⁹ Any comprehensive long-term follow-up strategy for bariatric surgery patients must monitor patients for weight loss (including excessive weight loss and later weight regain), compliance with recommended nutritional supplements, surgical and nutritional complications, loose skin, psychological and relationship issues, addiction transfer, and reemergence of comorbidities.

The aim of the review was to identify the existing corpus of literature and identify areas needed to inform a pragmatic long-term follow-up strategy for postsurgical patients.

Materials and Methods

The subject of long-term follow-up of bariatric patients is broad, extending beyond traditional biomedical clinical outcomes to encompass social and psychological aspects, necessitating a method which would capture both a wide range of literature and the complexities of the subject. A narrative review was thus chosen as the method to carry out the literature synthesis. Narrative reviews are a method of synthesizing a body of extant literature and have a wider scope for inclusion criteria than a systematic review, allowing a range of studies to be included to provide a comprehensive overview of a subject.¹⁰ Narrative reviews can provide context to an area which is ambiguous, and by presenting the existing publications in the area, can inspire debate and discussion.¹¹ Owing to a current lack of consensus on a definitive checklist, varied evidence base on different and broad aspects of bariatric patient aftercare, a narrative review was agreed as the most pragmatic approach.

To capture a wide range of subjects and published literature within the broad field of bariatric surgery, PubMed was chosen as the electronic database to conduct literature searches. Two independent searches of the PubMed database were carried out by two authors (K.M. and Y.G.) to identify all articles published in the English language on various aspects of long-term care of patients who have undergone bariatric or metabolic surgery. The key words used in various permutations to carry out the searches were “bariatric surgery,” “metabolic surgery,” “obesity surgery,” “bariatric,” “gastric bypass,” “sleeve gastrectomy,” “gastric banding,” “follow-up,” “vitamin,” “mineral,” and “supplementation.” Relevant articles were also identified from the reference lists of included articles. No time filter was used to allow a broad range of articles to be included. Case reports were excluded. The last of these searches was carried out on June 13, 2018. Both K.M. and Y.G. produced two independent lists of articles, which were selected based on agreed criteria of frequency of topic and relative to the presupposition from clinical and academic practice. The blinded lists were then given to C.H., who independently validated the findings of both. The results were then compared and discussed among the authors, with a final consensus of articles selected for inclusion in the review agreed.

Results

The searches returned 49 results. An in-depth critical analysis of the literature was carried out to identify common topics of relevance to postbariatric surgery long-term follow-up. A consensus of the areas of priority for long-term care and follow-up of bariatric surgery patients was independently cross-validated between the 3 researchers, with 12 areas of priority agreed.

Dietary advice

There is an emerging body of data suggesting that sustained long-term weight loss achieved through bariatric surgery is largely due to its effect on hunger and satiety.¹² At the same time, these effects on hunger and satiety are most pronounced in the first year after surgery, and it is uncommon for bariatric surgery patients to experience significant weight loss after the first year of surgery. After 2 years on average, most patients experience some weight regain.¹³ There is evidence to suggest that a high protein diet may not only enhance weight loss but also lead to better preservation of lean body mass.¹⁴ Although bariatric surgical patients, similar to other individuals, will benefit from following a healthy diet, there is currently no evidence to support other practices, such as avoiding water with food intake.¹⁵ Patients should be advised to monitor their weight regularly and adjust calorie intake accordingly to achieve their desired healthy weight. Reduced hunger after bariatric surgery should enable patients to maintain a lower calorie intake to match their own calorie expenditure in the long term. It is generally recognized that poor diet quality, inappropriate food choices, and lack of nutritional counseling can lead to weight regain.¹³ It is thus important that appropriate dietary counseling forms a key component of every bariatric follow-up visit.

