Bariatric Surgery: Postoperative Management 2020-08-26T17:37:22-04:00

Bariatric Surgery: Postoperative Management

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  • Adherence to consistent post-operative behavioural changes (behaviour modification for nutrition plans, physical activity and vitamin intake) can optimize obesity management and health while minimizing post-operative complications.
  • Working in partnership, the bariatric surgical centre, the local bariatric medicine specialist, the primary care provider and the patient living with obesity need to establish and commit to a shared care model of chronic disease manage­ment for long-term follow-up.
  • The primary care provider should refer patients with post-bariatric surgery complications back to the bariatric surgical centre, or to a local bariatric medicine specialist.
  1. Healthcare providers can encourage people who have un­dergone bariatric surgery to participate and maximize their access to behavioural interventions and allied health services at a bariatric surgical centre (Level 2a, Grade B).1,2
  2. We suggest that bariatric surgical centres communicate a comprehensive care plan to primary care providers on pa­tients who are discharged, including: bariatric procedure, emergency contact numbers, annual blood tests required, long-term vitamin and mineral supplements, medications, behavioural interventions and when to refer back (Level 4, Grade D, consensus).
  3. We suggest that after a patient has been discharged from the bariatric surgical centre, primary care providers should annually review: nutritional intake, activity, compliance with multivitamin and mineral supplements, and weight, as well as assess comorbidities, order laboratory tests to assess for nutritional deficiencies and investigate abnormal results and treat as required (Level 4, Grade D, consensus).
  4. We suggest that primary care providers consider referral back to the bariatric surgical centre or to a local specialist for technical or gastrointestinal symptoms, nutritional issues, pregnancy, psychological support, weight regain or other medical issues as described in this chapter related to bariatric surgery (Level 4, Grade D, consensus).
  5. We suggest that bariatric surgical centres provide follow-up and appropriate laboratory tests at regular intervals post-sur­gery with access to appropriate healthcare professionals (dietitian, nurse, social worker, surgeon, bariatric physician, psychologist/psychiatrist) until discharge is deemed appro­priate for the patient (Level 4, Grade D, consensus).
  1. If you have had bariatric surgery, it is important for you to take your nutritional supplements lifelong and to continue to follow the post-bariatric surgical nutrition plan, exercise and any other recommendations given by your original specialist team. By doing this, you will increase your chances of staying healthy and reduce complications that can arise from bariatric surgery.
  2. Attend all scheduled appointments and programming offered by your bariatric surgical site. Once you are dis­charged from the bariatric surgical site, schedule annual appointments with your primary care provider to check your blood work, reassess your medications and address any issues related to changes in your weight.
  3. After bariatric surgery, it is possible that there can be a negative impact on mood, relationships, body image, de­velopment of addictions and reduced ability to cope with stress. If you are struggling, discuss this with your original specialist team or, if you have been discharged, with your primary care provider.
  4. Remember that your lowest weight post-surgery will occur between 12 to 18 months. After this, there is a natural increase in weight that occurs. If you are gaining excessive amounts of weight, discuss this with your bariatric team or primary care provider.
  5. If you are 12 to 18 months post-bariatric surgery and are planning a pregnancy, discuss this with your bariatric team, primary care provider and obstetrician.

Post-bariatric surgery health behaviour changes

Post-bariatric surgery diet

Centres that perform bariatric surgery will typically provide pa­tients with a dietary protocol to follow. Initially, over several weeks, patients transition from liquid, to soft and then to a sol­id diet. Over the long term, patients are encouraged to follow a structured post-bariatric surgical diet involving small portions, three to five balanced and structured meals and healthy snacks (chew foods slowly and avoid sweets). For beverages, patients should not eat and drink at the same time (avoid liquids within 30 minutes of eating solids). Carbonated beverages and caffeinated drinks are to be avoided, as the phosphoric acid and caffeine, respectively, can increase the risk of ulcerations.

