Predictors of attrition in bariatric aftercare: a systematic review of the literature

Characteristics of Patients Lost to Follow-up after Bariatric Surgery

After bariatric surgery lifelong follow-up is recommended. Evidence of the consequences and reasons for being lost to follow-up (LTFU) is sparse. In this prospective study follow-up data of all patients who underwent bariatric surgery between 2008 and 2017 at a certified obesity centre were investigated. LTFU patients were evaluated through a structured telephone interview. Overall, 573 patients (female/male 70.9%/29.1%), aged 44.1 ± 11.2 years, preoperative BMI 52.1 ± 8.4 kg/m2 underwent bariatric surgery. Out of these, 33.2% had type 2 diabetes mellitus and 74.4% had arterial hypertension. A total of 290 patients were LTFU, of those 82.1% could be reached. Baseline characteristics of patients in follow-up (IFU) and LTFU were comparable, but men were more often LTFU (p = 0.01). Reported postoperative total weight loss (%TWL) and improvements of comorbidities were comparable, but %TWL was higher in patients remaining in follow-up for at least 2 years (p = 0.013). Travel issues were mentioned as the main reason for being LTFU. A percentage of 77.6% of patients reported to regularly supplement micronutrients, while 71.0% stated regular monitoring of their micronutrient status, mostly by primary care physicians. Despite comparable reported outcomes of LTFU to IFU patients, the duration of the in-centre follow-up period affected %TWL. There is a lack of sufficient supplementation and monitoring of micronutrients in a considerable number of LTFU patients.

Patient proximity to follow-up care after bariatric surgery: Does it matter?

One factor that may play a significant role in the follow-up care compliance and long-term weight loss of post-bariatric surgery patients is the geographical distance from the surgery center to the patient's home address. This is a retrospective review which aims to evaluate whether the distance from a patient's home address to two Gundersen Health System (GHS) facilities (La Crosse and Onalaska, Wisconsin) is predictive of follow-up appointment compliance and subsequent long-term weight loss. 1336 patients undergoing bariatric surgery at GHS between October 15, 2013 and Dec 31, 2022 were included. Patients were grouped according to the distance between their home addresses and GHS with 60 ​% of patients living less than 30 miles from GHS, 33 ​% living 30 to 60 miles from GHS, and the remaining 7.3 ​% living >60 miles away. No significant difference was observed in the distribution of patients falling short, meeting, or exceeding the recommended number of post-operative appointments with a surgery provider based on proximity (p ​= ​0.10). As distance increased, the number of nutrition and behavioral health appointments completed per year decreased [nutrition/dietary appointments (p ​= ​0.046); behavioral health appointments (p ​= ​0.040)]. The pattern of percent excess weight loss (%EWL) over time was significantly different based on distance from home (p ​< ​0.001). Specifically, we found a similar %EWL among all groups in the first year post-operatively but an 18.8 ​% higher %EWL in the >60-mile group compared to the <60-mile group at 5 years (SE ​= ​5.4, P ​= ​0.0014). The lower number of post-op nutrition and behavioral health visits among patients living farther from the surgery center was an expected result, given potentially greater inconvenience of follow-up appointments for these patients. However, there was a paradoxical finding of significantly increased %EWL among patients living >60 miles from the surgery center. Greater distance from the bariatric surgical center was therefore not found to represent a barrier to favorable weight loss outcomes.

Factors Impacting One-year Follow-up Visit Adherence after Bariatric Surgery in West China: A Mixed Methods Study

PURPOSE

Quality follow-up (FU) is crucial after bariatric surgery. However, poor adherence after surgery is prevalent. This research aimed to explore the factors related to FU adherence after bariatric surgery in West China.

MATERIALS AND METHODS

This study used a sequential explanatory mixed-methods research design. Participants (n = 177) were identified from the West China Hospital. Demographic information, disease profile, treatment information, and post-surgery FU information were obtained from the bariatric surgery database of the Division of Gastrointestinal Surgery of the West China Hospital. The survey data were analyzed using logistic regression. Semi-structured interviews with participants (n = 10) who had low adherence were conducted. The recording was transcribed verbatim and entered into qualitative data analysis software. Qualitative data were analyzed using a content analysis approach.