Physical exercise

Although postbariatric surgery patients subjectively report increased activity levels after surgery,¹⁶ the objective assessment shows that they have low physical activity levels and lead sedentary lifestyles.^17,18 There is a recognized significant positive association between higher postsurgery physical activity levels and better postoperative weight loss outcomes.^13,18,19 Long-term follow-up after bariatric surgery must hence encourage patients to increase their physical activity levels and take up regular exercise. Patients who exercise also experience higher loss of fat mass and higher gain of lean body mass, although the total weight loss might be similar between the exercise and nonexercise groups.²⁰

New medication use

Bariatric surgery generally leads to an overall reduction in the use of medicines,²¹ but patients may also be started on several new medications and are further recommended a number of vitamin and mineral supplements. They are generally prescribed proton pump inhibitors for a period of several months to aid healing of staple lines after sleeve gastrectomy and for prophylaxis of marginal ulcers after gastric bypass. Although most patients are able to stop their proton pump inhibitors after 6–12 months, those deemed at high risk of marginal ulcers—such as those who continue to smoke or those on nonsteroidal anti-inflammatory drugs or corticosteroids²¹—could benefit from continued long-term prophylaxis, although evidence to support this advice is currently lacking. Patients are also advised Ursodeoxycholic acid for prophylaxis of gallstones during the first 6 months after surgery when the weight loss is most rapid. There are data which support that dosages of 1000–1200 mg daily are superior to lower dosages, but the compliance is better with dosages of 500–600 mg daily.²²

Adjustment to patients' routine medications

Bariatric surgery alters the bioavailability of drugs through its effect on gastric emptying, gastric acid, reduced small bowel absorptive surface, and concomitant use of medications like proton pump inhibitors.²³ It also generally lowers the requirement of medicines by altering total body mass and lean body mass and through improvement on a range of medical conditions. In most cases, it is sufficient to closely follow-up patients for the clinical effect of the drugs and make dose adjustment as necessary. Generally, medications for diabetes, hypertension, dyslipidemia, asthma, etc. can be monitored clinically and can be either significantly reduced or discontinued. For drugs that have narrow therapeutic spectra like Lithium, antiepileptics, or immunosuppressants, it may be necessary to closely monitor serum levels and adjust dosages accordingly until weight stabilizes. Although dose adjustments for drugs used to treat common conditions such as diabetes, hypertension, dyslipidemia, and so on may have to be left to patients' general practitioners, monitoring of levels and subsequent dose adjustment of drugs such as antiepileptics, antipsychotics, immunosuppressants, anticoagulants, and so on are best carried out by respective specialists. Patients should, therefore, be advised to consult appropriate doctors regarding their preexisting medications as soon as possible after bariatric surgery.

Micronutrient supplementation and monitoring

Patients undergoing bariatric surgery suffer from a number of preexisting micronutrient deficiencies.²⁴ In addition, because of the reduction in total calorie intake after bariatric surgery, the intake of various micronutrients is significantly reduced. Although this reduced intake of micronutrients is most pronounced in the early period after bariatric surgery, changes persist in the long term.²⁵ In addition, bariatric surgery results in a variable reduced capacity of the body to absorb a range of micronutrients.²⁶ This places bariatric surgery patients at high risk of developing a number of micronutrient deficiencies (Table 1).

Table 1.

Approximate Incidence of Common Nutritional Deficiencies After Bariatric Surgery

Complication	Incidence
Vitamin D deficiency	25.0–75.0%
Vitamin B1 (thiamine) deficiency	10.0–15.0%
Vitamin B12 deficiency	20.0–35.0%
Iron (Fe) deficiency	15.0–45.0%
Zinc (Zn) deficiency	15.0–50.0%
Copper (Cu) deficiency	4.0–20.0%
Hypoalbuminemia/protein-calorie malnutrition	1.0–15.0%
Neurological complications	≤1.0%

It is therefore crucial that patients are on lifelong supplementation with a range of micronutrients after bariatric surgery. Although there are guidelines on the topic,^8,9 the evidence base for these guidelines is generally poor, and the precise supplementation dose for each micronutrient after each procedure is yet to be determined.^27–30 As a result, there are considerable variations in the supplementation protocol recommended by different bariatric surgery centers.³¹ Table 2 makes an attempt to summarize recommendations from major guidelines for supplementation after various bariatric procedures.