After bariatric surgery, patients need to follow a low-fat, mod­erate carbohydrate and high-protein diet. Post-operative pro­tein recommendations range from 1.2 to 1.5 g/kg/day based on goal body weight (minimum of 60 g protein/day for laparoscopic sleeve gastrectomy/Roux-en-Y gastric bypass, and 80–120 g/day for duodenal switch). Consulting a registered dietitian can sup­port changes in eating behaviours and guide patients on their nu­trition needs.3 There is no advantage to prescribing alternate diets (e.g. low carbohydrate, high protein), probiotics or amino acids.4-6

Other behavioural changes to consider

Alcohol intake should be minimal or avoided due to changes in pharmacokinetics. For example, in women who are post Roux-en-Y gastric bypass, two alcoholic beverages are equivalent in ab­sorption to four alcoholic beverages.7 Seven percent of patients report new high-risk alcohol use one year after bariatric surgery, though, on a more positive note, half who reported high-risk alco­hol use before surgery discontinued high-risk drinking.7

Activity: Long term, a standard of 150 to 300 minutes of ac­tivity/week is recommended for post-bariatric surgical patients. Post-operative higher-volume exercise can help promote further weight loss8-10 but sustaining this level activity is difficult.11

Smoking cessation: Abstention from cigarettes is recommend­ed. Cigarette smoking can increase risk of peptic ulcer disease, particularly marginal ulcers.

Marijuana: There is a paucity of studies on the use of marijuana post bariatric surgery. One concern would be the impact of weight loss and the chronic use of marijuana, which is traditionally known for its “munchies” effect. At this point, moderation, if not absten­tion, would be a safe recommendation.

Post-bariatric surgery vitamin supplementation

The evidence for the role of vitamin supplementation (amount, duration) varies depending on which vitamin, mineral or type of bariatric procedure are studied. Generally, some type of vitamin supplementation is needed for all bariatric surgical procedures, with tailoring for those that have a hypoabsorptive component (Roux-en-Y gastric bypass, duodenal switch).

Practically, it makes sense that a standardized minimum prescrip­tion of vitamins be set for all bariatric surgeries. It is a natural human tendency to eventually forget taking supplements. Setting a standard means that clinicians can be consistent in their mes­saging about taking vitamins. Deficiencies of vitamins and some minerals can leave serious and potentially nonreversible side ef­fects. Frequency of laboratory monitoring may vary depending on the individual and type of procedure, but at minimum an annual check should be conducted to ensure that patients are not be­coming malnourished. Tables 1 and 2 summarize the recommen­dations for vitamin supplementation, associated deficits that can occur with various deficiencies, and frequency of monitoring. Ta­ble 3 summarizes clinical features that may point toward a nutri­ent deficiency. A dietitian can help determine what combination of vitamins makes sense for a patient. In Canada, access to all-in-one bariatric supplements for surgical patients is improving and can help compliance by reducing the number of pills that need to be taken. Gummy vitamins should be avoided as they do not contain essential minerals.

Post-bariatric surgery complications

Many gastrointestinal (dumping syndrome) and metabolic compli­cations (e.g. bone, kidney stones) can be prevented by following the recommended post-bariatric surgery nutrition plan and vita­min intake.

Dumping syndrome

Dumping syndrome is divided into early and late phases. Early dumping syndrome occurs within the first hour after a meal. Be­cause of the hyperosmolality of the food, rapid fluid shifts occur from the plasma compartment into the intestinal lumen, resulting in hypotension and a sympathetic nervous system response. Early dumping is characterized by gastrointestinal symptoms such as abdominal pain, bloating, borborygmi, nausea and diarrhea, and vasomotor symptoms, such as fatigue, desire to lie down after meals (a classic symptom), flushing, palpitations, perspiration, tachycardia, hypotension, and, rarely, syncope. In contrast, late dumping usually occurs one to three hours after a meal and is a result of an incretin-driven hyperinsulinemic response after car­bohydrate ingestion. Hypoglycemia-related symptoms are related to neuroglycopenia (fatigue, weakness, confusion, hunger and syncope) and autonomic/adrenergic reactivity (perspiration, palpi­tations, tremor and irritability).12

Symptoms that persist despite returning to a post-bariatric surgery diet may benefit from a trial of either acarbose, a calcium channel blocker, diazoxide or octreotide. Referral to a bariatric medicine specialist or an endocrinologist for management and to rule out other causes of hypoglycemia (nesidioblastosis, insulinoma, facti­tious) may be warranted.13

Abdominal discomfort

Abdominal discomfort has a long differential from dietary indis­cretion (overeating), dumping syndrome, biliary colic, stenosis of the gastro-jejunostomy, marginal ulcer or small bowel obstruction. Presentation for small bowel obstruction can come at any time, but can be divided into early (< 30 days; secondary to adhesions or incarcerated hernias) or late (>1 year; internal hernia, which can be seen post Roux-en-Y gastric bypass or duodenal switch). During the first year, there is a need for a higher level of suspicion for pain secondary to a surgical complication. Tachycardia, unsta­ble vital signs and abdominal pain may be suggestive of a surgical leak, internal hernia or cholecystitis, which warrants immediate surgical referral. With diarrhea, constipation or bloating, referral to a dietitian can help identify healthier food choices and proper fibre content. Probiotics may improve symptomatic gastrointestinal episodes.

