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Post Bariatric Surgery Questions

After pondering about potential topics for this month, I decided to focus on post op follow up concerns. I have tried to compile the most important questions patients have regarding follow up, medications and treatments after surgery and my responses to them.

First off, it is important to remember to never stop a medication abruptly unless advised to do so by the hospital, the primary provider, a specialist or our office. Surgery is not a miracle pill. A surgery does not warrant stopping needed medications. Initially, some may be stopped (such as some diabetic and blood pressure medications) but not all. The patient and his, her primary care provider and specialist must work together to decide when and if medications can be stopped SAFELY.

After Bariatric surgery, hypertensive medications may need to be adjusted. The patient must first monitor his, her blood pressure twice daily in assessment of lower (or higher) blood pressure. Initially patients are told to hold medication if BP is <140/90. This is for a good reason. If borderline on this number and a medication is inadvertently dosed, it could unsafely lower blood pressure causing untoward side effects such as dizziness, lightheadedness or even syncope (passing out). I will add that beta blocker (medications ending in an OLOL) dosages may need to be reduced but the patient must be careful about stopping these without a doctor’s supervision as this type of medication has other functions besides lowering BP. If a patient is in doubt about what medications to take or not take, he or she is advised to consult the primary care provider or specialist who manages the medications.

With diabetic medications, the patient is initially told to monitor FBS (fasting blood glucose) at least twice daily but more often if dosing insulin. This is to closely monitor particularly for hypoglycemia. A common OHA (oral hypoglycemic agent) used after surgery is metformin as it has been shown to work well with the post gastric bypass patient without drastically reducing blood glucose. Some diabetics who have been on insulin and medications for a long period of time will find that it may take some time before they are able to safely stop medications. A general rule of thumb is the threshold of 150. If a FBS is <150, patients are usually told not to dose any medication but if greater than 150, instructions are given. Sometimes a level of 200 is allowed for a short period but this is usually for only SHORT TERM. As with the blood pressure medication, diabetic medication must be closely monitored by the primary care physician and specialists. They are the folks who know the patient the best and thus can add back or delete medications according to FBS levels and lab work.

A common apparatus used by many overweight patients before and after surgery is either a cpap (continuous positive airway pressure) or bipap (inspiratory and expiratory pressure) machine with or without supplemental oxygen. If a patient is using this before surgery, he or she will need to continue use after surgery. As significant weight is lost, pressure needs will decrease. Our practice usually schedules patients for retesting after the 6 month post op visit; however, patients who are on a high setting of either cpap or bipap may need to have pressures decreased sooner. A good rule of thumb to remember is this: if the pressure is keeping one awake rather than allowing sleep it may be that the pressure is too high. If this is the case, the patient is advised to consult his or her sleep specialist for possible titration (raising or lowering) of pressures.

Hypothyroidism is a common finding in both pre and post op bariatric patients. If taking thyroid supplementation before surgery, this will need to continue after surgery. I usually advise patients to have levels checked about every 3-6 months for the first 1-2 years after surgery to monitor for over treatment. An early sign of over treatment may be heart palpitations (feeling like one’s “heart is beating out of one’s chest”). If this symptom appears and it has been several months or longer since labs, the patient is advised to follow up with his or her primary care provider or specialist. The BPD patient may be at increased risk of developing hypothyroidism after surgery due to metabolic processes that occur in the months and years following surgery. For information on this phenomenon, the reader can be referred to OBES SURG 2010 20:61-68. I usually advise the BPD patient to have labs checked semiannually but at least yearly to monitor for this and other abnormalities.

Lastly, I cannot stress the importance of taking vitamin supplementation daily. This is necessary for ALL patients but most specifically the sleeve, bypass and BPD/DS. The patient must remember that they are NOT systemically the same as before surgery and absorption rates vary from patient to patient and surgery to surgery. Hence, it is extremely important that vitamins are taken daily and levels are monitored. Our practice requires that labs be checked at least annually but I have found many primary care providers and specialists checking labs more frequently than this—about every 6 months. If a patient is found to have a deficiency and is being managed for that lab work may be as frequent as every 3-6 months.
Of course, there are many more things that could be mentioned though I have found that these are the most commonly discussed on the pre and post op visits. Bariatric Surgery has become safer and more effective as new guidelines and technology have been developed. It is important to choose a Center of Excellence setting to insure the safest, most up to date guidelines and complete follow up will be available to you. Follow up in a multi-disciplinary setting IS the foundation for success and safety with weight loss surgery.

Kristine Vanhoose, MSN, APRN, FNP-BC.

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