Bariatric surgery (Guidelines)

Patients may present to primary care after having undergone bariatric surgery out with NHS Highland, NHS Scotland and the UK and therefore they may present with a range of resources and support available to them.

NICE guideline CG189 recommends that patients who have had bariatric surgery should be offered a follow-up care package for a minimum of 2 years within the bariatric service. If appropriate, patients can be advised to access this package of care.

Below is the blood monitoring and supplementation that these patients are expected to receive. 

Standard recommendations for post-op bloods carried out at 3, 6 and 12-months post-op and annually thereafter:

• U&Es
• LFTs
• TFTs
• Calcium
• Vit D
• FBC
• Ferritin
• Folate / Vit B12

These are all available via the ICE order set.

Other tests such as Vitamin A, Zinc, Copper and Selenium may be indicated if there are concerns. See BOMSS post-bariatric surgery nutritional guidance for GPs

Nutritional monitoring is an important component following bariatric surgery. Please refer to the Introduction to BOMSS GP Hub for more information.

• Introduction to BOMSS GP Hub
• BOMSS post-bariatric surgery nutritional guidance for GPs

Note on prescribing vitamins and minerals:

• BNF: ‘Vitamins are used for the prevention and treatment of specific deficiency states or where the diet is known to be inadequate; they may be prescribed in the NHS to prevent or treat deficiency but not as dietary supplements’.
• Where appropriate, patients can be asked to buy oral vitamin and mineral supplements over the counter.
• For patients who require vitamin B12, hydroxocobalamin injection needs to be prescribed.

Following gastric band

• A-Z vitamin and mineral supplement, eg:

Forceval capsule, taken once daily with food. (In presence of peanut or soy allergy Forceval soluble, one sachet daily)

All other procedures

• A-Z vitamin and mineral supplement, eg:

Forceval capsule, taken once daily with food. (In presence of peanut or soy allergy Forceval soluble, one sachet daily)

• Calcium and vitamin D (1000mg/800unit) eg:
  Accrete D3 One a Day chewable, one tablet once daily with food, not to be taken at the same time as iron
• Ferrous Fumarate 210mg once daily or Ferrous Sulphate 200mg once daily, with
• Hydroxycobalamin (vitamin B12) 1mg, 3-monthly via IM injection

The efficacy of oral vitamin B12 replacement is undetermined and injectable B12 is still advised.

Note on Baricol supplements

• This brand of supplement is specific to patients who have undergone bariatric surgery. If patients are taking these, they do not require any additional oral supplements. They can be purchased OTC in a variety of presentations and dosage is per the manufacturer recommendations.

PPIs                                                                                                

Patients may be prescribed a 3-month course of PPI therapy post-operatively, eg:

• Initial dose: lansoprazole oro-dispersible tablet, 30mg once daily.
• Maintenance dose, when patient is managing solid foods: lansoprazole capsules, 15mg once daily.

NSAIDS

Avoid prescribing drugs that irritate the gastric mucosa such as non-steroidal anti-inflammatory drugs (NSAIDS). Even in the presence of a PPI these drugs should be avoided long-term due to increased risk of stomal bleeding, stomal ulceration and anastomotic stricture.

Medication review for all patients post bariatric surgery

Non-solid oral dosage forms:

In the first few weeks after surgery, liquid or crushed preparations will be required until the patient is managing solid food (generally 6 to 8 weeks).

• Information on alternative formulations: Drug Administration via Enteral Feeding Tubes via Medicines Complete. Or for queries, contact pharmacy.
• If liquid preparations are used, they should be low sugar to reduce the risk of dumping syndrome.
• It is recommended to avoid effervescent formulations as any additional gas in the stomach pouch can cause discomfort, nausea and vomiting.

Modified Release

Slow-release and enteric coated medications may not be fully absorbed after bariatric surgery.

Special patient populations:

As the absorption of medication may be altered after bariatric surgery, patients who are on medication with a narrow therapeutic index or with conditions that need close control, such as epilepsy, may need input from their specialist teams.

• Epilepsy: Close monitoring of condition is required.
• Diabetes: In people with type 2 diabetes, blood sugars may drop rapidly after bariatric surgery. Medications often need to be reduced or stopped, alongside increased monitoring of blood
• Hypertension: Blood pressure will also decrease with weight loss. Weight loss will be more rapid in the initial weeks post-op due to reduced intake and medication should be adjusted accordingly.

This a condition that occurs when food moves too quickly from the stomach into the small intestine. It is often caused by high sugar foods and results in symptoms such as sweating, shaking, nausea, diarrhoea, facial flushing, and headache. These symptoms can occur within 30 minutes of food consumption (early dumping syndrome) or 1 to 3 hours after food (late dumping syndrome), which can be accompanied with low blood sugar.

There is no treatment for dumping syndrome, and it is recommended that patients make dietary/lifestyle changes to avoid the onset.

Recommendation: avoid food or fluids with more than 5g of sugar per 100g.

Guidance for people who become pregnant after bariatric surgery is in development

For further information and advice, refer appropriate patients as per the Tier 3 referral process. 

For details re Safe Haven see: NHS Highland Safe Haven (scot.nhs.uk) (NHS Highland intranet access required)

Supporting resources: 

• Specialist Weight & Health Service leaflet
• Bariatric surgery Frequently Asked Questions