There should be a high level of suspicion for an ulceration for patients who use non-steroidal anti-inflammatory drugs (NSAIDS). Referral to the bariatric surgical site should be considered when clinical red flags appear such as unexplained, frequent, moder­ate-to-severe abdominal pain, daily intolerance to most solid foods, daily nausea and vomiting, and/or a significant amount of weight regain (>25%–50% of total weight loss) in a short space of time. Every bariatric patient suffering from persistent vomit­ing severe enough to interfere with regular nutrition should be promptly started on oral or parenteral thiamine supplementation, even in the absence or before confirmatory laboratory data.14

Bone health

Post-bariatric surgery, bone demineralization 15–17 and fracture risk,18 particularly after duodenal switch, are increased. A major cause of bone loss is impaired intestinal calcium absorption, which leads to stimulation of parathyroid hormone (secondary hyper­parathyroidism) and bone resorption.17 The evidence for monitor­ing, prevention and treatment is not well described. At minimum, adequate protein intake in combination with routine physical ac­tivity in addition to the routine supplementation of calcium citrate and vitamin D are recommended.17,19 It is recommended to adjust calcium and vitamin D intake to achieve normal serum calcium, vitamin D and parathyroid hormone levels. Calcium citrate is pre­ferred over calcium carbonate as it is better absorbed in the ab­sence of gastric acid. Elevated parathyroid hormone in the setting of inappropriately high serum calcium and normal vitamin D levels is suggestive of primary hyperparathyroidism and requires further investigation.

The role of bone mineral density testing prior to bariatric surgery is controversial,20 particularly due to technical difficulties when pa­tients are at a higher body mass index (BMI). We suggest ordering bone mineral density testing on a patient at two years post-surgery, when weight is at its nadir. Subsequent bone mineral density test­ing can be ordered based on clinical need.20 If a patient does have osteoporosis, then intravenous bisphosphonates (zolendronate 5 mg once a year, ibandronate 3 mg every three months) are the preferred choice, as there is a risk of anastomotic ulcer with oral bisphosphonates. Prior to starting bisphosphonate therapy, it is im­portant that vitamin D levels be fully replete to prevent the devel­opment of hypocalcemia, hypophosphatemia and osteomalacia.21

Nephrolithiasis

Patients who have had bariatric surgery are at higher risk of new onset nephrolithiasis, with the mean interval from surgery to di­agnosis of nephrolithiasis ranging from 1.5 to 3.6 years. The risk of nephrolithiasis, typically calcium oxalate stones, varies by pro­cedure, being the highest for hypoabsorptive procedures (22% to 28.7%), intermediate for Roux-en-Y gastric bypass (7.65% to 13%) and the lowest for purely restrictive procedures (laparoscop­ic adjustable gastric banding, laparoscopic sleeve gastrectomy) where it approaches that of non-operative controls.22 Unabsorbed fat in the intestine binds with calcium, which typically would bind oxalate. Oxalate is reabsorbed from the intestine and is subse­quently filtered by the kidney, resulting in hyperoxaluria. With concomitant hypocitraturia (from intestinal alkali loss), there is a higher propensity for calcium oxalate stone formation. Basic ther­apeutic strategies to manage hyperoxaluria include calcium citrate supplementation, increased hydration, limiting dietary oxalate and adhering to a low-fat diet.17,23 Commonly, individuals often believe that kidney stones are caused by taking too much calcium, and that calcium supplementation should be discontinued. The exact opposite is true, in that they should remain on their calcium citrate supplementation, which not only helps bind intestinal oxa­late but also provides citrate for the urine. There is some evidence to suggest that pyridoxine (B6) deficiency plays a role in kidney stone formation, highlighting the importance of taking vitamin supplementation consistently.24 Certain probiotics (containing either Lactobacillus alone or in combination with Streptococcus thermophilus and Bifidobacterium) may play a complimentary role in reducing gastrointestinal oxalate absorption if basic strategies are insufficient.25,26

