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    Our Practice

    Supporting the Sunshine Coast for over 20 years, Dr Ian Baxter and his multi-disciplinary team at Sunshine Coast Medical Weight Loss Centre work in partnership with you and your patients to help them achieve positive long-term health outcomes.

    Bariatric surgery is a recommended treatment option for obese people who have unsuccessfully tried to lose weight for some time using supervised diet, exercise or other behaviour modification programs.

    Typically, these are people over 16 with a BMI of 35-40 or above, including those with existing co-morbidities or at risk of developing serious weight-related health conditions.

    Dr Baxter and his team of bariatric GPs, dietitians, psychologists and a Bariatric Navigator operate under one roof at Sippy Downs, making it easy for your patients to access all the services they need in one convenient location. Telehealth appointments are also available for people living outside of the area.

    Dr Baxter performs surgery at Buderim and Sunshine Coast University Private Hospital, including Gastric Banding, Gastric Sleeve, Mini-Bypass and bariatric revisional surgery.

    Expected Benefits

    Dependant of the person and the procedure, individuals can expect:

    • 17-35% weight reduction in the first 2 years [2]
    • Persistent 18% weight reduction up to 20 years [3]
    • Reduced cardiovascular mortality by 50% up to 14 years [4]
    • In obese diabetics, 50% achieve target HbA1c≤7.0% at 5 years [5]
    • In obese diabetics, 12–25% achieve cessation of hypoglycaemic medications at 5 years[4], and 50% reach a target HbA1c ≤7.0% at 5 years[5].
    • In sleep apnoea, reduced average respiratory distress index from severe to mild[6]
    • Improved quality of life scores by 16-17 on the RAND SF-36 survey[5]

    Who and what

    Patient Eligibility

    Who should have bariatric surgery?

    The NHMRC recommends bariatric surgery[7] be considered for

    • individuals with BMI >40 kg/m2
    • individuals with BMI >35 kg/m2 with one or more obesity-related complications.


    In a consensus statement by major international diabetes organisations endorsed by the Australian Diabetes Society[8], bariatric–metabolic surgery is recommended for

    • all individuals with T2 diabetes and BMI ≥40 kg/m2
    • individuals with BMI 35–40 kg/m2 with inadequate glycaemic control despite lifestyle and optimal medical therapy.

    What is the best bariatric procedure for my patient?

    In consultation, patients will be offered the most appropriate options depending on their BMI, co-morbidities, age, and other factors. As a guide:

    Adjustable Gastric Banding

    This is the least invasive bariatric procedure with the fewest perioperative complications. However, some patients will require band removal due to insufficient weight loss, GORD symptoms, or band slippage. It  requires ongoing medical management to adjust the band, although once stable the band may not need adjustment for months or years. Banding is well suited to older patients, those with higher operative risk, and those at the lower BMI range of obesity.

    Sleeve Gastrectomy

    This is moderately invasive as it involves the removal of around 70-80% of the stomach. Unlike banding, this procedure is not reversible. It can also cause increased GORD symptoms, however insufficient weight loss is less common and there is no band so there can be no slippage. Patients need fewer ongoing medical visits compared to banding, however they still require regular review for nutritional status. Sleeve gastrectomy is well suited to patients who require moderate weight loss or who have not had success with banding.


    Roux-en-Y and Omega Loop Gastric Bypass 

    is the most invasive bariatric procedure with the greatest postoperative morbidity, however it has the greatest average weight loss, and unlike banding and sleeve gastrectomy, it may reduce GORD symptoms. If necessary the bypass can be surgically reversed, although this is uncommon. As for gastrectomy, ongoing nutrition review is essential. Bypass is well suited for patients with higher BMIs, those with significant GORD, or where other procedures have not been successful.