RESULTS

Multiple logistic regression revealed that living in Chengdu (OR, 2.308), being employed (OR, 2.532), non-smoking (OR, 2.805), and having less than five years of obesity (OR, 2.480) were positive predictors of FU adherence within one year. Semi-structured interviews suggested that factors related to adherence to FU were lack of motivation, lack of opportunity, insufficient ability, and beliefs regarding consequences.

CONCLUSION

Factors impacting one-year FU visit adherence after bariatric surgery include not only demographic and disease-related factors but also social and family factors. These results will provide evidence to support healthcare professionals in developing personalized postoperative FU management strategies.

Development and complications of nutritional deficiencies after bariatric surgery

The clinical effectiveness of bariatric surgery has encouraged the use of bariatric procedures for the treatment of morbid obesity and its comorbidities, with sleeve gastrectomy and Roux-en-Y gastric bypass being the most common procedures. Notwithstanding its success, bariatric procedures are recognised to predispose the development of nutritional deficiencies. A framework is proposed that provides clarity regarding the immediate role of diet, the gastrointestinal tract and the medical state of the patient in the development of nutritional deficiencies after bariatric surgery, while highlighting different enabling resources that may contribute. Untreated, these nutritional deficiencies can progress in the short term into haematological, muscular and neurological complications and in the long term into skeletal complications. In this review, we explore the development of nutritional deficiencies after bariatric surgery through a newly developed conceptual framework. An in-depth understanding will enable the optimisation of the post-operative follow-up, including detecting clinical signs of complications, screening for laboratory abnormalities and treating nutritional deficiencies.

Weight Loss After Laparoscopic Sleeve Gastrectomy in Children and Adolescents

PURPOSE

For children and adolescents with severe obesity, metabolic and bariatric surgery including laparoscopic sleeve gastrectomy (LSG) is increasingly used to facilitate weight loss and reduce associated medical problems. Outcomes of LSG are understudied among patients under age 15 years. We sought to examine surgical complications and weight loss outcomes among children and adolescents who underwent LSG.

MATERIALS AND METHODS

This is a single-center retrospective cohort analysis at a high-volume metropolitan children's hospital in the northeast USA between 2011 and 2021. Weight loss was assessed at routine follow-up appointments for up to 36 months postoperatively.

RESULTS

There were 12 patients under 13 years of age (< 13), 45 from 13 up to 15 years of age (13-14), and 57 patients aged 15 years or over (≥ 15). Among all patients, 70% were female, 41% were Hispanic, and 18% were non-Hispanic Black. There were no operative mortalities. Two patients had surgical complications requiring reoperation. Follow-up beyond 6 months occurred for 62% of patients. Weight loss was evident for each group at all time points, and there was no statistically significant difference among groups at any time point. BMI Z-score reduction at 6 months was 1.53 for the < 13 group, 0.89 for the 13-14 group, and 0.86 for the ≥ 15 group and at 36 months was 1.79, 1.50, and 1.16, respectively.

CONCLUSION

These results support that LSG is a safe and effective method of achieving weight loss for young adolescents with severe obesity. Strategies to promote postoperative follow-up are needed.

How to get back on track? Experiences of patients and healthcare professionals regarding weight recurrence and needs for an intervention after bariatric-metabolic surgery

Background

Multidisciplinary lifestyle interventions are recommended as a first step in treating weight recurrence after bariatric-metabolic surgery (BMS). However, little is known about the experience of patients and healthcare professionals (HCP) with these interventions and how they should be tailored to the patients' needs. The aim of this study was to gain more insight into the experiences and needs of patients and HCP regarding weight recurrence after BMS and an intervention to get Back on Track. In addition, attitudes towards integrating e-Health into the care program were explored.

Methods

A qualitative process evaluation of an intervention for weight recurrence, the Back on Track (BoT), was conducted by means of in-depth interviews and focus groups with 19 stakeholders, including patients and HCP involved in BoT. Interviews were transcribed verbatim. Data were analyzed through thematic analysis.