Psychological complications and treatments post op

Though bariatric surgery is one of the most effective treatment options for obesity, clinicians should be aware of the potential post-bariatric psychological issues that may arise, including de­pression, suicide,27,28 body image disorder, eating disorders,29 and substance and alcohol abuse.7 Results from bariatric surgery may not meet a patient’s expectations or may not lead toward hoped improvements in quality of life, thus impacting mood.14 Beyond providing knowledge on diet and exercise, clinicians should address improvement in patient’s self-esteem and self-mo­tivation. Patients who have had post-bariatric comprehensive be­havioural-motivational nutrition education have decreased risk for depression and improved weight loss outcomes.1,30,31 Primary care providers may need to refer the post-bariatric surgical patient for more in-depth psychological counselling, such as cognitive or di­alectical behaviour therapy. Refer to The Role of Mental Health in Obesity Medicine and Effective Psychological and Behavioural In­terventions for People Living with Obesity chapters for more details.

Weight regain

Nadir weight (lowest weight point) occurs one to two years post-bariatric surgery. Weight loss stops partly because of adaptive changes in the intestine, changed patient habits, and metabolic adaptation.32 After this, it is normal to expect some weight regain. However, there is no consistent absolute number in the literature that defines pathological weight regain post bariatric surgery. Studies that have been conducted in the bariatric surgery popu­lation show that significant weight regain (≥ 15% gain of initial weight loss post bariatric surgery) occurs in 25%–35% of people who undergo surgery two to five years after their initial surgical date.33 The Swedish Obese Subjects study, the largest non-ran­domized intervention trial comparing weight loss outcomes in a group of over 4000 surgical and nonsurgical individuals, reported that, at 10 years, individuals who underwent Roux-en-Y gastric bypass had a mean weight regain of 12% of total body weight, which translates into regaining 34% of the maximal lost weight achieved at one year.29,34 The consensus for some Canadian bar­iatric surgical sites is that weight regain is defined as >25% regain of total weight lost. The underlying factors that influence weight regain following bariatric surgery are multifactorial, and include endocrine/metabolic alterations, anatomic surgical failure, nutri­tional indiscretion, mental health issues and physical inactivity.29

Even prior to surgery, emphasizing realistic weight trajectories and expectations may theoretically help reduce the anxiety that some patients go through as they mentally try to transition from losing weight to healthy living and maintaining weight loss. Patients who experience weight regain may perceive that the surgery has failed, or they may enter a cycle of helplessness by blaming themselves and feeling shamed. It is important that clinicians mitigate these feelings by explaining that some weight regain following bariatric surgery is normal, and then proceeding in a stepwise approach to address the weight regain. It is neither necessary nor economical to order an esophagogastroduodenoscopy or an upper gastroin­testinal contrast study to evaluate the gastrointestinal tract on ev­ery patient who is experiencing weight regain following surgery. The following steps are suggested to address weight regain:

  • Ensure that the patient continues to follow the recommended post-bariatric surgery nutrition plan and vitamin intake. Check bloodwork to ensure that vitamin and mineral levels are in the normal range. If a person is malnourished at baseline, then more harm occurs trying to help the person lose further weight. Referral to a dietitian can be helpful at this stage.
  • Psychological intervention may be required to address mood, anxiety, an eating disorder, or to help a patient make behaviour changes.
  • If on subsequent follow ups, despite adherence to post-bariat­ric surgery nutrition plan and vitamin intake, weight does not decrease, then an esophagogastroduodenoscopy or upper gas­trointestinal contrast study may rule out an anatomical failure. Detection of an anatomical failure would lead to a referral back the bariatric surgical team.
  • Consideration of medications for obesity management post-bariatric surgery may be made for patients who are trying to follow the post-bariatrc surgery nutrition plan and taking their vitamin supplementation. Orlistat should not be used in patients who have had hypoabsorptive procedures. Retrospec­tive reports have demonstrated that liraglutide35,36 or bupropi­on/ naltrexone37 may play a role in reducing weight regain.

After all the above steps, if weight regain still remains an issue, then consider referring back to a bariatric surgery centre for eligi­bility of surgical revision.

Medications

Following bariatric surgery and the resulting weight loss, many studies demonstrate a reduction of medications for diabetes, dys­lipidemia, cardiovascular and antihypertensive agents. There are a limited number of publications that focus on the pharmacody­namics of medications post-operatively (Table 4). Ultimately, there remains a large interindividual variation and the therapeutic ef­fects of a medication must be individually dose adjusted.