    Compare Surgical Options

    Bariatric Surgery Options

    ADJUSTABLE GASTRIC BAND SLEEVE GASTRECTOMY ROUX-EN-Y GASTRIC BYPASS
    DESCRIPTION Adjustable silicone band placed just below the gastroesophageal junction, applying gentle pressure that suppresses hunger. Level of restriction can be adjusted by varying the amount of fluid placed in the band Greater portion of the fundus and body of the stomach is removed. Gastric volume is reduced by about 80%
    1. Small stomach pouch created, thereby reducing gastric volume.
    2. The pouch is joined to the jejunum, hence, diverting nutrients from lower stomach, duodenum and proximal jejunum
    MEAN TOTAL BODY WEIGHT LOSS 17 – 30% 20 – 30% 25 – 35%
    MORTALITY RATE AT 30 DAYS 0.03 – 0.1% 0.3 – 0.5% 0.1 – 0.4%
    MORBIDITY AT 1 YEAR 4.6% 10.8% 14.9%
    NUTRITIONAL CONCERNS Low (deficiencies in iron, vitamin B12, folate, thiamine) Moderate (deficiencies in iron, vitamin B12, folate, calcium, vitamin D, thiamine, copper, zinc) Moderate (deficiencies in iron, vitamin B12, folate, calcium, vitamin D, thiamine, copper, zinc)
    ADVANTAGES
    • Effective, with good long-term weight maintenance
    • Degree of restriction adjustable
    • Reversible
    • Lowest morbidity and mortality rate
    		 Very effective with good mid-term weight maintenance
    • Largest amount of weight loss with good long-term weight maintenance
    • Highest rate of diabetes remission (for patients with pre-existing type 2 diabetes mellitus)
    DISADVANTAGES & KEY COMPLICATIONS Highest long-term re-operation rate Gastric pouch dilatation, erosion of band into the stomach, leaks to the adjustable gastric band system, weight regain.
    • Staple line leak, gastroesophageal reflux disease, dilatation of the gastric remnant, weight regain
    • Limited long-term data
    		 Staple line leak, dumping, stomal ulcer, intestinal obstruction, gallstones, nutritional deficiency, altered alcohol metabolism, weight regain
    ADJUSTABLE GASTRIC BAND
    DESCRIPTION
    Adjustable silicone band placed just below the gastroesophageal junction, applying gentle pressure that suppresses hunger. Level of restriction can be adjusted by varying the amount of fluid placed in the band
    WEIGHT LOSS
    17 – 30%
    30-DAY MORTALITY
    0.03 – 0.1%
    1-YEAR MORBIDITY
    4.6%
    NUTRITIONAL CONCERNS
    Low (deficiencies in iron, vitamin B12, folate, thiamine)
    ADVANTAGES
    • Effective, with good long-term weight maintenance
    • Degree of restriction adjustable
    • Reversible
    • Lowest morbidity and mortality rate
    DISADVANTAGES
    Highest long-term re-operation rate. Gastric pouch dilatation, erosion of band into the stomach, leaks to the adjustable gastric band system, weight regain.
    SLEEVE GASTRECTOMY
    DESCRIPTION
    Greater portion of the fundus and body of the stomach is removed. Gastric volume is reduced by about 80%
    WEIGHT LOSS
    20 – 30%
    30-DAY MORTALITY
    0.3 – 0.5%
    1-YEAR MORBIDITY
    10.8%
    NUTRITIONAL CONCERNS
    Moderate (deficiencies in iron, vitamin B12, folate, calcium, vitamin D, thiamine, copper, zinc)
    ADVANTAGES
    Very effective with good mid-term weight maintenance
    DISADVANTAGES
    • Staple line leak, gastroesophageal reflux disease, dilatation of the gastric remnant, weight regain
    • Limited long-term data
    ROUX-EN-Y GASTRIC BYPASS
    DESCRIPTION
    1. Small stomach pouch created, thereby reducing gastric volume.
    2. The pouch is joined to the jejunum, hence, diverting nutrients from lower stomach, duodenum and proximal jejunum
    WEIGHT LOSS
    25 – 35%
    30-DAY MORTALITY
    0.1 – 0.4%
    1-YEAR MORBIDITY
    14.9%
    NUTRITIONAL CONCERNS
    Moderate (deficiencies in iron, vitamin B12, folate, calcium, vitamin D, thiamine, copper, zinc)
    ADVANTAGES
    • Largest amount of weight loss with good long-term weight maintenance
    • Highest rate of diabetes remission (for patients with pre-existing type 2 diabetes mellitus)
    DISADVANTAGES
    Staple line leak, dumping, stomal ulcer, intestinal obstruction, gallstones, nutritional deficiency, altered alcohol metabolism, weight regain

