Information for health professionals

Should I refer my patient for weight loss/metabolic surgery?

Any referral for weight loss surgery needs to consider the potential benefits against the risks for patients. 


1) potential benefits

the main reason for referring is that a patient is suffering from a medical condition where weight is a signficant factor.  The most common indications include

  • diabetes
    • particularly in the first 7 years after diagnosis where there is signficant chance of inducing remission
  • osteoarthritis symtpoms
    • approximately 60% of patients will gain enough symtpom control that they can avoid or delay joint replacement surgery
  • metabolic syndrome
  • fatty liver disease not responding to lifestyle management
  • PCOS/infertility
  • in addition a lot of patients report increased energy levels and an improvement in their overall quality of life


2) potential drawbacks and issues to consider

  • surgical risks - weight loss surgery is major surgery and comes with operative risks.  Significant complications occur for example in 1-2% of patients undergoing sleeve gastrectomy, which is a similar complication rate to other surgery such as laparoscopic cholecystectomy. 
  • Is this the right time? 

Is the patient in a good place to in their life to succeed with lifestyle changes?  After weight loss surgery patients will lose weight over a 1 year period.  After this although it significantly easier to maintain the achieved weight loss, if the patient falls back into bad habits and fails to

  • Lifestyle/social changes 

living longer term with a smaller stomach size can impact socially in situations like going out for dinner, or if family meals are an important part of family celebrations.  It can be very helpful if the patient has discussed these changes with someone who has already had the surgery.  If they don't know anyone our rooms can help them connect with someone if they need to.

Follow up

All weight loss surgery patients should be monitored post operatively, and they succeed better if they are.  However the local and world wide trend is that up to 40% of patients never return to see their specialist.  We follow-up all our patients and contact them for annual reviews, but not all patients choose to participate in this.  We trust the following infomation is helpful if they turn up for review in their GP clinic.

Nutrition and vitamins

Multivitamin:  All weight loss surgery patients should be encouraged to use a multivitamin daily.  This is particularly important for patients who have had a gastric bypass, as they are slightly more prone to post operative nutritional defiencies.

Diet:  In the immediate post operative phase patients are advised to have a high protein diet.  After this adherance to a healthy diet is encouraged.

Annual review

The main aspects of an annual review include:

1) Weight check - if weight is going back on, patients should be encouraged not to panic, but to refocus on a healthy diet and regular exercise as weight regain is most easily arrested early.  It can be helpful to bring the patient back 2-3 months later for another weight check as a degree of monitoring can provide an external motivating factor.

2) Lifestyle check - checking that a healthy diet and some light but regular exercise is being undertaken.  A rough rule of thumb is exercising 4 times a week, with 2 sessions being aerobic exercise, and 2 sessions being anaerobic exercises. 

3) Blood tests.  Annual blood tests should include

  • FBC/EUC/LFTs
  • HbA1c/lipids.
  • Iron studies
  • thiamine, Vitamin B12, folate.
  • Vitamin A,D,E. 
  • Zinc

Common problems

Reflux:

Reflux is common after sleeve gastrectomy and one of the two gastric bypasses (single anastamosis, but not roux). 

  • Management is similar to normal reflux
  • use of over the counter medications as first line
  • use of PPI as second line
  • There are surgical options to treat reflux after weight loss surgery if the reflux is causing patients considerable morbidity. 

 

Gallstones:

With any weight loss, comes an increased risk of gallstones.  Whilst most general surgeons are comfortable treating gallstone disease, it is recommended that particularly for bypass patients they be referred back to their bariatric surgeon.  This is because it is relatively straightforward for the orginal bariatric surgeon to reassess the bypass during cholecystectomy, assess for other causes of abdominal pain, and because stones in the bile duct may need operative intervention as ERCP is often not feasable after a bypass. 


Abdominal pain:

Abdominal pains occur in about 5% of bypass surgery patients.  This can be anything ranging from gallstones, to ulcers or internal hernias.  Rereferral to their orginal surgeon is usually indicated.

Has my surgery been a success?

Many patients worry that their surgery may not have been a success.  This is most often the case when they didn't have clear goals pre surgery.


Success can be measured in different ways

  • the most improtant is whether or not they have had resolution or improvement in their weight related medical conditions
  • Health benefits are obtained for most medical conditions if patients lose 10% of their pre surgery weight.
  • On average, patients in Australia lose 25% of their presurgery weight.  This can be less in older patients, and patients on drugs that are known to be obesogenic.

Clinic
Location

ADDRESS 33 Etna Street
Gosford 2250 NSW

ADDRESSKanwal Medical Complex
STE c 16/654 pacific hwy,
hamlyn TRC NSW 2259