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Post-operative care

Post-operative care and the general practitioner

Almost half of all patients are receiving inadequate nutritional support following gastric bypass
The majority of GPs feel ill equipped to manage bariatric surgery patients

Two years after bariatric surgery patients are discharged to their GP for lifelong follow up and although lifelong vitamin, calcium and B12 supplementation and an annual weight check is recommended following gastric bypass surgery (LRYGB), whether GPs adhere to the recommendations in unknown. The research was presented at the 6th Annual Meeting of the British Obesity and Metabolic Surgical Society 21-23 January, in Newcastle, UK. 

Simon Walker (University of Newcastle upon Tyne Medical School) and colleagues wanted to assess if patients maintained sustained weight loss following discharge from the bariatric centre and complied with the recommended dietary supplementation following discharge back to the GP.

 

Simon Walker

They contacted the GP of all patients (n=104) who had a LRYGB more than five years ago and the GP was asked to provide the most recent weight and list all current medications. Three patients had moved from the area and four GP’s refused to participate in the study leaving 97 (94%) for analysis.

The median length of follow up was 6.3 years and the total weight loss and percentage excess weight loss were; two year (32.2%/64.5%), three year (31.1%/62%), four year (27.3%/55.8%) and five year (27.9%/55.9%). Thirty-two patients (33%) had not been weighed in the last year, 22 patients had not been weighed in two years and 15 patients had never been weighed. 

Only 38 patients (40%) were receiving regular B12 injections and only 57 patients (61%) were receiving appropriate calcium supplementation.

“Medium term weight loss results are excellent…however a significant proportion of patients are receiving inadequate follow up from their GP’s,” said Walker. “One third of patients are not attending their GP for an annual weight check and some patients have never been weighed by their GP. Almost half of all patients are receiving inadequate nutritional support following gastric bypass. Should patients receive medium term review in a bariatric centre or should GP’s be doing more?”

Co-authors in this study were Maureen Boyle2, Kamal Mahawar2, William Carr2, Shlok Balupuri2, Peter Small2, Neil Jennings2 (1University of Newcastle upon Tyne Medical School, Newcastle upon Tyne, UK, 2Sunderland Royal Hospital, Sunderland, UK)

GPs knowledge

 Although an estimated 257,000 people in England could qualify for and accept bariatric surgery, less than 9,000 procedures were carried out in 2010-2011. Primary care is the access point to these services for patients and provides critical support afterwards. For the NHS to meet the increasing demand for bariatric services primary care involvement is crucial.

Jack Allport (University Hospitals Coventry and Warwick NHS Trust) and colleagues undertook a questionnaire of GPs to assess their knowledge of the referral process for bariatric services and postoperative care. GPs throughout the West Midlands, North East, North West and South West of England were invited to answer an electronic questionnaire.

Jack Allport

A total of 2,417 GPs responded to the questionnaire and 67% thought it was appropriate for patients with BMI>35 and related co-morbidities whereas only 46% thought it appropriate for BMI>50 and lower rates for lower BMIs or the absence of co-morbidities.

Some 49% felt the tiered service delayed surgery while two thirds supported centralisation of services. Ninety percent of GPs felt ill equipped by current guidelines to manage post-operative patients and only 30% knew of guidelines regarding blood tests.

Questions relating to specific post-operative management had a large spread of answers (liquid diet requirement: two weeks 23%, four weeks 37%, eight weeks+ 39%), as did the appropriate post-operative medication forms (liquid 76%, crushed 34%, chewable 24%, tablet 10%). Free text analysis showed GPs wanted more information about these patients with a preference for detailed discharge summaries, written guidelines and general obesity management study days.

“To ensure appropriate patients have access to bariatric services, GPs need further education and guideline dissemination,” said Allport. “The majority of GPs feel ill equipped to manage bariatric surgery patients. The importance of detailed plans in discharge letters is clear. GPs would also benefit from post-operative guidelines and overarching obesity study days.”

Co-authors of this study were, Hannah Adams2, Shameen Jaunoo2, Sarah Toomey3, Sarah Cairney2 (2Warwickshire Surgical Research Group, Warwickshire, UK, 3Heart of England NHS Foundation Trust, Birmingham, UK)

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