    Pre-op

    Before the Procedure

    Initial Work-up

    We tailor assessment according to the individual’s risk factors. Common clinical observations and investigations include;


    History:

    Weight history (eg age of onset of obesity, minimum and maximum weight), previous weight loss attempts (including diets, medications, previous weight-loss surgery), triggers for weight gain/regain. Obesity-related comorbidities, family history, medication history. Current lifestyle: dietary behaviour and physical activity levels; work and home environment, psychosocial support.

    Physical Examination:

    Weight, body mass index, blood pressure. Signs of specific causes of obesity (eg hypothyroidism, Cushing’s syndrome).

    Investigations:

    Full blood count, urea and electrolytes, liver enzymes, coagulation screen, fasting lipids and glucose, HbA1c.

    In known T2DM, C-peptide for pancreatic beta cell function.

    Nutrition: ferritin, vitamin B12, folate, 25-OH vitamin D and Zinc.

    For individuals with specific risks: ECG, echocardiogram or cardiology referral. Endoscopy for GORD, upper GI ultrasound for NASH or gallstones. Polysomnography for sleep apnoea.

    Psychological:

    Assess commitment, motivation, readiness to change, as well as understanding and expectations of surgery. Psychiatry review if known or suspected history of psychiatric illness or substance abuse.

    We welcome referrals that include essential investigations as this can expedite the assessment process, however it is not necessary.

    Pre-operative Assessment

    Once a decision has been made for bariatric–metabolic surgery, a series of detailed assessments would be organised.

    Nutritional assessment:

    Every patient will see one of the dietitians at the SCMWLC prior to surgery. In this session, they will be prepared for what the journey ahead will look like from a nutritional perspective.  A state of high-energy malnutrition is often observed in clinically severe obesity, which is masked by ample energy excess. Up to 80% of bariatric–metabolic surgery candidates have micronutrient deficiencies pre-operatively, and appropriate nutritional assessment allows deficiencies to be corrected prior to surgery.

    Identifying and optimising complications prior to surgery:

    Pre-operative assessment also includes identification and optimisation of obesity-related complications, with the aim to improve peri-operative safety and outcomes after surgery.

    Psychological assessment:

    Prior to surgery, thorough assessment of the patient’s behaviour, home and work environments, family dynamics, and their ability to incorporate nutritional and lifestyle changes should be conducted. Incorrect beliefs and unrealistic expectations on what the procedure can achieve must be rectified. Depression, anxiety and other psychiatric disorders are prevalent in individuals considering bariatric–metabolic surgery.

    Anatomical assessment:

    As part of the pre-operative assessment, evaluation of the upper gastrointestinal anatomy may be performed, depending on factors such as the presence of gastrointestinal symptoms or type of surgery being considered.

    timeline

    Post-Operative Care Plan

    The team at SCMWLC have a very strong presence in the patient’s journey post-surgery.

    Week of Surgery

    Post-Op Call

    The team will do a post-operative phone call with the patient to ensure they are travelling well and to answer any questions or concerns they may have coming into the weekend.

    1 WEEK AFTER

    Surgeon Assessment

    You’ll have a post-operative appointment with Dr Baxter to review your wounds and overall recovery. For patients who need to travel, this appointment can also be completed via telehealth.

    3 WEEKS AFTER

    Dietitian – Soft Food

    Appointment with the Dietitian where they will prepare the patient for the soft stage.

    8 WEEKS AFTER

    Dietitian – Full Food

    Appointment with the Dietitian where they will prepare the patient to move to full food.

