BOMSS nutritional guidance

BOMSS Guidelines on perioperative and postoperative biochemical monitoring and micronutrient replacement for patients undergoing bariatric surgery

for and on behalf of BOMSS Council, October 2014
BOMSS Guideline Working Party

Mary O’Kane, Jonathan Pinkney, Erlend Aasheim,
Julian Barth, Rachel Batterham, Richard Welbourn

Summary

Bariatric surgery is now an essential option for the treatment of obesity and its associated comorbidity. Many patients presenting for surgery will have pre-existing vitamin deficiencies and all bariatric surgical procedures compromise nutrition to varying extents, and have the potential to cause clinically significant micronutrient deficiencies. Therefore, long term nutritional monitoring and follow-up are essential components of all bariatric surgical services. However, there are no current standard guidelines in the UK for the biochemical monitoring and replacement of essential micronutrients in patients undergoing different forms of bariatric surgery. Furthermore, a survey of members of BOMSS revealed a wide diversity of local guidelines and practices. This suggested a need for standard guidelines. We undertook a review of existing guidelines and the associated literature on micronutrient deficiencies following bariatric surgery. Our aim was to summarise existing evidence for the monitoring and replacement of vitamins and minerals prior to, and following bariatric surgery, and to make recommendations for safe practice in the UK setting. This publication is an abbreviated version of the fuller report.

Download the BOMSS Guidelines on perioperative and postoperative biochemical monitoring and micronutrient replacement for patients undergoing bariatric surgery

BOMSS nutritional guidelines


BOMSS statement on MGBs

BOMSS has released a position statement on mini gastric bypass operations (MGBs).

In an MGB, the stomach is divided to form a long gastric pouch with subsequent anastomosis of that pouch to the jejunal loop. The narrow tube of gastric pouch affords a restrictive component and the bypassed small bowel contributes the malabsorptive element.

BOMSS has published a position statement on the use of MGBs which describes its benefits as including the requirement for a single anastomosis – making it a more technically simple operation than other options and one which has fewer potential sites for leaks and internal hernias.

Professor Duff Bruce, BOMSS member and consultant surgeon at Aberdeen Royal Infirmary, said; “Results to date suggest non-inferiority of MGB compared to the gold standard Roux-en-Gastric bypass in terms of mortality, weight loss, comorbidity resolution and quality of life.

“If the MGB is introduced into routine bariatric surgical practice it is recommended that it is within the confines of careful prospective data collection by surgeons working within the framework described in BOMSS Professional Standards guidelines. Follow-up data should be submitted to the National Bariatric Surgery Registry.”

Some potential disadvantages of MGBs have been noted and include the possible risk of reflux, a theoretical association between biliary reflux and oesophageal carcinoma and a lack of long-term outcome data.

BOMSS will review its MGB position statement after two years.


BOMSS unveils post-op poster for GPs

BOMSS has issued a traffic lights-style poster to help GPs care for patients who have had bariatric surgery.

Council member Mr Sean Woodcock designed the at-a-glance poster displaying a range of possible symptoms which will require referral back to bariatric specialists. Symptoms are categorised in traffic light colours to show whether they warrant emergency, urgent or routine attention. The poster – “Primary care management of post-operative bariatric patients” – also suggests how soon after an operation the symptoms are most likely to occur.

Mr Woodcock, consultant surgeon at Northumbria NHS Foundation Trust, said: “The poster will help GPs decide how urgent the situation may be if a patient presents symptoms following an operation and how quickly they should be referred back to a specialist.

“Bariatric procedures are often extremely beneficial to people with serious weight problems but like all operations there can be complications. This traffic lights-style poster will help GPs decide how serious any complications may be and help make sure they refer patients to a specialist in good time.”

The poster – Primary care management of post-operative bariatric patients can be viewed at http://www.bomss.org.uk/primary-care-management-of-post-operative-patients/

 


Consultation on NICE guidance opens

New draft guidelines from the National Institute of Health and Care Excellence (NICE) on eligibility for bariatric surgery have been released.

Consultation on the proposed new guidelines is now open – and will close at 5pm on August 8. It is anticipated that full guidance will then be issued in November.

Current guidance says surgery is an option for people with a BMI above 35 who have other health conditions.

The update in guidance strengthens the focus on those with type 2 diabetes. It states that people who have been diagnosed in the past decade and have a BMI over 35 should be assessed for surgery.

The guidelines also suggests doctors should consider those with a BMI of 30 or more on a case-by-case basis.

The Guidelines can be viewed here – http://www.nice.org.uk/Guidance/GID-CGWAVE0682/Consultation


Looking forward to a strong BOMSS presence at AUGIS

The 18th AUGIS Annual Scientific Meeting will be held at the Brighton Centre, Brighton, from September 18-19

BOMSS always has a strong presence at the AUGIS meetings and we expect the same to be the case this year.

Among many invited national and international speakers, Dr Justin Dimick of the University of Michigan has agreed to give this year’s BJS Lecture: Does Surgical Skill Really Count? There will also be a plenary session discussing current topical issues including Service Commissioning, the Shape of Training and Emergency Surgery.

As usual there will be a plenary short paper session for the BJS prize in addition to a parallel paper session on Bariatric (and OG and HPB) topics.

The Provisional Scientific Programme for the meeting – which will be updated as it develops – is available now on the AUGIS 2014 Annual Scientific Meeting microsite which gives delegates access to all the necessary information for the Meeting.

