Student Article Series

Bariatric surgery – The What, The How, and The Why

This article will explore bariatric surgery, what it is, how it works, why it is used, and the various healthcare professionals working in this specialist setting.

Article Written by Piotr Hipsz, Dietetic Student

Introduction

What is bariatric surgery?

Bariatric surgery, sometimes also called ‘weight-loss surgery’ is one of the treatments devised to treat severe obesity. In brief, the surgery changes the structure of the gastrointestinal tract. What follows is the changes to the patient’s appetite, as well as changes to how much food they are able to ingest.

Types of bariatric surgery

There are various types of bariatric surgery. Different types of bariatric surgery confer varying levels of effectiveness in terms of subsequent weight loss, and avoidance of complications. Although the types of surgery are multiple, perhaps the two most commonly performed bariatric surgeries in the UK are; Roux-en-Y Gastric Bypass (abbreviated to RYGB or simply Gastric Bypass), and Sleeve Gastrectomy (sometimes referred to as, gastric sleeve)1.

Bariatric surgery: Then and now

Bariatric surgery was introduced in the 1950’s, however, not only has the medical landscape changed dramatically since then2, but the health of the population nationally, scarcely resembles that of the population in 1950s. To illustrate this point, obesity levels in the UK almost doubled from 15% in 1993, to 28% in 20193 the prevalence of obesity is expected to reach 35% in England by year 20304. This means that a third of the population in England, will be living with obesity in 2030.

Public Health England report from 20195 stated that the causes of obesity exist where we live, work, play, and purchase our food. Risk factors for obesity permeate through our environments, and thereby make it a difficult and cumbersome task to say the least, to tackle overweight and obesity at a wider scale. Bariatric surgery, incorporated together with lifestyle management, is a treatment option for people who live with severe obesity1.

Bariatric Surgery Pathway

Weight management in the United Kingdom is currently based on a tiered system:

  • Tier 1 consisting of general, healthy lifestyle advice aimed at a population level such as the 5-a-day recommendation and the physical activity guidelines.
  • Tier 2 involving commercial or local authority led behavioural weight management services.
  • Tier 3 has recently been removed and replaced with “Specialist Weight Management Services”6.
  • Tier 4 being the Bariatric Surgery.

To go from tier 1 all the way through to being in the theatre room and ready for surgery can take up to two years or more, depending on patient’s health state, co-morbid health conditions, and geographical location7.

Dietitians involvement with the patient on the bariatric surgery pathway is multi-faceted

Welcome to The Clinic Room – The Role of a Dietitian

Formerly known as Tier 3, the Specialist Weight Management Service (SWMS) is where Dietitians are most commonly situated alongside other specialists such as; Consultants, GPs, Clinical Nurse Specialists, Psychiatrists / Psychologists, and Physiotherapists8. SWMS could be located within community or large hospitals. Once the patient has made it to the SWMS stage of the Bariatric surgery pathway, they are then invited to attend a Bariatric Surgery seminar.

Group education

Dietitians involvement with the patient on the bariatric surgery pathway is multi-faceted. Initially, it is likely that the Dietitian will co-deliver the bariatric surgery seminar together with the Consultant surgeon. In brief, the seminar encompasses various aspects such as; the process from now until surgery, the benefits as well as potential risks and side-effects of surgery, as well as the do’s and don’ts from the dietetic point of view.

Dietetic Assessment

Amongst the multitude of duties and responsibilities that a Dietitian has within the Bariatric multidisciplinary team (MDT), perhaps the most important ones are the dietetic assessment, and the pre & post-surgery dietary information. Although this may vary between organisations, to start with, the patient may be given a “target weight” that they have to reach before moving onto the next stage in the process. Reaching the target weight usually tends to involve weight loss of around 3-5% of body weight, and this helps to prepare the patient for surgery, but also shows that the patient is committed to the process and able to make the necessary changes in lifestyle.

Dietetic support

The Dietitian accompanies and leads on this process from day 1. This would involve; taking regular diet histories, helping the patient gain a better understanding of their eating habits, and encouraging changes that will facilitate weight loss. Close monitoring of patient’s micronutrient deficiencies secondary to types of food habitually consumed by the patient is also an area that a Dietitian will pay attention to9.