    3 MONTHS AFTER

    Surgeon & Dietitian Appointment

    Appointment with both the Dietitian and Dr Baxter to assess their weight loss and how they are travelling.

    6 MONTHS AFTER

    Psychologist Assessment + Blood Test

    Appointment with Psychologist and Dietitian. This is a very important appointment where the team organise full bloods to be taken prior to. The dietitian will assess their blood levels to make sure they are not lacking anything and that they are getting in enough protein and having a healthy relationship with food. The psychologist will meet up with the patient at 6 months, as this appears to be the time when patients experience “the head games”.

    12 MONTHS AFTER

    Continued Care

    Dr Baxter or the Bariatric Navigator will follow up with the patient and organise full bloods to ensure they are not malnourished.

    Maintenance of physical activity post bariatric–metabolic surgery aids in maintaining muscle strength, enhanced fitness and greater weight loss. Moderate-intensity physical activity of at least 150 minutes per week and a future target of 300 minutes per week (including strength training) two to three times per week is recommended.

    Medications

    Adjustment of Chronic Medications

    In patients with T2DM, adjustments to the antidiabetes agents are frequently necessary in the early postoperative period to prevent hypoglycaemia.

    • Insulin secretagogues (ie sulphonylureas, metiglinides) should be discontinued.

    • Insulin doses should be reduced as appropriate.

    • Metformin may be continued postoperatively, with withdrawal considered if stable non-diabetic glycaemia (ie glycated haemoglobin in the normal range) is demonstrated.

    Screening for diabetes complications should continue even with diabetes remission, at least for the first five years.

    Lipids and Blood Pressure

    The effect of weight loss on lipids, especially low-density lipoprotein, is variable and generally modest. Therefore, lipid-lowering medications should not be discontinued unless clearly indicated.

    Although blood pressure often improves with weight loss, antihypertensives should be actively titrated on follow-up.

    Medications Requiring Close Monitoring

    Medications with a narrow therapeutic index (eg warfarin, digoxin, lithium, antiepileptic medications) require close monitoring and titration because of altered oral drug bioavailability following bariatric–metabolic surgery.

    Monitoring(9)

    Post Operative Monitoring

    Weight Loss & Lifestyle

    • Monitor weight loss progress and complications at each visit
    • Monitor adherence to appropriate diet and physical activity levels

    Laboratory Assessment

    • Every 6–12 months: Full blood count, urea and electrolytes, liver function tests, uric acid, glucose, lipids, Zinc and Vit A
    • Every 12 months: 25-OH vitamin D, iPTH, calcium, albumin, phosphate, B12, folate, iron studies, Zinc and Vit A (more frequently if deficiencies identified)

    Medication Review

    • Avoid nonsteroidal anti-inflammatory drugs (use them occasionally only)
    • Adjust antihypertensives, lipid medications as appropriate
    • Adjust diabetes medications – requirement for anti-diabetes medications often decreases, and in many cases, diabetes remission is achieved. Preference for use of agents with favourable weight profile.

    Nutritional Supplements

    • Adult multivitamin and multimineral – containing iron, folic acid, thiamine, vitamin B12. Doses: two daily for sleeve gastrectomy or Roux-en-Y or Omega Loop gastric bypass; one daily for adjustable gastric band
    • Citrated calcium – elemental calcium 1200–1500 mg/day
    • Vitamin D – titrate to 25-OH vitamin D levels >30 ng/mL. Typical dose required 3000 IU/day
    • Additional iron and vitamin B12 supplementation as required, based on lab results

