Bariatric surgery is indicated for certain high-risk patients who have clinically severe obesity. A key aspect of care for the post-bariatric surgery patient population is addressing non-surgical aspects of perioperative care, most notably nutritional and metabolic support. Clinical endocrinologists can and should play a central role in assisting bariatric surgery patients with this support and in making decisions on the most appropriate bariatric operation to select.
A multidisciplinary team approach has been emphasized in the care of patients with metabolic diseases, including obesity, but this emphasis has not been as strong for patients undergoing or considering bariatric surgery. Clinical endocrinologists have been largely underutilized in bariatric surgery. However, these specialists can be of great assistance by:
Helping manage the causes and complications of obesity.
Discussing surgical risks and benefits, procedural options, and choices of surgeon and medical institution.
Providing patients with education and guidance throughout the course of treatment.
Nutritional Evaluation Before Bariatric Surgery
According to guideline recommendations, all patients considering bariatric surgery should undergo an appropriate nutritional evaluation, including selective micronutrient measurements, before any procedure is performed. Clinical endocrinologists can help during this phase of treatment, especially for malabsorptive procedures in which more extensive perioperative nutritional evaluations are required. They can also assist patients during their protocol-derived staged meal progression based on the type of surgical procedure that is selected.
Patient education on nutrition and meal-planning guidance before bariatric surgery and during the early postoperative hospital course is critical. This education can be reinforced during future outpatient visits. Additional education can be given on a balanced meal plan; appropriate intake of protein, nutritional supplements, and fluids; and parenteral nutrition, if necessary.
Managing Diabetes Postoperatively
In addition to monitoring weight loss, clinical endocrinologists can be a great asset to the bariatric surgery team by assisting patients with metabolic and nutritional management (see also, Bariatric Surgery for Diabetes: Significant Benefits Observed). They can routinely monitor patients—especially those with type 2 diabetes, hyperlipidemia, or hypertension—with continued surveillance and provide appropriate screenings as recommended by guidelines. Patients can be assessed for the possibility of postoperative abnormalities of the endocrine system, especially when malabsorptive surgical procedures are performed in individuals with nutritional deficiencies. Clinical endocrinologists can also further support the efforts of other healthcare providers by promoting physical activity and encouraging patients to participate in ongoing support groups after they are discharged.
Regardless of the discipline of the professional guiding the initial evaluation, it is paramount for patients to be well informed. This educational process can be accomplished through the use of support groups and counseling sessions with members of the bariatric surgery team, including clinical endocrinologists. Unfortunately, there is a national shortage of physicians with expertise in nutritional medicine, which complicates the management of this expanding patient population. To revolutionize management paradigms, greater involvement of clinical endocrinologists is necessary. Continued attention and research are needed from clinical endocrinologists to focus on important issues in bariatric surgery, including gastric banding for mild obesity, surgery for treatment of diabetes, sleeve gastrectomy, metabolic bone disease, and complicated nutritional and metabolic consequences.
Readings & Resources (click to view)
Mechanick JI. Bariatric surgery and the role of the clinical endocrinologist: 2011 update. Endocr Pract. 2011;17:788-797. Available at: http://aace.metapress.com/content/p57m0142t25651j8/.
Mechanick JI, Kushner RF, Sugerman HJ, et al; American Association of Clinical Endocrinologists; Obesity Society; American Society for Metabolic & Bariatric Surgery. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Obesity (Silver Spring). 2009;17(Suppl 1):S1-S70. Available at: http://www.nature.com/oby/journal/v17/n1s/full/oby200928a.html.
Handelsman Y, Mechanick JI, Blonde L, et al; and the AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of diabetes mellitus. Endocr Pract. 2007;3(Suppl 1):1-68.
Vora AC, Saleem TM, Polomano RC, et al. Improved perioperative glycemic control by continuous insulin infusion under supervision of an endocrinologist does not increase costs in patients with diabetes. Endocr Pract .2004;10:112-118.