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Bariatric surgery: Postoperative and long-term management

of the uncomplicated patient
Author: Giselle Hamad, MD
Section Editor: Daniel Jones, MD
Deputy Editor: Wenliang Chen, MD, PhD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Sep 2020. | This topic last updated: Jul 03, 2019.

INTRODUCTION

Obesity, a chronic illness identified in children, adolescents, and adults, has reached epidemic
proportions worldwide [1-4]. In the United States alone, 39.8 percent of adults and 18.5 percent of
youth are obese [5-7], and the rate of obesity has more than doubled since 1990 [8,9]. Worldwide, the
rate of obesity has tripled between 1975 and 2016; more than 39 percent of adults and more than 18
percent of children in the world are obese or overweight [10].

Bariatric surgery, a commonly performed procedure in the United States [11], remains the most
effective method of weight loss and can result in partial or complete resolution of multiple obesity-
related comorbidities, including type 2 diabetes mellitus, hypertension, hypercholesterolemia, and
obstructive sleep apnea [12].

The immediate postoperative care for the uncomplicated postsurgical patient and outpatient
management of all bariatric surgical patients will be discussed in this topic. The indications and types
of bariatric procedures, complications, management of complicated postoperative patients (eg,
multiple or refractory comorbidities) in the intensive care unit, and outcomes are reviewed separately:

● (See "Bariatric procedures for the management of severe obesity: Descriptions".)

● (See "Bariatric operations: Perioperative morbidity and mortality".)

● (See "Bariatric surgery: Intensive care unit management of the complicated postoperative
patient".)

● (See "Outcomes of bariatric surgery".)

IN-HOSPITAL POSTOPERATIVE CARE

The typical transfers for patients with an uncomplicated preoperative and intraoperative course are
from the operating room to the post-anesthesia unit to the inpatient surgical floor. However,
admission to a unit that can provide continuous cardiac and oxygen saturation monitoring for 24 to 48
hours is standard for patients with a history of cardiac arrhythmias or coronary artery disease and/or
chronic obstructive pulmonary disease (COPD), sleep apnea, and/or asthma.

Surgical Intensive Care Unit (SICU) monitoring is rarely necessary following a bariatric operation unless
the patient has complicated or refractory comorbid illnesses or the operation was complicated with a
large amount of blood loss, cardiac instability, or the need for prolonged intubation. (See "Bariatric
surgery: Intensive care unit management of the complicated postoperative patient".)

Post-anesthesia care unit — Most stable patients undergoing a bariatric operation, including those
patients without complicated preoperative comorbidities, are admitted to the post-anesthesia care
unit (PACU) immediately at the conclusion of the operation. PACU management is reviewed separately.
(See "Anesthesia for the obese patient", section on 'Post-anesthesia care unit management'.)

Surgical floor inpatient management — After anesthetic and surgical management in the PACU is
completed, most patients are transferred to the inpatient surgical postoperative unit. For the next 24
hours, the postoperative priorities include control of pain, nausea and/or vomiting, intravenous fluid
management, pulmonary hygiene, and ambulation. Pain is controlled with oral oxycodone elixir.
Incentive spirometry is encouraged to reduce atelectasis. Oxygen is administered by nasal cannula in
the PACU and weaned thereafter. Patients with obstructive sleep apnea are managed with continuous
positive airway pressure (CPAP) [13].

Patients are typically maintained with nil per os (NPO) and intravenous fluids. Urine output is
monitored overnight. Ambulation is encouraged beginning on the night of surgery. Antiemetics such
as ondansetron are given as needed. On postoperative day (POD) 1, a basic metabolic profile (eg,
electrolytes, renal function blood tests) and a complete blood count are obtained. (See "Management
of acute perioperative pain".)

Radiographic studies — Routine use of upper gastrointestinal (UGI) series is controversial [14-18].

Surgeons who routinely await radiologic confirmation of anastomotic integrity before starting a diet
contend that clinical signs may not predict a leak [15] and that routine imaging may identify a leak
earlier [17]. Conversely, opponents of routine UGI imaging argue that anastomotic leak is uncommon
[14,18] and that UGI has low sensitivity for detecting leaks [16]. Furthermore, there is evidence that the
vast majority of staple line leaks after a sleeve gastrectomy (SG) are not diagnosed on routine
postoperative UGI series; instead they present clinically in 10 to 14 days after the patient is already
discharged [19,20].