    risks

    Complications

    Early complications

    Complication Signs and Symptoms Management
    Surgical complications (eg leaks, perforations, obstruction, infection, haemorrhage) Abdominal pain, tachycardia, breathlessness, drop in haemoglobin
    • Usually detected during immediate postoperative period and managed by the surgical team
    • Presence of these symptoms should prompt urgent referral back to the surgical team
    Hypoglycaemia (usually in patients with pre-existing diabetes) Sweating, dizziness, headaches, palpitations
    Low capillary blood glucose on testing
    • Fairly common, especially in patients on insulin or insulin secretagogues
    • Stop sulphonylureas, and stop insulin or decrease dose
    • Close self-monitoring of capillary blood glucose
    Dumping syndrome after Roux-en-Y bypass Abdominal pain, diarrhoea, nausea, flushing, palpitations, sweating, agitation, and syncope after meals rich in simple carbohydrates
    • Dietary modification, with small regular meals containing protein and complex carbohydrates
    • Acarbose may be helpful in some refractory cases
    SURGICAL COMPLICATIONS
    COMPLICATION
    Surgical complications (eg leaks, perforations, obstruction, infection, haemorrhage)
    SIGNS & SYMPTOMS
    Abdominal pain, tachycardia, breathlessness, drop in haemoglobin
    MANAGEMENT
    • Usually detected during immediate postoperative period and managed by the surgical team
    • Presence of these symptoms should prompt urgent referral back to the surgical team
    HYPOGLYCAEMIA
    COMPLICATION
    Hypoglycaemia (usually in patients with pre-existing diabetes)
    SIGNS & SYMPTOMS
    Sweating, dizziness, headaches, palpitations
    Low capillary blood glucose on testing
    MANAGEMENT
    • Fairly common, especially in patients on insulin or insulin secretagogues
    • Stop sulphonylureas, and stop insulin or decrease dose
    • Close self-monitoring of capillary blood glucose
    DUMPING SYNDROME
    COMPLICATION
    Dumping syndrome after Roux-en-Y bypass
    SIGNS & SYMPTOMS
    Abdominal pain, diarrhoea, nausea, flushing, palpitations, sweating, agitation, and syncope after meals rich in simple carbohydrates
    MANAGEMENT
    • Dietary modification, with small regular meals containing protein and complex carbohydrates
    • Acarbose may be helpful in some refractory cases

    Later complications

    Complication Signs and Symptoms Management
    Iron-deficiency anaemia Microcytic, hypochromic anaemia, lethargy, anorexia, pallor, hair loss, muscle fatigue
    • Oral iron supplements, consider intravenous iron for severe deficiency
    • Vitamin C to increase iron absorption
    • Rule out bleeding ulcers, neoplastic disease or diverticular disease
    B12 deficiency Macrocytic anaemia, leukopenia, glossitis, thrombocytopenia, peripheral neuropathy
    • Vitamin B12 repletion (oral or intramuscular)
    • Prevention – B12 containing multivitamin supplementation
    • Annual serum B12 level evaluation
    Thiamine deficiency Neurological symptoms, Wernicke’s encephalopathy in severe cases
    • Appropriate postoperative diet, with regular dietitian follow-up
    • Screen for other nutritional deficiencies
    • Thiamine supplementation
    Over-restricted gastric band (for patients with adjustable gastric band) Maladaptive eating, gastro-oesophageal reflux disorder, vomiting, regurgitation, chronic cough, or recurrent aspiration pneumonia
    • Reduce amount of fluid in gastric band
    • Consider referral to bariatric surgeon for assessment of band position and function
    Weight regain Maximal weight loss usually achieved at one to two years after surgery, with some weight regain thereafter
    • For patients with laparoscopic adjustable gastric band – evaluation of band, adjust as required
    • Consider adjuncts (eg very low energy diet, pharmacotherapy)
    • *Consider referral back to weight management clinic
    IRON-DEFICIENCY ANAEMIA
    SIGNS & SYMPTOMS
    Microcytic, hypochromic anaemia, lethargy, anorexia, pallor, hair loss, muscle fatigue
    MANAGEMENT
    • Oral iron supplements, consider intravenous iron for severe deficiency
    • Vitamin C to increase iron absorption
    • Rule out bleeding ulcers, neoplastic disease or diverticular disease
    B12 DEFICIENCY
    SIGNS & SYMPTOMS
    Macrocytic anaemia, leukopenia, glossitis, thrombocytopenia, peripheral neuropathy
    MANAGEMENT
    • Vitamin B12 repletion (oral or intramuscular)
    • Prevention – B12 containing multivitamin supplementation
    • Annual serum B12 level evaluation
    THIAMINE DEFICIENCY
    SIGNS & SYMPTOMS
    Neurological symptoms, Wernicke’s encephalopathy in severe cases
    MANAGEMENT
    • Appropriate postoperative diet, with regular dietitian follow-up
    • Screen for other nutritional deficiencies
    • Thiamine supplementation
    OVER-RESTRICTED GASTRIC BAND
    SIGNS & SYMPTOMS
    Maladaptive eating, gastro-oesophageal reflux disorder, vomiting, regurgitation, chronic cough, or recurrent aspiration pneumonia
    MANAGEMENT
    • Reduce amount of fluid in gastric band
    • Consider referral to bariatric surgeon for assessment of band position and function
    WEIGHT REGAIN
    SIGNS & SYMPTOMS
    Maximal weight loss usually achieved at one to two years after surgery, with some weight regain thereafter
    MANAGEMENT
    • For patients with laparoscopic adjustable gastric band – evaluation of band, adjust as required
    • Consider adjuncts (eg very low energy diet, pharmacotherapy)
    • *Consider referral back to weight management clinic

