Laurie Barclay, MD

November 9, 2010 — An Endocrine Society Clinical Practice Guideline discusses postbariatric surgery management and recommends multidisciplinary care, according to new recommendations reported online November 8 in the Journal of Clinical Endocrinology & Metabolism.

"We sought to provide guidelines for the nutritional and endocrine management of adults after bariatric surgery, including those with diabetes mellitus," write David Heber, from the David Geffen School of Medicine at University of California Los Angeles, and colleagues. "The focus is on the immediate postoperative period and long-term management to prevent complications, weight regain, and progression of obesity-associated comorbidities. The treatment of specific disorders is only summarized."

A task force chair, 5 additional experts, a methodologist, and a medical writer prepared this guideline without corporate funding or remuneration. Their conclusions were that bariatric surgery does not guarantee successful weight loss and maintenance but, rather, that patients increasingly tend to regain weight. This is especially true after restrictive bariatric surgeries such as laparoscopic banding, rather than after malabsorptive surgeries such as Roux-en-Y bypass. After bariatric surgery, all patients should undergo active nutritional patient education and clinical management to prevent and identify nutritional deficiencies.

"Management of potential nutritional deficiencies is particularly important for patients undergoing malabsorptive procedures, and strategies should be employed to compensate for food intolerance in patients who have had a malabsorptive procedure to reduce the risk for clinically important nutritional deficiencies," the task force writes. "To enhance the transition to life after bariatric surgery and to prevent weight regain and nutritional complications, all patients should receive care from a multidisciplinary team including an experienced primary care physician, endocrinologist, or gastroenterologist and consider enrolling postoperatively in a comprehensive program for nutrition and lifestyle management. Future research should address the effectiveness of intensive postoperative nutritional and endocrine care in reducing morbidity and mortality from obesity-associated chronic diseases."

Specific Recommendations
Specific recommendations in the guideline for postbariatric surgery management are as follows:

• To prevent and treat weight regain, a technically proficient surgical team, preferably accredited by a national certifying organization, and an integrated medical support team offering dietary education and behavior modification, should be available after surgery and during long-term follow-up.
• Postoperative treatment of weight regain should be multidisciplinary, including diet instruction, increased physical activity, behavior modification, and pharmacologic therapy.
• If postoperative weight gain is severe or unremitting, the clinician should determine whether the surgery is still anatomically intact (eg, absence of gastrogastric fistula after Roux-en-Y bypass, integrity of band after a restrictive procedure). If not intact, the multidisciplinary team should consider patient education, behavioral modification, additional weight loss treatment, and/or referral for revisionary surgery.
• Postoperative nutritional management should include average daily protein intake of 60 to 120 g to maintain lean body mass during weight loss and for the long term. Although recommended for all patients, this is especially needed to prevent protein malnutrition and its effects in patients who underwent malabsorptive procedures.
• To prevent nutritional deficiencies, long-term vitamin and mineral supplementation should be considered in all patients, particularly those who had malabsorptive procedures.
• To detect micronutritional and macronutritional deficiencies, patients should undergo periodic clinical and biochemical monitoring after bariatric surgery.
• To manage diabetes mellitus and lipid metabolism, postoperative glycemic control should achieve glycated hemoglobin level of 7% or less, fasting blood glucose level of 110 mg/dL or less, and postprandial glucose level of 180 mg/dL or less. Physicians and floor nurses should be familiar with glycemic targets, insulin protocols, and the use of dextrose-free intravenous fluids and low-sugar liquid supplements.
• Obese patients with type 1 diabetes should receive scheduled insulin therapy as needed during hospitalization.
• The National Cholesterol Education Program guidelines (Adult Treatment Panel III) should be used to treat lipid abnormalities. If low-density lipoprotein cholesterol and triglyceride levels remain above desired goals after surgery, existing lipid-lowering therapy should be continued.
• Patients who have undergone malabsorptive procedures should have postoperative vitamin D and calcium supplementation, with doses adjusted based on monitoring of vitamin D, calcium, phosphorus, parathyroid hormone, and alkaline phosphatase levels every 6 months, and annual dual-energy x-ray absorptiometry until stable.
• Patients with frequent gout attacks should have prophylactic treatment to reduce the risk for acute gout as they lose weight postoperatively.
• Bariatric surgery patients should be discharged only if they are satisfactorily tolerating oral fluids. Particularly after gastric restrictive procedures, food consistency should gradually be increased for weeks to months to allow patients to adjust to a restrictive meal plan and to reduce vomiting.
• Symptoms associated with dumping include abdominal pain and cramping, nausea, diarrhea, lightheadedness, flushing, tachycardia, and syncope. To reduce the frequency of these symptoms, new nutritional habits discouraging consumption of simple carbohydrate-dense foods and beverages should be continually reinforced.
• Patients with neuroglycopenic symptoms or other postprandial symptoms of hypoglycemia should be further evaluated for possible insulin-mediated hypoglycemia.

Conclusion
"[T]reatment of diabetes and metabolic disease through surgical intervention requires greater study," the task force authors conclude. "The scientific rationale for the approach is sound, but questions remain pertaining to long-term outcome and the possible occurrence of nesidioblastosis after gastric bypass. These issues and the impact on overall mortality in diabetes deserve much more attention in future clinical research."

Some of the task force members have disclosed various financial relationships with Herbalife International, the Medical Nutrition Council, the American Society for Nutrition, ABIC International Consultants, BAROnova, Basic Research Inc, Catalyst Pharmaceutical Partners, General Nutrition Corp, Health and Nutrition Technology, Lipothera, Nastech Pharmaceuticals, Orexigen Therapeutics, GlaxoSmithKline, Leptos Biomedical, Novo Nordisk, Schering-Plough Research Institute, Jenny Craig, Merck Research Labs, GI Dynamics, Johnson & Johnson, Davol, Stryker Development, Gelesis, Blue Cross & Blue Shield, Ethion-Endosurgery, the Obesity Action Coalition, Surgical Review Corp, and/or ABPNS American Board of Physician Nutrition Specialists.
J Clin Endocrinol Metab. Published online November 8, 2010.

Authors and Disclosures
Journalist
Laurie Barclay, MD
Freelance writer and reviewer, Medscape, LLC

Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.