Results

Patients and HCP reported a wide array of causes of weight recurrence. Patients found it difficult to decide when weight recurrence is problematic and when they should ask for help. Patients reported feeling like the exception and ashamed, therefore experiencing a high threshold to seek help. E-Health was seen as a promising way to improve tailoring, screening, autonomy for the patient, and accessible contact.

Conclusion

Patients should be adequately counselled on weight recurrence after BMS and the importance of intervening early. It is important to lower the threshold for seeking help. For example by offering more long-term standard care or by adding e-Health to the intervention.

Postoperative Follow-up Compliance: The Achilles' Heel of Bariatric Surgery

Regular postoperative follow-up appointments are critical for assessing the effectiveness of the operation and ensuring adequate nutrition, as well as for prompt identification of any complications. In this study, we aimed to determine compliance to follow-up appointments after bariatric surgery and examine factors associated with compliance. We performed a retrospective analysis of all patients who underwent bariatric surgery at the University of Illinois at Chicago between January 1st 2019 and December 30th 2019. Demographics, socio-economic variables (type of insurance, education, income, distance to hospital), type of consultation (in person vs. telehealth), and type of surgery were ascertained. Follow-up rates at the 3-month, 6-month, 12-month and 24-month visits were 61.9%, 41.2%, 29.6%, and 6.5%, respectively. In multivariable logistic regression analysis, White patients (OR 5.13 95% CI 2.03-12.95) and those using telehealth (OR 5.84, 95% CI 3.01 - 11.38) were significantly more likely to be compliant with follow-up. Strategies for improving patient adherence to postoperative follow-up are needed, particularly among persons from racial/ethnic minority backgrounds who also experience both a disparately high burden of severe obesity and poor access to quality care.

Financial Incentives to Improve Patient Follow-up and Weight Loss After Bariatric Surgery

OBJECTIVE

To examine effects of a financial incentives program on follow-up and weight loss after bariatric surgery.

SUMMARY BACKGROUND DATA

Consistent follow-up may improve weight loss and other health outcomes after bariatric surgery. Yet, rates of follow-up after surgery are often low.

METHODS

Patients from 3 practices within a statewide collaborative were invited to participate in a 6-month financial incentives program. Participants received incentives for attending postoperative appointments at 1, 3, and 6 months which doubled when participants weighed less than their prior visit. Participants were matched with contemporary patients from control practices by demographics, starting body mass index and weight, surgery date, and procedure. Preintervention estimates used matched historic patients from the same program and control practices with the criteria listed above. Patients between the 2 historic groups were additionally matched on surgery date to ensure balance on matched variables. We conducted differ-ence-in-differences analyses to examine incentives program effects. Follow-up attendance and percent excess weight loss were measured postoperative months 1, 3, 6, and 12.

RESULTS

One hundred ten program participants from January 1, 2018 to July 31, 2019 were matched to 203 historic program practice patients (November 20 to December 27, 2017). The control group had 273 preinter-vention patients and 327 postintervention patients. In difference-in-differ-ences analyses, the intervention increased follow-up rates at 1 month (+14.8%, P <0.0001), 3months (+29.4%, P <0.0001), and 6 months (+16.4%, P <0.0001), but not at 12 months. There were no statistically significant differences in excess weight loss.

CONCLUSIONS

A financial incentives program significantly increased follow-up after bariatric surgery for up to 6 months, but did not increase weight loss. Our study supports use of incentivized approaches as one way to improve postoperative follow-up, but may not translate into greater weight loss without additional supports.

Determinants of Patient's Adherence to the Predefined Follow-up Visits After Bariatric Surgery

INTRODUCTION

Multidisciplinary care after bariatric surgery is essential for long-term safety and optimal weight loss. However, many patients do not participate in routine postoperative follow-ups. We have explored the determinants of patients' adherence to scheduled follow-up visits after bariatric surgery.

METHOD

A retrospective cohort study was performed on patients who underwent bariatric surgery from 2009 to 2019. Cohort participants with a proportion of attendance above the median were compared with those below the median in the first-year post-operation and the period after that. We assumed that the contribution of each predefined session to the overall attendance at eligible sessions is not equal. We weighted each predefined session by the proportion of attendance of all cohort members scheduled for that session. We then calculated the proportion of attendance for each individual at each period. Discriminatory logistic regression was used to identify factors separating adherers from non-adherers.

