Consultation with the bariatric surgeon includes discussion of the recommended procedure with explanation of the risks and benefits. The final decision whether treatment is offered is then based on completion of the cumulative multidisciplinary evaluation. Baseline laboratory studies include a complete blood count, comprehensive metabolic profile, type and screen, coagulation studies, liver function, lipid profile, thyroid function, glycosylated hemoglobin, ferritin levels, and vitamins. Ultrasonography of the abdomen is performed to assess for biliary tract pathology and cholelithiasis. Patients in the high-risk medical group are referred for additional investigations or consultations from other subspecialties as medically indicated, with special emphasis on cardiopulmonary assessment. Standard investigations will at minimum include a chest X-ray and electrocardiogram. Patients that demonstrate a significant cardiac history or major clinical predictors for a cardiac event (unstable coronary syndromes, decompensated CHF, significant arrhythmias, or severe valvular disease) are referred to cardiology for preoperative evaluation. Patients with poor functional capacity (<4 METS) or have at least intermediate clinical predictors for a cardiac event (mild angina pectoris, prior myocardial infarction, compensated or prior CHF, diabetes mellitus, and renal insufficiency) are often evaluated with an echocardiogram or dobutamine stress echocardiogram as indicated as well as consideration for the use of perioperative beta blockade. Patients with a BMI > 50 or an Epworth sleepiness scale > 10 are routinely referred for polysomnography and consultation with sleep medicine to evaluate need for a continuous positive airway pressure (CPAP) device [41].

The number of nutritional sessions (range 3–6 months) is typically designated by different insurance carriers. Each session should document weight, diet, exercise regimens, and overall compliance. With regard to the psychological assessment, patients under the age of 18 years are evaluated by adolescent medicine or pediatric behavioral health. Adults are seen by a team of psychologists, and recommended follow-up visits are determined depending on pathway classification after the initial interview and brief questionnaire. Patients may also be referred to behavioral health groups (Table 3) to help change behavioral, emotional, or psychological patterns that may interfere with a good surgical outcome.

Revisional bariatric surgery patients are at higher risk for operative complications; therefore, a specific pathway was created for their preoperative assessment. Available previous medical records and diagnostic studies are obtained and reviewed. In addition to the above mentioned evaluation, all patients undergo upper endoscopy and UGI barium swallow studies for complete understanding of patient anatomy and physiology prior to selecting the appropriate revision or staged procedure indicated.

Regular follow-up visits after surgery serve as a continuation of the initial assessment to help patients maintain their personal and health goals as well as evaluate compliance with lifestyle changes. The outpatient follow-up scheme is shown in Table 4. Routine follow-up appointments after bariatric surgery are scheduled at 1 week postoperatively, followed by 1 month postoperatively, and then every 3 months until 18 months at which time they return annually. Surgeons visit with the patients at the 1 week, 1 month, and annual visit. The remainders of the visits starting at the 1-month visit consist of appointments held with nutrition, psychology, and the bariatrician. Patients receive individual monitoring of diet progression, medications and nutritional supplements, exercise, blood work as needed, and disease management. The bariatrician then leads a shared appointment of patients in groups of 10–12 for 90 min to discuss relevant health-care issues in a relaxed and supportive group setting, allowing for patients to have the opportunity to talk with each other about their own experiences or concerns. Patient feedback from this type of follow-up visit has been positive as it provides companionship within the group for supportive reassurance and encouragement.