Postoperative imaging studies and early complications following bariatric operations are reviewed
elsewhere. (See "Imaging studies after bariatric surgery" and "Bariatric operations: Perioperative
morbidity and mortality".)

Reoperation — For patients who have an anastomotic leak or obstruction identified in the early
postoperative period, an immediate return to the operating room for an exploration and revision is
warranted.
 ● Respiratory distress – Subtle indications of respiratory distress in the first few hours to days after
bariatric surgery may reflect the respiratory compensation to lactic acidosis, which is induced by
substantial tissue hypoperfusion and may be an early sign of an impending abdominal
catastrophe [21].

● Sustained tachycardia – For patients who have undergone a Roux-en-Y gastric bypass (RYGB) or
an SG and who develop sustained tachycardia of greater than 120 beats per minute without a
cardiac event, an anastomotic leak must be suspected [22]. There should be no delay in exploring
these patients; a negative exploration is preferable to an undiagnosed leak and the potential for
disastrous sequelae. One should not dismiss tachycardia; a leak may be present despite the
absence of fever, leukocytosis, abdominal pain, or abdominal tenderness.

● Persistent vomiting – Persistent vomiting in the early postoperative period after RYGB is not
routine. If there is bilious vomiting or dilated small bowel on radiographic studies (eg, abdominal
films), a technical complication causing the obstruction is highly likely, and the patient should be
re-explored promptly [23,24]. (See "Bariatric operations: Perioperative morbidity and mortality".)

Venous thromboembolism — Most bariatric surgery patients are considered high risk for venous
thromboembolism (VTE) given the prevalence of risk factors that promote VTE, including obesity,
obstructive sleep apnea/hypoventilation syndrome, and exposure to general anesthesia.

Nevertheless, there is considerable variability among bariatric surgeons in the approach to

thromboprophylaxis because of a lack of consensus regarding the optimal thromboprophylaxis
strategy for this population [25,26]. The current American Society of Bariatric and Metabolic Surgeons
(ASMBS) guidelines regarding VTE prophylaxis state that all bariatric patients receive mechanical
prophylaxis and are recommended to ambulate early in the postoperative period. Additionally, the
surgeon may routinely utilize chemical prophylaxis consisting of either low-molecular-weight heparin
[27] or unfractionated heparin [28]. (See "Bariatric surgery: Intensive care unit management of the
complicated postoperative patient", section on 'Anticoagulant dosing'.)

Patients who are considered at a higher level of risk for VTE, such as patients with hypercoagulable
disorders, history of previous VTE, or body mass index greater than 60 kg/m2, may be considered for
extended administration of VTE prophylaxis [29]; there is no consensus regarding indications for
extended prophylaxis for patients undergoing bariatric surgery [30-32].

Prevention of postoperative VTE is reviewed in detail separately. (See "Prevention of venous

thromboembolic disease in adult nonorthopedic surgical patients".)

Diabetes mellitus — For patients with diabetes, serum glucose is monitored every six hours during
the hospital admission with a goal of maintaining glucose levels between 140 and 180 mg/dL [33].
Close glucose monitoring is necessary after discharge, especially following RYGB, because of the risk of
developing hypoglycemia after RYGB [34]. Preoperative classes are generally offered in bariatric
centers to familiarize patients with a glucometer and insulin administration. Signs, symptoms, and
treatment of hypoglycemia and hyperglycemia are discussed. The protocols for managing diabetes
after bariatric surgery vary between centers. (See "Overview of general medical care in nonpregnant
adults with diabetes mellitus" and "Outcomes of bariatric surgery", section on 'Diabetes mellitus'.)
POSTOPERATIVE CARE AFTER DISCHARGE

Patients undergoing a laparoscopic adjustable gastric band (LAGB) operation are typically discharged
home on the first postoperative day, while patients undergoing laparoscopic Roux-en-Y gastric bypass
(RYGB) or sleeve gastrectomy (SG) are discharged on postoperative day 2, providing that they are
tolerating a clear liquid diet. Patients who have an open procedure remain hospitalized for a day or
two longer, or until they are able to tolerate a liquid diet and ambulate.

Hydration — Patients must be educated preoperatively so that they know what to expect

postoperatively, and this includes hydration. Fluid intake after discharge should be emphasized
because of the vicious cycle of dehydration and nausea that often results in emergency room visits for
dehydration.

Nutrition and supplementation — Within the first 14 days after bariatric surgery, vitamin and
mineral supplementation consists of a daily multivitamin for all patients [35]. Additional vitamin
supplementation can be offered to RYGB and SG patients at the discretion of bariatric surgeons
[36,37]. (See "Bariatric surgery: Postoperative nutritional management", section on 'Micronutrient
deficiency, supplementation, and repletion'.)