Pre-surgery

The Dietitian will also support the patient with specialist dietary advice in the weeks leading up to surgery. This dietary advice can be instrumental in the success of surgery or even the surgery going ahead at all.

Post-surgery

Dietary advice post-surgery is equally important and once again, led by the Dietitian. It is not possible for the surgical patient to resume normal eating patterns immediately post-surgery as the gastrointestinal tract is unable to handle various textures and larger amounts of food.

The surgical area has to recover and heal, and adaptations to the eating technique, as well as the changes to amounts of food and textures consumed, form parts of the recovery process11.

Long-term support

Since Bariatric surgery affects absorption of micronutrients post-surgery, the Dietitian will, closely monitor the patient for any deficiencies and advise the MDT as appropriate9.

 

Dietetic Role in Bariatric Surgery

Mary O'Kane shares her experience and career journey while working in this specilaist area

Inspirational Story

Mary O’Kane

Dietitian

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Multidisciplinary Team

Dietitian’s input towards care of a patient on the Bariatric pathway has been briefly introduced above. Now is the time to consider the wider team of healthcare professionals involved in the Bariatric pathway.

What is the Multidisciplinary team?

The MDT consists of healthcare professionals from various disciplines providing care in a joint manner. The multi-factorial nature of obesity as well as the need for regular follow-up and monitoring post-surgery warrants multi-professional involvement in Bariatric patient care. Although bariatric patients may experience changes in their physiology during various phases of the bariatric pathway, the most dramatic changes are observed post-surgically. Changes will be observed in weight and diet, psychological state, body image, and medication requirement. In order to address each one of these areas, input from a variety of professionals is needed 8.

Physician

Metabolic physicians, or physicians with a specific interest in obesity management may conduct the primary assessment with the patient, which may involve the assessment of any co-morbid conditions, or endocrine abnormalities.

Surgeon

The Bariatric surgeon will assess patient’s fitness and suitability for surgery. During bariatric seminars, or one-on-one consultations, the surgeon will inform the patient on different surgical procedures, as well as the potential related complications, risks, and benefits.

Psychiatrist / Psychologist

Psychiatrists and/or psychologists are an integral part of the MDT, and may be required to conduct an initial assessment of patient’s mental state. Further follow-up reviews may, or may not be required, depending on whether the patient is deemed psychologically fit for surgery, and whether the patient is compliant with the pre & post-surgery recommendations 12.

Specialist Bariatric Physiotherapist

Physiotherapists may be involved in patient’s journey as part of the bariatric team, although yet again, this may differ between organisations and the funding that is available 13. Bariatric patient may be under physiotherapist’s care to help manage co-morbid conditions such as arthritis, this does not imply however, that the physiotherapist is part of the bariatric team. 

On other occasions, Specialist Bariatric Physiotherapist’s may provide other treatments, such as ‘Chest Physiotherapy’ after bariatric surgery, which aims to improve respiratory function 14. Patient’s progression of activities of daily living, before, or after surgery such as sit-to-stand as well as advice around bariatric beds or chairs may also be provided by a physiotherapist.

Other AHPs?

Intriguingly, Dietitians and Physiotherapists may be the only two AHPs involved in bariatric care. Of course, this is not universal, and there may be organisations where a wider range of AHPs, for instance occupational therapists and operating department practitioners, are involved. However, this depends on a wider context, and the funding available.

Specialist Bariatric Nurse

The Specialist Bariatric Nurse, or the Clinical Nurse Specialist (CNS), may be working closely with the bariatric surgeon, advising on various processes such as the need to conduct a sleep apnoea assessment on a particular patient. On occasions, CNSs may take charge of running bariatric outpatient clinics if the surgeon is not present.

From the MDT point of view, it is evident that each practitioner offers contributions and services that are invaluable in progressing the patient from the moment of referral to discharge in a safe manner.

Wider considerations

Increasing trends of obesity are especially pronounced in the most deprived and underserved communities. This is problematic because these communities are also less likely to access healthcare in comparison to communities living in the least deprived areas 16. This contributes to the widening of health inequalities. Dietitians and other Allied Health Professionals are perfectly suited to broaden health literacy amongst the less privileged communities.