Table 2.

Summary Recommendations on Nutritional Supplementation After Bariatric Surgery as Per American Society for Metabolic and Bariatric Surgery and British Obesity and Metabolic Surgery Society Guidelines

Supplement	Guideline	Gastric band	Sleeve gastrectomy	Gastric bypass	BPD/DS
Multivitamin/mineral supplements	ASMBS Guideline: multivitamin/mineral tablet containing iron, folic acid, and thiamine (Grade B, Level 2).	1 tablet daily	2 tablets daily	2 tablets daily	2 tablets daily
Multivitamin/mineral supplements	BOMSS Guideline: multivitamin/mineral tablet containing iron, selenium, 2 mg copper, and zinc (8–15 mg zinc per mg of copper)	1 tablet daily	2 tablets daily	2 tablets daily	2 tablets daily
Calcium and vitamin D	ASMBS Guideline: calcium citrate 1200–1500 mg/day (Grade B, Level 2)	Yes	Yes	Yes	Yes
	ASMBS Guideline: vitamin D (at least 3000 U/day titrated to levels >30 ng/mL) (Grade A, Level 1)	Yes	Yes	Yes	Yes
	BOMSS Guideline: At least 800 mg Calcium and 20 μg vitamin D	No	Yes	Yes	Yes
Vitamin B12 supplements	ASMBS Guideline: vitamin B12 orally or parenterally as needed (Grade B, Level 2)	Yes	Yes	Yes	Yes
Vitamin B12 supplements	BOMSS Guideline: vitamin B12 injection 1 mg 3 monthly	No	Yes	Yes	Yes
Iron (Fe)	ASMBS and BOMSS Guidelines: 45–60 mg elemental iron daily	No	Yes	Yes	Yes

ASMBS, American Society for Metabolic and Bariatric Surgery; BOMSS, British Obesity and Metabolic Surgery Society; BPD/DS, biliopancreatic diversion/duodenal switch.

Compliance with supplements is another major issue.^32,33 As a result, a significant proportion of patients become anemic after surgery or suffer from other micronutrient deficiencies.^34,35 This is the rationale for guidelines'^7,8 to recommend regular testing for a range of micronutrients after bariatric surgery (Table 3).

Table 3.

Summary Recommendations Regarding Monitoring After Bariatric Surgery as Per American Society for Metabolic and Bariatric Surgery and British Obesity and Metabolic Surgery Society Guidelines