    Further Information

    www.racgp.org.au/afp/2017/july/bariatric–metabolic-surgery-a-guide-for-the-primary-care-physician/

    References

    1. Kaplan, Warren, et al. Priority Medicines for Europe and the World 2013 Update. World Health Organisation, 2013.
    2. Sjöström L, Narbro K, Sjöström CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007;357(8):741–52.
    3. Sjöström L. Review of the key results from the Swedish Obese Subjects (SOS) trial – A prospective controlled intervention study of bariatric surgery. J Intern Med 2013;273(3):219–34.
    4. Kwok CS, Pradhan A, Khan MA, et al. Bariatric surgery and its impact on cardiovascular disease and mortality: A systematic review and meta-analysis. Int J Cardiol 2014;173(1):20–28.
    5. Schauer PR, Bhatt DL, Kirwan JP, Wolski K, Aminian A, Brethauer SA, et al. Bariatric surgery versus intensive medical therapy for diabetes — 5-year outcomes. N Engl J Med 2017;376(7):641–51. doi: 10.1056/nejmoa1600869
    6. Haines KL, Nelson LG, Gonzalez R, Torrella T, Martin T, Kandil A, et al. Objective evidence that bariatric surgery improves obesity-related obstructive sleep apnea. Surgery 2007;141(3):354–8. doi: 10.1016/j.surg.2006.08.012
    7. National Health and Medical Research Council. Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. Melbourne: NHMRC, 2013. Available at www.nhmrc.gov.au/about-us/publications/clinical-practice-guidelines-management-overweight-and-obesity [Accessed 18 Aug 2019].
    8. Diabetes Australia. National Position Statement on weight loss surgery (bariatric surgery) and its use in treating obesity or treating and preventing diabetes [online]. 2011. Available at: https://static.diabetesaustralia.com.au/s/fileassets/diabetes-australia/23e8bc73-ca89-46bc-bb79-57dae257d89c.pdf [Accessed 19 Aug 2019].
    9. Lee PC, Dixon J. Bariatric–metabolic surgery: A guide for the primary care physician. Australian Family Physician 2017;46(7):465-471.
    10. Picot J, Jones J, Colquitt JL, Gospodarevskaya E, Loveman E. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess 2009;13(41) doi: 10.3310/hta13410
    11. Hoerger TJ. Economics and Policy in Bariatric Surgery. Current Diabetes Reports. 2019;19(6). doi: 10.1007/s11892-019-1148-z
    12. Medicare Benefits Schedule – Note AN.0.56 [online]. Available from: http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&qt=NoteID&q=AN.0.56 [Accessed 18 Aug 2019].
    —CL 2019
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