Surgical Followup

The surgical team sees a patient fairly frequently in the early time period after surgery.  As the patient recovers the time interval tends to stretch out so that in the long run the patient is seen annually (and as needed) for life.  Note that Band patients are seen very frequently for Band adjustments in the first few months.

This is a simplified outline of the usual course of follow up for patients who undergo surgery with New Dimensions.

Usual Appointment Schedule

• 2 weeks after surgery: surgeon visit
• 6 weeks after surgery: surgeon plus dietician
• 4 months after surgery:  surgeon plus dietician.  Labs are usually drawn before the appointment so that results may be reviewed in person at the appointment.
• 8-10 months after surgery.  Labs preceding appointment, and prn to monitor deficiencies.
• 16-18 months after surgery.  Labs preceding appointment, and prn to monitor deficiencies.
• Annually and as needed for life.  Labs preceding appointment, and prn to monitor deficiencies.
• Band adjustments, as indicated.  Patients may undergo Band adjustment at one week intervals.  Adjustment is done by the surgeon or Physician Assistant.  Band adjustments may begin as early as the 2 week appointment, and the Band is usually “tuned” to each patient by 2-3 months post-op.

We are also providing copies of the instructions that we give to patients after surgery, as follows:

Gastric Bypass instructions, 2 weeks after surgery

Gastric Bypass instructions, 6 weeks after surgery

Gastric Bypass instructions, 16 weeks after surgery

Gastric Band instructions, 2 weeks after surgery

Gastric Band instructions, 6 weeks after surgery

Gastric Band instructions, 16 weeks after surgery

Usual Follow up Labs and other studies

These tests are usually arranged by the New Dimensions team; this is provided for patients and their physicians who may be interested.

• Complete Metabolic Profile, plus Magnesium
• CBC
• B12 and folate
• Iron level, Ferritin
• PTH, Vitamin D (25 –OH) levels
• Lipid profile, thyroid studies, or HgbA1C may be done, if these are pertinent to pre-operative conditions
• A DEXA bone density scan may be useful, though no formal guidelines have been published.  A baseline study is probably useful, with a follow up study about 1 year after surgery.  It is not clear what the subsequent interval ought to be.

Recommended supplements

The following recommendations apply to all patients, regardless of which operation they have undergone.  Although some of the operations do not create any malabsorption, our experience has been that patients can develop deficiency states from the very low overall intake caused by any bariatric surgical procedure.  For this reason and to improve compliance through uniform teaching, supplement recommendations are the same for all patients:

• Multivitamin plus Iron, 1 twice each day.  Usually this is taken first thing in the morning and last thing at night, to avoid absorption problems related to calcium (see below).
• Calcium Citrate plus Vitamin D, 1 three times per day at mealtimes.  Note that calcium interferes with absorption of Iron, some vitamins, and many medications.  The good news is that calcium absorbs very well with food.  Therefore, taking the calcium at mealtime is a convenient regimen which is also effective.  Also note that this does NOT mean that a patient must eat to take calcium – if a patient is not hungry then they should not eat at that time.  Designating calcium for mealtime is simply a convenient way to organize and remember.  There are many different dose formulations of Ca Citrate on the market – we are satisfied if a patient takes one tablet or chewable tid, and we don’t believe the exact dose is as important.
• B12 sublingual, 1 daily.
• Fiber, 1 Tbsp twice each day.  This is not usually started until about 3 months post-op, because it is too much “load” for the stomach pouch in the early time period.  We find that the powdered forms of fiber seem more reliable than the tablets.  Fiber is recommended because all bariatric surgical patients tend toward constipation that is probably related to decreased bulk in the diet.  (Note that patients also tend to run a bit dehydrated, so we want to be sure they stay well hydrated as well).

Medication Management after bariatric surgery

Medications for diabetes are usually stopped within the first days or weeks after surgery, especially if the patient has undergone gastric bypass.  Anti-hypertensive medications (for blood pressure) can usually be weaned down or off over 2-4 months - the New Dimensions team prefers if the primary physician manages changes in blood pressure meds.  CPAP (if sleep apnea is present) can usually be discontinued 2-4 months after surgery (we recommend re-testing for apnea).

NSAID’s (aspirin, ibuprofen, and all related medications) should be avoided for life after either operation, because the mucosal weakening effect caused by NSAID’s is more significant in the setting of surgically modified anatomy – GI bleeding from an ulcer is a significant risk if NSAID’s are taken.  Usually Celebrex is OK.

Diuretics should be used with care.  In particular, K-wasting diuretics lead to a risk of profound hypokalemia because the patient’s overall intake is so dramatically decreased.

Essentially all other medications can be taken normally, and are handled normally by the gut and the rest of the system.  In our experience, some dose adjustment of thyroid replacement may be required.

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