Registration for the meeting will be opening shortly. Click on the link to access the microsite: http://www.augis.org.uk/brighton2014/

The Brighton Centre is ideally placed on the seafront in the centre of town.


BOMSS supports call for better obesity services in Wales

BOMSS – along with the The Royal College of Surgeons – has responded to the National Assembly’s Health and Social Care Committee report into the ‘Availability of Bariatric Services’ in Wales.We welcome the report’s call for the government to fully implement the All Wales Obesity Pathway. This will serve to optimise patients’ outcomes and ensure that patients in Wales have access to sustainable, safe and high quality bariatric services.

In a report, published today, the Health and Social Care Committee say just one out of seven health boards has sufficient Level Three specialist services – which include weight management clinics – in place for obese patients.

During its inquiry, the Committee found that the Welsh Government’s All Wales Obesity Pathway focuses on tackling the issue but needs to be fully implemented for all patients to receive consistent services which can help them with lifestyle, exercise and dietary regimes.

Currently 59% of adults in Wales are overweight or obese.


FRCS honour for Dr Henry Buchwald

Bariatric surgeon Dr Henry Buchwald has been award an honorary FRCS (Fellowship of the Royal College of Surgeons) in recognition of his surgical work.

Dr Buchwald, who practices in the US, has been a leader in bariatric surgery for 40 years and has served as President of the American Society of Bariatric Surgery and International Federation of Surgery for Obesity.

BOMSS President Mr Richard Welbourn said: “This is a well-deserved honour for Dr Buchwald. He has made a tremendous contribution to bariatric surgery over several decades.”

Professor Alberic Fiennes, past president of BOMSS, and BOMSS council member Mr Kesava Mannur are pictured with Dr Buchwald (centre) at a dinner to mark his achievements.

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BOMSS welcomes new body contouring commissioning guide

A body contouring commissioning guide, which aims to address variation across England in provision and quality of body contouring surgery for patients who have undergone massive weight loss, is launched by the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) and the Royal College of Surgeons (RCS).

BOMSS contributed to the consultation about the guidance and welcomes its publication.

Full details can be found here


Concern over obesity rates in Wales as medical professionals call for better funding for bariatric surgery

Surgeons and healthcare professionals in Wales are concerned over a lack of funding for bariatric surgery and obesity treatments across the country, despite the launch of an all-Wales strategy more than three years ago.

The Royal College of Surgeons Professional Affairs Board in Wales and the British Obesity and Metabolic Surgery Society (BOMSS) have outlined their concerns in a written submission to the National Assembly for Wales’ Health and Social Care Committee Inquiry into the availability of Bariatric Services in Wales.

The document highlights that both organisations believe the current system in Wales is skewed and results in patients being forced to wait until they develop life-threatening illnesses such as diabetes or a stroke before they meet the qualifying criteria for surgery.

Consultant surgeon and BOMSS member Jon Barry, based at the Morriston Hospital Swansea, says: “We have serious concerns about a lack of access to weight management and preventative services in Wales. We believe that patients are being denied life-saving and cost-effective treatments and effectively encouraged to gain more weight in order to have a more complex operation further down the line. We believe to limit surgery to the most severely obese is denying patients effective clinical treatment and a better quality of life.”

The Royal College of Surgeons and BOMSS are calling on the Welsh Government to fully implement the recommendations in Welsh Health Specialised Services Committee’s ‘Review of Bariatric Surgery Provision and Access Criteria in the Context of the All Wales Obesity Pathway Report’ to optimise patients outcomes and ensure that patients in Wales have access to sustainable, safe and high quality bariatric services.

They also want a “step by step increase” in the population rate of bariatric surgery to ensure a move to full compliance with NICE guidelines and BOMSS standards.

National Institute for Health and Care Excellence (NICE) guidelines stipulate morbidly obese patients with a BMI of 40 or higher should have access to bariatric surgery, or with a BMI of 35 or higher if they suffer from other obesity-related illnesses.

However, in Wales, current restrictions mean patients require a BMI higher than 50 – and to suffer from other related health problems such as high blood pressure, diabetes or cardiovascular disease – before they can access surgery.

There is currently only one unit in Wales funded to provide obesity surgery, the Welsh Institute of Metabolic and Obesity Surgery (WIMOS) at Morriston Hospital, Swansea. WIMOS provides a full multi-disciplinary team, pre-operative assessment and follow-up service for two years following surgery. WIMOS has two full time consultant bariatric surgeons. Currently, patients in North Wales travel to England to have surgery.

Notes to editors

• The Royal College of Surgeons is a professional body that sets the highest possible standards for surgical practice and training in order to deliver safe and high quality patient care. The Royal College of Surgeons Professional Affairs Board in Wales provides a means by which surgeons at the front line can work together to share information, bring concerns to local decision-makers and look for solutions which benefit patients and lead to better patient outcomes. http://www.rcseng.ac.uk

• The British Obesity & Metabolic Surgery Society (BOMSS) is the professional society of surgeons involved in obesity management. Membership of the society includes medical professionals and allied health professionals including specialist nurses, psychologists and dieticians. BOMSS aims to promote the development of high quality centres for obesity surgery, to educate and train future obesity surgeons and practitioners and to guide commissioning and policy for the use of obesity surgery in the UK.
http://www.bomss.org.uk