Blood work should be obtained immediately following surgery to assess the patient’s electrolyte and blood counts. In addition, patients with super morbid obesity or extended operative times should have a creatine phosphokinase level checked to rule out the possibility of gluteal compartment syndrome and rhabdomyolysis. In such patients, early intervention could be lifesaving and decrease the potential for renal damage [5].

It is critical in the immediate postoperative period to ensure that patients are adequately hydrated. Laboratory values, along with urine output and fluid balance assessment, aid the clinician in assessing adequate hydration. Routine blood work including complete blood count, basic metabolic panel, and magnesium levels should be obtained on morning rounds during the inpatient stay. The suspicion of intraluminal or intraperitoneal hemorrhage may prompt the clinician to order additional hematocrit levels and coagulation studies. Patients with known diabetes mellitus or elevated perioperative blood glucose should undergo glucose level testing while on NPO and when diet is begun. Insulin regimens frequently need to be adjusted due to altered dietary intake, highlighting the importance of close glucose monitoring [6].

Inadequate pain control in the postoperative period may lead to patient discomfort, dissatisfaction, and increased length of stay. It can also limit the patient’s ability to take deep breaths and attain early ambulation. This can consequently contribute to other complications such as atelectasis, pneumonia, and VTE. Tachycardia may result, which can unnecessarily confound the clinical picture for the surgeon and trigger an unnecessary work-up. There must be a balance between appropriate pain management and over-sedation of the patient. Clinicians and ancillary staff must have a high index of suspicion for over-sedation and the potential cardiopulmonary consequences.

Intravenous (IV) opioids may be scheduled or delivered by patient controlled anesthesia depending on the surgeon’s preference. Adjuncts to this may include IV administration of acetaminophen and ketorolac if not contraindicated. Once a clear liquid diet is started, conversion to oral pain medication is appropriate with use of IV opioids for breakthrough pain only. Strategic administration of local anesthetics using continuous delivery catheters has also been utilized by some in efforts to decrease opioid use. Abdominal binders and icing may assist in ameliorating postoperative discomfort.

The postoperative respiratory care of the bariatric patient is of paramount importance. Immediately upon arrival to the floor, patients should be provided with an incentive spirometry device and be instructed on spirometer utilization as well as coughing and deep breathing. This aggressive pulmonary toilet routine can decrease pulmonary complications such as atelectasis and pneumonia [7]. A dedicated respiratory therapist plays an important role in the pulmonary toilet regimen.

Many bariatric patients suffer from obstructive sleep apnea and proper utilization of their own CPAP or BiPAP machines is essential at all times while sleeping. Oxygen supplementation may also be necessary and O₂ saturations should be monitored in patients with known obstructive sleep apnea or other pulmonary symptoms requiring O₂. This can be done safely on a monitored floor [8].

Bariatric patients are predisposed to develop venous thrombosis leading to pulmonary embolism [9, 10]. Laparoscopic bariatric procedures are often associated with prolonged operative times, steep reverse Trendelenburg positioning, pneumoperitoneum pressures up to 18 mmHg, and decreased perioperative mobility. These factors further contribute to the increased risk of VTE in bariatric surgical patients. Although VTE may be infrequent, it still remains a significant postoperative cause of death in this patient population, making VTE prophylaxis crucial [11].

Preoperatively, patients may benefit from 5,000 units of subcutaneous heparin prior to inducing general anesthesia [12]. Postoperative recommendations include early ambulation, sequential venous compression devices, and aggressive hydration [13]. Additionally, chemoprophylaxis may be considered and is an acceptable practice. However, there is no level I evidence to substantiate additional benefits of chemoprophylaxis over its risks in bariatric surgery patients. Continuation of anticoagulation for approximately 1 or 2 weeks following discharge has been considered and employed in high-risk patients with super morbid obesity, known hypercoagulable state, or history of VTE [14].

In some practices, upper gastrointestinal (UGI) contrast study is performed routinely on postoperative day 1 to evaluate the integrity and patency of the gastrojejunostomy in LRYGB and the duodenojejunostomy in BPD-DS or the patency of a sleeve gastrectomy. A delayed film may also be performed to assess the patency of the jejunojejunostomy. However, the utility of routine UGI contrast studies has come into question. Several authors advocate the use of selective UGI contrast studies based upon each patient’s clinical status, symptoms, and drain amylase level [15]. Following purely restrictive procedures, such as the LAGB and LSG, an UGI contrast study is often employed to rule out obstruction and to obtain a baseline radiograph of band position. However, some have advocated that the utility of UGI contrast studies in LAGB may be limited [16].

Patients generally remain on NPO with IV hydration on the night of surgery and are started on a bariatric clear liquid diet on postoperative day 1 [6]. For patients undergoing a routine UGI contrast study, diet is started after the study is determined to show no complication. The bariatric clear liquid diet consists of no added sugar liquids with minimal gastrointestinal residue and no carbonation or caffeine [6]. Fluid intake is usually regulated during the inpatient postoperative stay to ensure that patients are able to tolerate diet before advancement. The familiarity of the bedside nurse and patient with the dietary restrictions is essential. Patient education regarding further diet progression following discharge from the hospital should be provided. Also, patients may be encouraged to record fluid intake and keep a diet journal to improve compliance. The traditional diet advancement after discharge involves clear to full liquid, pureed, soft, and finally to a regular maintenance bariatric diet [17]. As diet is advanced, patients should continue to eat small, balanced meals with adequate protein intake in the range of 60 g/day up to 1.5 g/kg/day based on ideal body weight [6]. Commencement of vitamin and trace element education should also start before discharge.