In our practice, we recommend additional routine supplementation for RYGB patients with oral
Vitamin B12 500 micrograms daily, Vitamin C 500 mg daily (taken with iron), calcium carbonate or
citrate 500 mg twice a day, and ferrous sulfate 325 mg daily [38-40]. Calcium and iron supplementation
should not be administered simultaneously.

SG patients should receive additional Vitamin B12 and iron supplementation [41]. Both RYGB and SG
patients are at risk of Vitamin D deficiency and require routine supplementation with Vitamin D3 2000
international units daily [42,43].

Diet — The dietary regimen depends upon the type of bariatric procedure performed. All patients
are advised to avoid concentrated sweets and to avoid carbonation and straws when drinking liquids
to minimize gastric bloating. (See "Bariatric surgery: Postoperative nutritional management", section
on 'Diet and texture progression'.)

● For patients undergoing an RYGB or SG procedure, they are instructed to limit oral intake to clear
liquids for the first two weeks after discharge. They should consume 64 ounces (1.89 liters) of clear
liquids daily since dehydration is a common reason for readmission. Patients are then advised to
consume a pureed diet or full liquids for the next two weeks, then a soft diet for two months. At
the third postoperative month, the patients are advanced to a regular diet.

● For patients undergoing an LAGB procedure, they are instructed to consume clear liquids for one
week. The diet is advanced on a weekly basis from full liquids to a pureed diet and then to a soft
diet for a week. They are then advanced to a regular diet.

Vitamin K — For those patients requiring warfarin, close monitoring of prothrombin time and
International Normalized Ratio (INR) is required when restarting warfarin postoperatively because of
the tendency for these patients to become coagulopathic. This may be secondary to altered
pharmacokinetics or pharmacodynamics, medication interactions, or an alteration in the absorption,
intake, or storage of vitamin K [44]. Prothrombin time and INR should be obtained daily until the
values stabilize.

The interaction of vitamin K and warfarin and the management of warfarin as an outpatient are
reviewed separately:

● (See "Overview of vitamin K".)

● (See "Warfarin and other VKAs: Dosing and adverse effects".)

● (See "Management of warfarin-associated bleeding or supratherapeutic INR".)

● (See "Biology of warfarin and modulators of INR control".)

Activity restrictions — Patients must refrain from working for one to two weeks following an LAGB
operation and for two to four weeks following an RYGB and SG operation. Patients may shower but are
instructed not to soak in a bathtub. They are also advised to avoid heavy housework and may not lift
more than 10 pounds.

Medications — Patients are sent home with liquid oxycodone. They may take oral acetaminophen to
reduce opiate utilization. Patients are advised not to drive a motor vehicle or operate heavy machinery
while taking pain medication. RYGB patients must not take ibuprofen, naproxen, or other anti-
inflammatory medications because of the risk of marginal ulcer development [45]. They are not
permitted to take aspirin unless they have a vascular or coronary stent or a prior cerebrovascular
accident. Those who need to take aspirin or prednisone for medical conditions should also take a
proton pump inhibitor to prevent marginal ulcers [46]. RYGB patients should crush tablets or take
liquid medications. They may not crush extended-release medications or open capsules [47].

Warning signs of potential complications — Patients should notify their surgeon for a temperature
greater than 100.5°F (38.1°C), severe abdominal pain, redness around the incisions, drainage from the
incisions, vomiting, chest pain, shortness of breath, or severe pain, warmth, or redness in the calf.

Follow-up schedule — Follow-up schedules vary among bariatric surgeons. In the absence of

postoperative complications, postoperative follow-up is determined by the type of procedure. For
example:

● Patients who had an RYGB or SG are scheduled for routine office visits at two and four weeks
following discharge; then at 3, 6, and 12 months; then annually.

● Patients undergoing an LAGB are seen in the outpatient office two and six weeks after discharge,
then every four to six weeks for the first year. If the patient is doing well by six months, the interval
between visits is increased to 8 to 12 weeks. After the first year, patients are seen every six months
if they have no complications and are compliant with the diet plan. If a patient is not doing well,
they will be advised to keep a food journal and return in two weeks, followed by monthly visits.

LONG-TERM MANAGEMENT
Bariatric surgical patients require lifelong follow-up visits. Ongoing monitoring of body weight and
compliance with the postsurgical regimen is necessary for long-term success and micronutrient
deficiency detection [38,48,49].

