Patients should refrain from use of tobacco. Cessation of smoking is encouraged at least 6 weeks prior to surgery; however, some insurance companies may require cessation before that point. Cessation is important due to tobacco’s deleterious effects on wound healing, anastomotic ulcer development, and overall poor health.

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) is the accrediting body for bariatric surgery centers. Each level of accredited centers performs within a certain facility volume, patient age range, and with specific required standards.

A multidisciplinary care team is essential to the care of patients receiving bariatric surgery, and this multidisciplinary team works with the program director to guide therapy and monitoring of patients within the center.

In addition to surgical teams, these may consist of mental health professionals, exercise physiologists, dietitians, bariatricians, internists, pharmacists, and nurses.

Many bariatric surgery programs have implemented Enhanced Recovery After Surgery (ERAS) protocols that include oral intake of a high-carbohydrate liquid the night before surgery and 2–4 hours prior to surgery. Antiemetics and multimodal pain medication regimens, including acetaminophen, gabapentin, celecoxib, scopolamine, and aprepitant, among other agents, are used to limit postoperative nausea and vomiting (PONV) and narcotic usage.

Use of ERAS has also been associated with decreased length of stay, with no difference in adverse effects.

Medications for mental illness, seizures, thyroid conditions, and others where abrupt withdrawal will cause issues (e.g., beta blockers) are continued immediately postoperatively.

Medications that impact blood glucose, such as insulin or sulfonylureas, may be held with appropriate monitoring. Short-acting insulin is used commonly in the immediate postoperative period to control blood glucose, though at discharge from the surgical encounter, insulin may only be necessary for patients with insulin-dependent diabetes mellitus.

Some blood pressure agents (i.e., diuretics, angiotensin-converting enzyme inhibitors) are typically withheld to avoid dehydration or acute kidney injury immediately following surgery.

Patients are at increased risk of VTE following surgery and should receive VTE chemo-prophylaxis for a short period of time following surgery in addition to early ambulation and sequential compression devices. Risk calculators, such as one from the Cleveland Clinic, are available to assess the risk of VTE using patient-specific factors. As with preoperative VTE prophylaxis, dosing strategy following surgery is not universally recognized; provider discretion in collaboration with the patient’s primary care provider is common practice.

Patients require acid-suppression therapy, such as proton pump inhibitors, for at least 3 months following surgery to protect the anastomoses and staple line. Continuation of these after the 3-month period is dependent upon patient-specific factors, such as reflux.

Use of vitamins is critical to obtaining adequate vitamin and mineral levels following surgery. Vitamin and mineral levels should be monitored every 3, 6, or 12 months to ensure adequate nutrition and vitamin supplementation.

Some medications may increase the risk of complications in the postoperative period.

As examples, use of medications that decrease blood glucose levels should be avoided or have the dose reduced to avoid hypoglycemia; estrogen-containing medications may increase the risk of VTE and should be avoided, particularly in patients who have additional risk factors.

Nonsteroidal anti-inflammatory drugs (NSAIDs) should be completely avoided after bariatric surgery, if possible, because they have been implicated in the development of anastomotic ulcerations/perforations. Use of alternative medication classes, such as corticosteroids, may be substituted for NSAIDs if future diagnoses require, such as pericarditis or arthritis.

Vitamin deficiencies occur in bariatric surgery patients due to inherently low-caloric intake, alterations in gastric acid production and gastrointestinal (GI) transit time, bypassed portions of small bowel, and small intestinal bacterial overgrowth.

The most commonly deficient nutrients are fat-soluble vitamins or those normally absorbed by the bypassed duodenum. Patients must take supplemental folate, iron, calcium, in addition to vitamins B1 (thiamine), B12 (cyanocobalamin), A, and D.

There are commercially available over-the-counter preparations in doses appropriate for bariatric patients, or usual over-the-counter sources may be used in amounts greater than standard recommendations. For example, RYGB patients require a multivitamin with 200% of the recommended daily dose of nutrients.

Special attention to dosage forms is required following bariatric surgery. Alterations in gastric pH, time spent within the stomach, and specific location of absorption from the GI tract are critical elements that may alter how much of an oral medication is absorbed.

Surgeries that alter the length of the GI tract, such as RYGB, are likely to have a bigger impact upon the dosage forms used to deliver medication compared with restrictive procedures.

Patients requiring oral contrast following bariatric surgery require a lower volume with imaging performed more quickly than in nonbariatric surgery patients.