Monitoring recommendation	Guideline	Gastric banding	Sleeve gastrectomy	Gastric bypass	BPD/DS
Frequency of visits	ASMBS Guideline: initial, interval until stable, once stable (months)	1, 1–2, 12	1, 3–6, 12	1, 3–6, 12	1, 3, 6
Frequency of visits	BOMSS Guideline:	Nothing specific for each procedure but generally recommends follow-up at 3, 6, and 12 months and annually after that
FBC	ASMBS Guideline: FBC at each visit	Yes	Yes	Yes	Yes
FBC	BOMSS Guideline: (3, 6, and 12 months in the first year and then annually)	Only annually	Yes	Yes	Yes
Urinary calcium	ASMBS Guideline: 24-h urinary calcium excretion at 6 months and then annually	Yes	Yes	Yes	Yes
Urinary calcium	BOMSS Guideline: No recommendation	—	—	—	—
Hematological and bone health parameters	ASMBS Guideline: folic acid, iron studies, vitamin D, parathyroid hormone	No	No	Yes	Yes
Hematological and bone health parameters	BOMSS Guideline: U+E, LFT, ferritin, folic acid, calcium, vitamin D, parathyroid hormone (3, 6, and 12 months in the first year and annually thereafter)	No	Yes	Yes	Yes
Vitamin B12	ASMBS Guideline: vitamin B12 (annually).	No	Yes	Yes	Yes
Vitamin B12	BOMSS Guideline: 6 and 12 months in the first year and then annually. No need to monitor if the patient is on IM injections	No	Yes	Yes	Yes
Vitamin A	ASMBS Guideline: vitamin A (initially and 6–12 monthly thereafter)	No	No	Optional	Yes
Vitamin A	BOMSS Guideline: monitor as follows	No	No	Measure if steatorrhea or symptoms of night blindness	Monitor annually
Zinc and copper	ASMBS Guideline: evaluate with “specific findings”	No	No	Evaluate as appropriate	Evaluate as appropriate
Zinc and copper	BOMSS Guideline: monitor as follows	No	No	Monitor annually	Monitor annually
Selenium	ASMBS Guideline: selenium evaluation with “specific findings”	No	No	Yes	Yes
Selenium	BOMSS Guideline: monitor as appropriate (unexplained fatigue, anemia, metabolic bone disease, chronic diarrhea, or heart failure)	No	No	Yes	Yes
Thiamine	ASMBS Guideline: thiamine evaluation with “specific findings”	Yes	Yes	Yes	Yes
Thiamine	BOMSS Guideline: as clinically appropriate	Yes	Yes	Yes	Yes
Vitamin E and K	ASMBS Guideline: insufficient evidence to recommend routine screening	—	—	—	—
Vitamin E and K	BOMSS Guideline: monitor vitamin E in unexplained anemia, neuropathy. Consider vitamin K deficiency if excessive bruising/coagulopathy	No	No	As clinically appropriate	As clinically appropriate
Lipid profile	ASMBS Guideline: lipid evaluation every 6–12 months based on risk and therapy	Yes	Yes	Yes	Yes
Lipid profile	BOMSS Guideline: monitor in those with dyslipidemia	Yes	Yes	Yes	Yes

BPD/DS, biliopancreatic diversion/duodenal switch; FBC, full blood count; IM, intramuscular; LFT, liver function tests; U+E, urea + electrolytes.

These recommendations to detect and treat every single subclinical micronutrient deficiency can, however, result in unnecessary patient anxiety and costs.^28,29 The effort and expenditure incurred in monitoring and optimizing all the possible micronutrient deficiencies can deter primary care practitioners from following up bariatric surgery patients. The current guidelines may place a significant burden in terms of time and cost on health care systems. Owing to the lack of Level 1 evidence to suggest that regular, intensive hematological monitoring is practical, beneficial, and cost-effective, the authors propose a practical algorithm (Fig. 1) that can be used in general practice for majority of the postbariatric surgery patients.

FIG. 1.

A proposed practical algorithm for the hematological monitoring of postbariatric patients in general practice. Cu, copper; Fe, iron; Hb, hemoglobin; PTH, parathyroid hormone; ZN, zinc.

Patients deemed to be high risk within a bariatric surgical cohort should be identified at follow-up. For example, pregnant women will need additional monitoring to ensure adequate folate levels and should be referred back to the bariatric team for careful monitoring. Similarly, patients who are known to be suffering from Cirrhosis, those undergoing distal gastric bypass, those who have undergone malabsorptive procedures like Duodenal Switch or Biliopancreatic Diversion, those presenting with new illnesses, and losing weight too rapidly or showing signs and symptoms of protein-calorie malnutrition should have their liver functions checked³⁵ and urgently referred back to their bariatric teams. Those with neurological symptoms should also be sent back to their parent teams promptly.

Identify and treat complications

In addition to the nutritional issues described above, bariatric surgery patients are at risk of developing a number of long-term surgical complications (Table 4). Health care professionals looking after these patients should be aware of the common modes of presentations of these complications. Signs that may indicate serious problems include patients experiencing abdominal pain, nausea/vomiting, inability to eat, hypoglycemic symptoms, gastroesophageal reflux disease uncontrolled on medical management, excessive weight loss, and protein-calorie malnutrition and should be urgently referred back to the bariatric surgical center for further diagnosis and management.

Table 4.

