Dietetic-led management of patients undergoing laparoscopic gastric banding: early results

Preoperative nutritional management of bariatric patients in Australia: The current practice of dietitians

AIM

The aim of this observational study was to investigate the reported practices of Australian dietitians managing bariatric surgery patients in the preoperative stage.

METHODS

An online survey of dietitians providing nutritional care to bariatric patients was developed for the purpose of this investigation. The survey questions were guided by the Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic and Nonsurgical Support of the Bariatric Surgery Patient guidelines and current literature.

RESULTS

Ninety-nine dietitians completed the survey. Most participants recommended one to two different medical nutrition therapy strategies for preoperative weight loss (n = 69, 74%), with a very-low-energy diet exclusively from liquid meal replacements being the most frequently prescribed (n = 62, 69%). A significantly higher proportion of dietitians working privately reported the involvement of a bariatric surgeon in the multidisciplinary team (P = 0.002). More private practitioners also reported providing education on the nutritional consequences of the different types of bariatric procedures (P = 0.005) and postoperative vitamin and mineral supplementation (P = 0.013), as well as the use of the guidelines to guide their practice (P = 0.014), compared to dietitians who worked in the public sector. A higher proportion of dietitians working in metropolitan areas reported that screening occurred more frequently for vitamin D (P = 0.008), fasting blood lipids (P = 0.03) and glycated haemoglobin (P = 0.003) compared to those in regional/rural/remote areas.

CONCLUSIONS

Reported preoperative screening practices were not consistent with the recommendations from the literature and current American guidelines. Further investigation into the difference in the nutritional management strategies and work environments is warranted.

Weight loss outcomes among patients referred after primary bariatric procedure

BACKGROUND

Bariatric patients may not always obtain long-term care by their primary surgeon. Our aim was to evaluate weight loss outcomes in patients who had surgery elsewhere.

METHODS

We conducted a retrospective analysis. Postreferral management included nonsurgical, revision, or conversion. Primary outcomes were percent excess weight loss (%EWL) overall, according to original operation, and based on postreferral management.

RESULTS

Between 2001 and 2013, there were 569 patients. Mean follow-up was 3.1 years. Management was 42% nonsurgical, 41% revision, and 17% conversion. Overall, mean %EWL was 45.3%. Based on original surgery type, %EWL was 41.2% for adjustable gastric banding vs 58.3% for Roux-en-Y gastric bypass (P ≤ .0001). Management affected %EWL (41.2% nonsurgical vs 45.3% revision vs 55.1% conversion, P ≤ .0001).

CONCLUSIONS

Patients referred after bariatric surgery can achieve satisfactory weight loss. This differs based on surgery type and management strategy.

Outcome reporting in bariatric surgery: an in-depth analysis to inform the development of a core outcome set, the BARIACT Study

Outcome reporting in bariatric surgery needs a core outcome set (COS), an agreed minimum set of outcomes reported in all studies of a particular condition. The aim of this study was to summarize outcome reporting in bariatric surgery to inform the development of a COS. Outcomes reported in randomized controlled trials (RCTs) and large non-randomized studies identified by a systematic review were listed verbatim and categorized into domains, scrutinizing the frequency of outcome reporting and uniformity of definitions. Ninety studies (39 RCTs) identified 1,088 separate outcomes, grouped into nine domains with most (n = 920, 85%) reported only once. The largest outcome domain was 'surgical complications', and overall, 42% of outcomes corresponded to a theme of 'adverse events'. Only a quarter of outcomes were defined, and where provided definitions, which were often contradictory. Percentage of excess weight loss was the main study outcome in 49 studies, but nearly 40% of weight loss outcomes were heterogeneous, thus not comparable. Outcomes of diverse bariatric operations focus largely on adverse events. Reporting is inconsistent and ill-defined, limiting interpretation and comparison of published studies. Thus, we propose and are developing a COS for the surgical treatment of severe and complex obesity.

The relationship of distance from the surgical centre on attendance and weight loss after laparoscopic gastric bypass surgery in the United Kingdom

Obesity remains a significant worldwide health problem and is currently increasing. Surgery remains the only proven long-term intervention and has been shown to be cost-effective. Evidence suggests that regular follow-up following laparoscopic adjustable gastric banding is related to improved outcome, such evidence is lacking for laparoscopic gastric bypass surgery (laparoscopic Roux-en-Y gastric bypass [LRYGB]). This study examines the effect of distance on attendance at post-operative clinics and subsequent weight loss following surgery. A prospectively maintained database was interrogated to analyze patients undergoing LRYGB before August 2010. Patient demographics, percentage excess weight loss (%EWL), compliance with out-patient clinic attendances and the distance the patients lived from the hospital were examined. Perfect clinic attendees were compared with non-attendees and the distances patients lived from the hospital evaluated. There was a significantly greater %EWL at 1 year post-op observed in the perfect attendees group (65.5 vs. 59.5, P = 0.01). Increased %EWL was also evident at 2 years post-op but did not reach statistical significance (66.9 vs. 59.5, P = 0.06). There was a negative correlation observed between post-operative weight loss and distance from the bariatric centre (R = -0.21, P = 0.04). Close follow-up following LRYGB is essential to optimize outcomes. Increased frequency of out-patient clinic visits was associated with improved post-operative weight loss. Increasing distance between the patient's home and the bariatric centre was associated with worse post-operative weight loss.

Laparoscopic adjustable gastric banding: a 10-year single-centre experience of 575 cases with weight loss following surgery

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) is one of the commonest bariatric procedures in the UK. This study reports our experience with this procedure over the last 10 years.

METHODS

A prospectively maintained database of all the patients undergoing LAGB at our centre between March 2000 and August 2010 was analysed.

RESULTS

Five hundred seventy-five patients underwent LAGB at our centre. There was no mortality in this series. Early (30-day) morbidity rate was 2.2 %. Late complications (20 %) comprised: 78 repositioning of the inflation port in 65 patients, repositioning of band in 24 patients (4 %), removal of band in 20 patients (3.4 %), conversion to bypass in 41 patients (7 %), diagnostic laparoscopy in 1 patient and subtotal gastrectomy in 1 patient. Median follow-up was 29 months. The median of percentage of weight loss (%WL) and excess body weight loss (EBWL) was 18.3 and 40 %, respectively, at ≥ 5 years post-LAGB. Patients with body mass index (BMI) over 50 kg/m(2) were compared to those with BMI ≤ 50 kg/m(2). No significant difference was noted in the weight loss between both of these groups. No significant difference was noted with regards to weight loss between patients <60 and >60 years of age.

CONCLUSIONS

In this cohort of patients, %WL and EBWL were 18.3 and 40 % ≥ 5 years after LAGB, respectively, and early and late complication rates were 2.2 and 20 %, respectively. Majority of late complications were in the first 100 patients. Multifactorial causes included the surgical learning curve and patient selection process.