Long-term, all patients are encouraged to drink water and to avoid carbonation and straws because of
the risk of gastric bloating. Caffeinated beverages should be avoided because of the diuretic effect
[50]. Processed snack foods and sweetened beverages are discouraged because they increase calorie
intake unnecessarily.

Consumption of lean protein sources is encouraged. The need for vitamin and mineral
supplementation should be reinforced at every visit to avoid micronutrient deficiencies [51]. Routine
exercise should be encouraged [52,53]; walking is an appropriate way to start exercising. Patients with
degenerative joint disease may benefit from aquatic exercise to reduce joint pain.

Multidisciplinary team — Nurses and advanced practice providers assist the bariatric surgeon in
addressing postoperative questions and concerns and can triage a patient who presents with a
potential complication. A registered dietitian can optimize results by reinforcing the bariatric dietary
regimen [54]. Free monthly support groups are offered and are attended by both preoperative and
postoperative bariatric surgery patients. Our team also offers cooking classes, exercise classes, and
behavioral therapy. (See "Bariatric operations for management of obesity: Indications and
preoperative preparation", section on 'Preoperative assessment'.)

Assessment and management of changes in comorbid diseases — Comorbidity status is routinely

assessed at every postoperative visit, including hypertension, diabetes, metabolic deficiencies,
hyperlipidemias, and sleep apnea. However, there is variability in the frequency and type of testing
ordered among bariatric surgeons. Medication changes are typically managed by the primary care
physician or specialist (eg, cardiologist, endocrinologist).

Medical outcomes after a bariatric operation are reviewed elsewhere (see "Outcomes of bariatric
surgery", section on 'Metabolic effects'):

● Hypertension has been closely linked to obesity. Blood pressure is routinely measured at every
postoperative visit to monitor response to the operation, and antihypertensive medications are
reviewed. (See "Overweight, obesity, and weight reduction in hypertension".)

● Diabetes is effectively treated by bariatric surgery, and the need for insulin and/or oral
hyperglycemics should be evaluated on each visit in the early postoperative time frame. HgA1C is
followed to monitor diabetes severity, and changes in diabetic medications are reviewed. (See
"Bariatric surgery: Postoperative nutritional management" and "Management of persistent
hyperglycemia in type 2 diabetes mellitus".)

● Metabolic deficiencies can be created by Roux-en-Y gastric bypass (RYGB) and are monitored by
laboratory evaluations that include serum calcium, iron, vitamin B12, vitamin D, folate, and
thiamine every six months for the first two years, then annually. (See "Bariatric surgery:
Postoperative nutritional management", section on 'Micronutrient management'.)
 ● Hyperlipidemia is monitored by evaluation of serum lipids and cholesterol and any medication
adjusted accordingly. (See "Management of low density lipoprotein cholesterol (LDL-C) in the
secondary prevention of cardiovascular disease".)

● Sleep apnea may be reassessed with a sleep study in 6 to 12 months after surgery to reassess the
continuous positive airway pressure (CPAP) requirement. (See "Management of obstructive sleep
apnea in adults" and "Clinical presentation and diagnosis of obstructive sleep apnea in adults".)

● Gastroesophageal reflux and dysphagia should be evaluated in patients who had a laparoscopic
adjustable gastric banding (LAGB) or sleeve gastrectomy. For those with persistent reflux,
vomiting, or abdominal pain, an upper gastrointestinal (UGI) study may be indicated to evaluate
for band slippage, gastric prolapse, esophageal dilatation, esophageal dysmotility, or gastric
obstruction [55]. Upper endoscopy should be performed to rule out esophagitis, Barrett’s
esophagus, or band erosion [56]. (See "Medical management of gastroesophageal reflux disease
in adults" and "Complications of gastroesophageal reflux in adults" and "Surgical management of
gastroesophageal reflux in adults".)

Additional comorbid illnesses that may develop long-term (more than 30 days) following bariatric
surgery are described in a separate topic and include (see "Late complications of bariatric surgical
operations"):

● Dumping syndrome is assessed for patients who had undergone an RYGB procedure, which is
particularly evident after patients consume sweet foods [57]. This may result in tachycardia,
abdominal pain, diaphoresis, nausea, vomiting, diarrhea, and, later, hypoglycemia [58]. These
patients should be counseled to take dietary measures to avoid the triggering food or drink. (See
"Postprandial (reactive) hypoglycemia", section on 'Alimentary hypoglycemia'.)