Long-Term Complications After Commonly Performed Bariatric Procedures

Procedure	Complication	Approximate incidence	Management options
Gastric band	Band slippage	3.0–10.0%	Removal
	Gastric pouch and/or esophageal dilatation	4.0–20.0%	Deflation with gradual refilling or more commonly band removal
	Band erosion	1.0–10.0%	Endoscopic (or laparoscopic removal if endoscopic not possible)
	Port/tubing complications	5.0–15.0%	Port replacement/tube shortening/port repositioning
	Reflux esophagitis	0–20.0%	Band deflation ± PPI or band removal
Sleeve gastrectomy	GORD	10.0–20.0%	PPI and/or conversion to RYGB
	Stricture	0.2–0.3%	Endoscopic dilatation, laparoscopic seromyotomy or wedge resection or conversion to RYGB
	Twist or kink	0.2–0.3%	Conversion to RYGB
RYGB	Internal hernia	1.0–3.0%	Reduction of the hernia and closure of spaces (Petersen's, J-J defect, ±mesocolic defect)
	Reactive hypoglycemia	0.5–2.0%	Medical management, very occasionally reversal of RYGB, or conversion to sleeve gastrectomy
	Marginal ulcer	3.0–5.0%	Medical treatment (i.e., Lansoprazole 30 mg BD and Sucralfate 1.0 g 6 hourly), Treat for Helicobacter Pylori if present, stop smoking, exclude gastrinoma, Revision of anastomosis
	Nonspecific abdominal pain	5.0–10.0%	Look and treat for gallstones, ulcers, hernia, renal stones. In persistent cases, consider a reversal
One anastomosis gastric bypass	Marginal/anastomotic ulcer	1.0–5.0%	Medical treatment (i.e., Lansoprazole 30 mg BD and Sucralfate 1.0 g 6 hourly), treat for H. Pylori if present, stop smoking, exclude gastrinoma, reversal or conversion to Roux-en-Y configuration
	Malnutrition	0–1.0%	Shorten the biliopancreatic limb, reversal
	GORD	5.0–10.0%	Medical management (PPI), Conversion to Roux-en-Y configuration, Braun's anastomosis
	Reactive hypoglycemia	0.5–1.0%	Medical management, reversal
	Internal hernia	Rare	Reduction of the hernia and closure of spaces

GORD, gastroesophageal reflux disease; PPI, proton pump inhibitor; RYGB, Roux-en-Y gastric bypass.

Importance of follow-up

Although some studies suggest that patients who do not attend follow-up appointments have poorer weight loss outcomes,^36,37 it is currently unclear if this is a cause and effect relationship, with conflicting studies in this area.³⁸ Regardless of the impact on weight loss, regular follow-up also allows for earlier identification of problems and enables long-term evaluation of bariatric procedures. Furthermore, there is a negative correlation between weight loss and distance to bariatric center³⁶ suggesting a need for local follow-up mechanisms for patients who do not reside close to the center.

Support group

Many bariatric programs facilitate a patient support group³⁸ where patients can learn from each other's experience. Patients value these interactions where they can share their feelings and issues informally, but there is a risk that wrong messages get disseminated in these groups. It may hence be useful to ensure that a health care professional is present for the support group meetings.

Contraception and pregnancy

Women of childbearing age are advised to avoid pregnancy for at least 2 years after their weight loss has stabilized³⁹ as the outcome of pregnancies conceived during the early phase of rapid weight loss may not be favorable. Since the absorption of oral contraceptive pills may be unreliable, especially after a gastric bypass, these patients should look at alternative modes of contraception.⁴⁰ Furthermore, since bariatric teams may not feel comfortable offering advice on contraception, it may be best to organize referrals to providers or signpost patients to a range of contraceptive providers.⁴⁰

Body contouring surgery

Owing to the amount of weight loss and change to body shape, many patients have a degree of loose skin after bariatric surgery. The magnitude of the problem depends on patients' preexisting state as it is not uncommon for patients to have a large abdominal apron even before surgery and the weight loss. A recent large study from France found that by 7 years follow-up, 21.0% patients had undergone a plastic surgery after bariatric surgery.⁴¹ There is little doubt about inadequate provision of body contouring surgery. Plastic surgery to deal with loose skin may not only improve patients' psychological well-being,⁴² but may also have a beneficial effect on long-term weight-loss outcome.⁴³