For the first three to eight weeks post-surgery, medications should be consumed in a crushed or liquid form or by opening capsule contents. It is important that the liquid form does not contain ab­sorbable sugars to avoid dumping syndrome.38 Some medications, however, should not be crushed.39 Post Roux-en-Y gastric bypass and duodenal switch, the pharmacokinetic profile of many med­icines may be altered due to changed intestinal absorption sur­face, lipophilicity of drugs, increased pH in the stomach, reduced cytochrome P450 (CYP) enzyme activity and first-pass intestinal metabolism, time after bariatric surgery, and changes in volume of distribution.40 Immediate-release formulations are generally preferred over extended release. Nonsteroidal anti-inflammatory drugs should be avoided after Roux-en-Y gastric bypass or duo­denal switch due to risk of anastomotic ulceration/perforations. For other bariatric procedures, non-steroidal anti-inflammitories (NSAIDs) use should be accompanied with proton pump inhibitors (PPIs) for mucosal protection.41 Patients who need to remain on low dose aspirin for secondary prevention may do so but should have additional PPI protection. Especially for Roux-en-Y gastric by­pass and duodenal switch procedures, patients taking long-term warfarin require a postoperative dose reduction of >20% with closely monitored international normalized ratio (INR). Direct oral anticoagulants (DOACs) should be avoided due to the potential for decreased drug absorption. If a betablocker after bariatric surgery is needed, a hydrophilic compound like atenolol may be preferred. Bioavailability of oral contraceptives may be reduced post-bariatric surgery, and alternate methods of contraception need to be considered. Antidiabetic medications with a risk for hypoglycemia (such as sulfonylureas) should be discontinued and insulin doses adjusted. Metformin may be continued but the dose may need to be reduced due to increased absorption.42 Primary care providers may benefit from working with a patient’s commu­nity pharmacist for medication adjustments.

Special considerations for bariatric surgery on fertility

Bariatric surgery should not be considered a treatment fora infer­tility.54 Many studies related to fertility in women post-bariatric surgery are small, and appropriate control groups have not al­ways been included. Together, the evidence suggests that bariatric surgery improves fertility, whether it is through improvements of sex hormonal profiles or resolution of polycystic ovary syndrome markers which influence fertility (including anovulation, hirsutism, hormonal changes, insulin resistance, sexual activity and libido).55 The type of surgery does not appear to be related to changes in fertility, as only the amount of weight lost (a BMI decrease of greater than 5 kg/m2) and the BMI achieved at time of conception were predictive of becoming pregnant.56

In men, surgery-induced massive weight loss does not impact sperm quality, but it does increase the quality of sexual function, total tes­tosterone, free testosterone and FSH, and reduces prolactin.57 Over­all, in men, the balance between positive (hormonal, psychological and sexual improvements) and negative (nutritional depletion due to selective food maldigestion and malabsorption) impacts will de­termine the final effect on seminal quality and fertility.57

Women who became pregnant before one year after bariatric sur­gery presented with a higher rate of fetal loss in comparison to wom­en whose pregnancy occurred after this period of time (35.5 versus 16.3 %). Pregnancy is therefore not recommended in the first 12–18 months following bariatric surgery,58 by which time weight is more stable and women are able to consume a nutritionally balanced diet. Thus, adequate contraception should be offered to women of repro­ductive age who undergo bariatric surgery. As estrogen is absorbed in the upper gastrointestinal tract which is modified during bariat­ric surgery, oral contraception pills should be avoided for Roux-en-Y gastric bypass and biliopancreatic diversion/duodenal switch. Instead, normal forms of hormonal contraception (etonogestrel implant59 or a levonorgestrel releasing intrauterine device60 may be considered. There is no definitive contraindication to oral contraception pills for gastric banding and sleeve gastrectomy.14,61

Special considerations in women who have had bariatric surgery and pregnancy

Compared with women who have obesity and who have not un­dergone bariatric surgery, women who became pregnant after bariatric surgery had a lower risk of gestational diabetes, hyper­tensive disorders, and macrosomia. However, risk of small-for-ges­tational-age newborns increases after bariatric surgery.62

Preconception care

Women planning conception post-bariatric surgery should have daily oral supplementation with a multivitamin containing 1.0 mg folic acid, beginning at least three months before conception. Women should continue this regime until 12 weeks gestation­al age. From 12 weeks gestational age, continuing through the pregnancy, and for four to six weeks postpartum or as long as breast feeding continues, continued daily supplementation should consist of a multivitamin with 0.8 mg to 1.0 mg folic acid.63 B12 levels should be checked and corrected if deficient prior to initia­tion of additional folic acid. Women are advised to avoid vitamin and mineral preparations which contain vitamin A in the retinol form in the first 12 weeks of pregnancy, as supplements contain­ing retinol may increase the teratogenic risk (especially in the first trimester). It is therefore recommended that pregnant women and those planning pregnancies following bariatric surgery are supple­mented with vitamin A in the beta-carotene form.