● Marginal, or gastrojejunal, ulcers occur in up to 25 percent of RYGB patients and typically

present with epigastric pain and nausea. Risk factors include tobacco, aspirin, and nonsteroidal
anti-inflammatory medications (NSAIDs) [45,59]. Treatment consists of proton pump inhibitors,
sucralfate, and discontinuation of the offending agents. If severe, marginal ulcers may be
complicated by gastrointestinal (GI) bleeding or perforation. Prophylactic protein pump inhibitors
have been advocated for ulcer prevention [46,60]. (See "Imaging studies after bariatric surgery"
and "Postgastrectomy complications".)

● Cholelithiasis is a common cause of upper abdominal pain after bariatric surgery because of a
change in bile composition [61]. In addition, rapid weight loss promotes gallstone formation
[62,63]. Patients who still have their gallbladders are started on ursodeoxycholic acid (ursodiol)
300 mg orally twice a day for six months to prevent gallstone formation [62]. (See
"Choledocholithiasis: Clinical manifestations, diagnosis, and management".)

● Nephrolithiasis is identified in approximately 8 percent of RYGB patients [64]. RYGB patients are
prone to an increase in oxaluria that can promote kidney stones and can progress to oxalate
nephropathy and renal failure [65,66]. Therefore, patients should be counseled to avoid dietary
oxalate. (See "Diagnosis and acute management of suspected nephrolithiasis in adults" and
"Options in the management of kidney and ureteral stones in adults".)
 ● Depression may be a preoperative comorbid illness or present as a postoperative manifestation.
The bioavailability of serotonin reuptake inhibitor antidepressant medications is reduced after
RYGB [67]; therefore, patients with mental illness may be at risk for exacerbation of depressive
symptoms and should be monitored closely after RYGB. (See "Screening for depression in adults"
and "Unipolar depression in adults: Assessment and diagnosis".)

● Stenosis following a sleeve gastrectomy (SG) can lead to gastric outlet obstruction and present as
dysphagia or vomiting [68]. This is diagnosed by a UGI study and may be managed with
endoscopic dilation. Surgical revision may be required if endoscopic management fails [69]. (See
"Imaging studies after bariatric surgery" and "Endoscopy in patients who have undergone
bariatric surgery".)

● Unexplained abdominal pain can occur in any patient after an intra-abdominal operation. For
patients who have had an RYGB procedure and present with unexplained abdominal pain, there
should be a low threshold for offering surgical exploration, which may be approached
laparoscopically, to identify an occult internal hernia, intussusception, or small bowel obstruction,
even if physical examination is impressive and imaging studies are unrevealing. (See "Imaging
studies after bariatric surgery" and "Evaluation of the adult with abdominal pain" and "Causes of
abdominal pain in adults".)

Improvements in physical function — Bariatric surgery results in complete or partial resolution of

multiple medical comorbidities as well as an improvement in quality of life [70-72]. Weight loss
promotes an increased level of physical activity [73]. Exercise regimens are discussed, and patients are
encouraged to incorporate both cardiovascular exercise and resistance training on a regular basis.
Patients may elect to undergo body contouring surgery when their weight is stable to address hanging
skin on the abdomen, buttocks, breasts, arms, and legs.

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions around the
world are provided separately. (See "Society guideline links: Bariatric surgery".)

SUMMARY AND RECOMMENDATIONS

● For the first 24 hours after the bariatric operation, the postoperative priorities include control of
pain, nausea and/or vomiting, intravenous fluid management, pulmonary hygiene, and
ambulation. (See 'Surgical floor inpatient management' above.)

● For patients who have an anastomotic leak or obstruction identified in the early postoperative
period, an immediate return to the operating room for an exploration and revision is warranted.
Sustained tachycardia over 120 beats per minute may be the presenting symptom of an intra-
abdominal adverse event. (See 'Reoperation' above.)
 ● Patient management after surgery includes an assessment of hydration and medical comorbid
illnesses, such as hypertension, diabetes, and sleep apnea. (See 'Postoperative care after
discharge' above.)

● For long-term success and early identification of complications, lifelong follow-up is recommended
after bariatric surgery. (See 'Long-term management' above.)

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Topic 88610 Version 13.0

Contributor Disclosures
Giselle Hamad, MD Nothing to disclose Daniel Jones, MD Consultant/Advisory Boards: Allurion Technologies
[Weight loss]. Wenliang Chen, MD, PhD Nothing to disclose

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