Psychological support

Bariatric surgery results in overall improvement in psychological health through its effect on body weight, body image, and self-esteem, but some patients struggle with weight loss, altered body image, complications, and later, weight regain.⁴⁴ There are data to suggest a higher risk of relationship breakdown⁴⁵ and self-harm⁴⁶ after bariatric surgery suggesting a need to identify and support the at-risk group postoperatively. Bariatric surgery patients further report that social aspects of the surgery are not widely appreciated by others in the society.⁴⁷ It is crucial that clinicians looking after these patients to understand how patients adjust to life after surgery to be able to support them better.

Hematological monitoring

The purpose of hematological monitoring at the time of long-term bariatric review is to monitor patients' other health conditions like diabetes or dyslipidemia and to screen for common nutritional problems after bariatric surgery. Since anemia⁴⁸ and secondary hyperparathyroidism⁴⁹ are relatively common in postbariatric surgery patients, especially those undergoing a gastric bypass, it may make sense to screen all the patients for them. Concurrently, screening these patients for every possible vitamin and mineral deficiency, some of which are rare, may not be cost-effective^28,29 and might engender a false sense of security. The focus could be on determining the appropriate dosages for the prophylactic supplementation of each vitamin or mineral after each bariatric procedure, then ensuring that patients are compliant with their supplementation regime.

There is a further need to ensure that patients and clinicians do not ignore warning signs of early nutritional deficiencies. Most vitamin or mineral deficiencies are easily corrected if diagnosed in time. The current scenario of overreliance on blood tests means that the diagnosis and treatment of nutritional issues following bariatric surgery are often delayed with significant consequences for the patients.

Discussion

From the 12 identified areas of proposed care of postbariatric surgical patients, there were three core key considerations identified, the responsibility of follow-up, the frequency of follow-up, and patient education.

The responsibility of follow-up

It is generally accepted that until weight loss is stabilized, the follow-up of patients should be primarily led by the bariatric surgical teams. However, there is less clarity on who should look after patient's preexisting medical comorbidities during this period. Furthermore, there is no consensus on if and when the primary responsibility for the follow-up should be transferred to primary care after a stable weight has been achieved.

In the United Kingdom, the provisions of bariatric surgery are shaped by the National Institute for Health and Care Excellence (NICE) Guideline CG 189. The guideline advises that follow-up for the first 2 years after surgery should be within “the bariatric service” and that it should include monitoring of “nutritional intake (including protein and vitamins) and mineral deficiencies, monitoring for comorbidities, medication review, dietary and nutritional assessment, advice, and support, physical activity advice and support, psychological support tailored to the individual, and information about professionally led or peer-support groups.”⁵

The time frame of 2-year period after surgery appears to be arbitrary, but it seems appropriate because most patients can be expected to have reached a plateau weight by the end of this period and because most complications related to surgery are likely to occur during this period. It is reasonable for bariatric teams to provide most of the aspects of the follow-up recommended in the NICE guidance, but the expectation of the bariatric team to concurrently monitor a number of comorbidities that these patients might suffer from and review the medications puts the onus on bariatric teams to provide all encompassing medical care in areas in which they may not have the appropriate skills or resources to deliver aspects of care. It is hence recommended that a shared approach toward follow-up is adopted right from the outset where primary care continues to take responsibility for looking after patients' other medical conditions while bariatric surgery teams look after surgery and its related issues.

After the 2-year period, NICE advises that patients are discharged from the bariatric surgery service. Although this is a reasonable goal and there is no reason why health care professionals in primary care cannot provide most of the routine postbariatric surgery advice and care, there needs to be a close liaison with the bariatric surgical teams as patients remain at risk of developing a number of surgical and nutritional complications in the long term. These issues should be promptly identified and patients urgently referred back into the surgical units.