Waiting lists for surgery is a factor that often discourages patients from commencing their bariatric treatment on the NHS. In addition, the COVID-19 pandemic resulted in a dramatic reduction of bariatric surgeries performed nation-wide, and the concomitant, increasing back-log of patients 17. Building up of frustration amongst patients may lead to patients considering bariatric surgery overseas.

Around 8000 people a year may be going abroad for bariatric surgery 7. One benefit, however, of undergoing bariatric surgery in the UK, and on the NHS, is that the patient receives aftercare which could be considered as the cornerstone of effective recovery and optimum outcomes. This may not the case when patients travel abroad for bariatric surgery.

Unfortunately, even though bariatric surgery might be offered at a fraction of the cost when compared to private providers in the UK, the quality of surgeries provided overseas is debatable, and increasing numbers of patients return to UK with severe complications, which in some cases result in patient death 7, 18.

References

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  1. Małczak, P., Pisarska, M., Piotr, M., Wysocki, M., Budzyński, A. and Pędziwiatr, M., 2017. Enhanced recovery after bariatric surgery: systematic review and meta-analysis. Obesity surgery, 27, pp.226-235.
  1. NHS Digital (2022), Health Survey for England, 2021. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/health-survey-for-england/2021/health-survey-for-england-2021-data-tables (accessed 31st July, 2024)
  1. Luli, M., Yeo, G., Farrell, E., Ogden, J., Parretti, H., Frew, E., Bevan, S., Brown, A., Logue, J., Menon, V. and Isack, N., 2023. The implications of defining obesity as a disease: a report from the Association for the Study of Obesity 2021 annual conference. EClinicalMedicine, 58.
  1. Public Health England (2019), Whole systems approach to obesity. Available at: https://www.gov.uk/government/publications/whole-systems-approach-to-obesity (Accessed 31st July, 2024)
  1. British Obesity & Metabolic Surgery Society (2023), Updated CG189 NICE guidance for obesity. Available at: https://bomss.org/cg189-nice/ (Accessed 31st July, 2024)
  1. British Obesity & Metabolic Surgery Society (2024), BOMSS Yearbook 2024. Available at: https://bomss.org/wp-content/uploads/2024/05/BOMSS-Yearbook-2024-v1.pdf (Accessed 8th August, 2024).
  1. Kaur V, Bowen L, Bano G, Reddy M, Khan O. Multidisciplinary team in bariatric surgery: structure and role. InObesity, Bariatric and Metabolic Surgery: A Comprehensive Guide 2022 Mar 11 (pp. 1-8). Cham: Springer International Publishing.
  1. O’Kane, M., Parretti, H.M., Pinkney, J., Welbourn, R., Hughes, C.A., Mok, J., Walker, N., Thomas, D., Devin, J., Coulman, K.D. and Pinnock, G., 2020. British Obesity and Metabolic Surgery Society Guidelines on perioperative and postoperative biochemical monitoring and micronutrient replacement for patients undergoing bariatric surgery—2020 update. Obesity Reviews, 21(11), p.e13087.
  1. Edholm D, Kullberg J, Haenni A, Anders Karlsson F, Ahlström A, Hedberg J, Ahlström H, Sundbom M. Preoperative 4-week low-calorie diet reduces liver volume and intrahepatic fat, and facilitates laparoscopic gastric bypass in morbidly obese. Obesity surgery. 2011 Mar;21:345-50.
  1. British Obesity & Metabolic Surgery Society (2023), BOMSS post-bariatric surgery nutritional guidance for GPs. Available at: https://bomss.org/bomss-post-bariatric-surgery-nutritional-guidance-for-gps/ (Accessed 8th August, 2024).
  1. Ogden J, Ratcliffe D, Snowdon‐Carr V. British obesity metabolic surgery Society endorsed guidelines for psychological support pre‐and post‐bariatric surgery. Clinical obesity. 2019 Dec;9(6):e12339.
  1. British Medical Association (2024) Health Funding Data Analysis. Available at: https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/funding/health-funding-data-analysis (Accessed 19th August, 2024)
  1. Duymaz T, Karabay O, Ural IH. The effect of chest physiotherapy after bariatric surgery on pulmonary functions, functional capacity, and quality of life. Obesity Surgery. 2020 Jan;30:189-94.
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