Nutritional monitoring during pregnancy

Standard complete multivitamins routinely used post-bariatric sur­gery should be substituted for prenatal multivitamins to reduce vitamin A intake, which should not exceed 5000 IU/day. Continue all other regular supplementation that the patient typically would be on, and then adjust according to laboratory testing. Laboratory testing at each trimester should include CBC, ferritin, albumin, B12, 25-Hydroxy (OH) vitamin D, calcium, parathyroid hormone and folate. Patients who have had hypoabsorptive surgery should additionally have zinc, copper and vitamin A levels (and possibly vitamin E and K levels with duodenal switch) monitored during pregnancy.14,55,64,65

If the patient is vitamin A deficient, then supplementation should be in the form of beta-carotene vitamin A.64 Patients suffering from nausea and intractable vomiting should have immediate B1 supplementation and careful monitoring of B1 levels. Nutrition advice from an experienced registered dietitian should be offered to review deficiencies, vitamin supplementation and ensure a rec­ommended daily protein intake of 60 g.54 Possible recommended gestational weight gain would be based on pre-pregnancy BMI as per the Institute of Medicine.66

Other considerations during pregnancy

In addition to nutritional deficiencies, there is also the potential for severe, life-threatening complications, such as internal hernias, bowel obstructions, volvulus, intussusception and gastric perfo­rations, which generally occur one to three years after bariatric surgery. Because of the upward pressure from the gravid uter­us, these late sequelae may present in pregnancy and during the immediate postpartum period. Abdominal pain in a post-bariat­ric surgical gravid woman would need to include these potential complications in the differential diagnoses. Radiologic evaluation with computed tomography scan should be reviewed by bariatric surgeons or radiologists with specialized expertise in this area.67

Post-surgical patients may not tolerate the 50 g glucose solution commonly administered at 24–28 weeks of gestation to screen for gestational diabetes. Alternative measures to screen for ges­tational diabetes should be considered for patients who have un­dergone hypoabsorptive-type surgery. One proposed alternative is home glucose monitoring (fasting and two-hour postprandial blood sugar) for approximately one week during the 24–28 weeks of gestation.54

Postpartum

Breast feeding should be encouraged. It is important that postpar­tum bariatric surgical patients continue their recommended vitamin supplementation, as there have been documented cases of nutri­tional deficiencies in breast fed infants born to mothers who have had Roux-en-Y gastric bypass.68

Table 1: Post-Bariatric Surgery Nutrition and Exercise, Vitamin Supplementation and Monitoring for Prevention of Complications

Table 2: Treatment for Post-Operative Deficiencies and Suggested Supplementation 43–47

Table 3: Clinical Features that Patients Might Present Post-Bariatric Surgery with Possible Related Nutrient Deficiency 43,47

Table 4: Pharmacotherapy After Bariatric Surgery

Judy Shiaui, Laurent Bierthoii

i) Division of Endocrinology and Metabolism, University of Ottawa

ii) Department of Surgery, Laval University

A complete list of author’s competing interests can be found on the CMAJ website, HERE

Cite this Chapter

Shiau J, Biertho L. Canadian Adult Obesity Clinical Practice Guidelines: Bariatric Surgery: Postoperative Management. Downloaded from: https://obesitycanada.ca/guidelines/postop. Accessed [date].

Update History

Version 1, August 4, 2020. Adult Obesity Clinical Practice Guidelines are a living document, with only the latest chapters posted at obesitycanada.ca/guidelines.

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This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND 4.0). For reprint and all other inquiries please contact guidelines@obesitynetwork.ca / +1-(780)-492-8361.

The summary of the Canadian Adult Obesity Clinical Practice Guidelines is published in the Canadian Medical Association Journal, and contains information on the full methodology, management of authors’ competing interests, a brief overview of all recommendations and other details. More detailed guideline chapters are published on the Obesity Canada website at www.obesitycanada.ca/guidelines.

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