The frequency of follow-up

The purpose of follow-up during early stages after surgery is early identification of any complications, to ensure appropriate dietetic and lifestyle advice is reinforced, and monitor the nutritional status of patients. Obviously, this will mean that patients are seen once or twice in the first couple of months and at regular intervals thereafter until the weight reaches a plateau stage and patients are comfortable with their new dietary patterns and lifestyle. One reasonable protocol can be to offer follow-up at 10–14 days, 6 weeks, 6 months, and then at 6 monthly intervals until the stable state is reached or 2 years, whichever is later. The purpose of medium-to-long term follow-up is to reinforce appropriate diet and lifestyle messages, monitoring of weight, early identification of surgical and nutritional complications, monitoring of comorbidities, and hematological monitoring as indicated. Although most of these objectives can be achieved at the time of patients' annual health check in the primary care, there has to be a recognition that patients may develop issues at other times.

Patient education

Current guidelines almost entirely focus on the role of the health care professionals without involving patients in the decision-making and follow-up process. NICE guidelines⁵ clearly state that bariatric surgery is only a treatment option if the patient “commits to the need for long-term follow up” and this should be explained to the patients before surgery and afterward. Patients could be further provided with a list of warning symptoms (Table 5) that should prompt them to contact their General practitioners.

Table 5.

Warning Symptoms After Bariatric Surgery

Level of urgency	Warning symptoms	Action
Emergency (needs immediate attention)	Sudden abdominal pain	Refer to nearest A&E and inform the bariatric team
	Overt gastro-intestinal bleeding	Refer to nearest A&E and inform the bariatric team
	Attempted suicide	Refer to crisis team and inform the bariatric team
	Inability to consume liquids	Refer to nearest A&E and inform the bariatric team
	New neurological symptoms like paresthesia, numbness, weakness, altered consciousness	Refer to nearest A&E and inform the bariatric team
	Liver decompensation/liver failure	Refer to nearest A&E and inform the bariatric team
Urgent (needs to be seen in <2 weeks)	Chronic abdominal pain	Refer to bariatric team
	Nausea/vomiting	Refer to bariatric team
	Inability to consume solids	Refer to bariatric team
	Features of reactive hypoglycemia	Refer to endocrinology and inform the bariatric team
	Anemia	Refer to bariatric team
	Protein-calorie malnutrition	Refer to bariatric team
	Self-harm	Refer to psychiatry and inform the bariatric team
	Pregnancy	Refer to bariatric team and inform the local maternity team
Elective (needs to be seen in <6 weeks)	Psychological or relationship issues	Refer to mental health and inform the bariatric team
	Weight regain or unsatisfactory response to surgery	Refer to bariatric team
	Gall stones	Refer to bariatric team
	Loose skin	Refer to plastic surgeons

Conclusion

Patients should further be educated about the need to take lifelong micronutrient supplements as advised by their bariatric team. Repeated blood tests on a patient who is not compliant with supplements without even an attempt to understand the reasons for lack of compliance can only achieve little. The review has several limitations. First, the broad nature of the subject means that not all literature pertaining to postsurgical follow-up was identified. The use of a narrative as opposed to systematic approach may have influenced findings. Only one electronic database was used for this review, but other databases may have uncovered additional literature. In addition, we did not search the gray literature in this field, and we acknowledge that the personal biases of the authors may have influenced the literature chosen for inclusion in the review.

There is currently a need to streamline and improve long-term follow-up of bariatric surgery patients. This article attempts to identify all the various aspects of follow-up of these patients and suggest a pragmatic multidisciplinary pathway. Further research into the subject of long-term follow-up after bariatric surgery in terms of including cost-benefit analysis is recommended.

Authors' Contributions

K.M. conceived the idea of the article, undertook one of the blind literature searches and led on the writing up of the article. Y.G. undertook a further blind literature search and assisted with the writing up. C.H. assisted with the writing up of the article. All authors have seen the final draft and approve of it.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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