RESULTS

We followed 5245 patients who underwent bariatric surgery for up to 10 years. The median follow-up was 2 years. Patients with the following characteristics were more likely to comply with the postoperative attendance schedule: female sex, older age, higher body mass index at the first visit, non-smoker, readmission after surgery, being operated in a general hospital, and one-anastomosis gastric bypass (OAGB) or Roux-en-Y gastric bypass (RYGB) surgery type. Comorbidities did not significantly affect patients' adherence to the predefined follow-up schedules.

CONCLUSION

Younger male smokers are more likely non-adherers. Patients with comorbidities are not at an increased risk of missing predefined postoperative follow-up visits.

Analysis of the Lack of Follow-Up of Bariatric Surgery Patients: Experience of a Reference Center

Few studies have evaluated the association between non-clinical and clinical determinants in terms of discontinuing follow-up after bariatric surgery. This cohort study aims to assess these associations. Data were collected from a prospectively maintained database of patients who underwent laparoscopic bariatric surgery from January 2012 to December 2019. The Cox model was used to assess the influence of preoperative determinants on follow-up interruptions for more than one year. Multilevel logistic regression was used to evaluate the association between clinical factors and post-operative weight loss with the regularity of follow-up. During the study period, 9607 consultations were performed on 1549 patients. The factors associated with a follow-up interruption from more than 365 days included male gender (HR = 1.323; CI = 1.146−1.527; p = 0.001) and more recent years of intervention (HR = 1.043; CI = 1.012−1.076; p = 0.0068). Revisional bariatric surgery was associated with a lower risk of follow-up interruption (HR = 0.753; CI = 0.619−0.916; p = 0.0045). Independent risk factors of an irregular follow up were higher age (HR = 1.01; CI = 1.002−1.017; p = 0.0086); male gender (OR = 1.272; CI = 1.047−1.545; p = 0.0153); and higher %TWL (Total Weight Loss) (OR = 1.040 CI = 1.033−1.048 p < 0.0001). A higher preoperative BMI (OR = 0.985; CI = 0.972−0.998; p = 0.0263) and revisional surgery (OR = 0.707; CI = 0.543−0.922; p = 0.0106) were protective factors of irregularity. This study suggests that the male gender and most recent dates of surgery are the two independent risk factors for follow-up interruption. Older age, male gender, and higher weight loss were all independent risk factors of an irregular follow-up. Revision bariatric surgery is a protective factor against interruption and irregular follow-up with a higher preoperative BMI. Further studies are needed to obtain long-term results in these patients with discontinued follow-ups.

Long-Term Outcomes after Adolescent Bariatric Surgery

BACKGROUND

Metabolic and bariatric surgery (MBS) is a safe and effective treatment option for adolescents with severe obesity, but no long-term studies are available with more than10 years of follow-up data to document sustained improved outcomes.

METHODS

A total of 96 patients who completed MBS at 21 years of age or younger in a tertiary academic center 2002 to 2010 were contacted for a telehealth visit. Body weight, comorbidity status, social/physical function status, and long-term complications were evaluated 10 to 18 years after surgery.

RESULTS

Mean participant (83% female, 75% Hispanic) age at MBS was 18.8 (±1.6) years (median age 19 years, range 15-21 years), and median pre-MBS BMI was 44.7 kg/m 2 (SD 6.5). At follow-up (mean 14.2 [±2.2] years) post-MBS (90.6% Roux-en-Y gastric bypass [RYGB] or 8.3% laparoscopic adjustable gastric banding [LAGB]) mean total body weight decreased by 31.3% (interquartile range [IQR] 20.0% to 38.9%); 32.0% (IQR, 21.3% to 40.1%) among RYGB participants and 22.5% (IQR, 0.64% to 28.3%) among LAGB participants. Patients with pre-MBS hyperlipidemia (14.6%), asthma (10.4%), and diabetes/hyperglycemia (5.2%) reported 100% remission at follow-up (p < 0.05 for all). Pre-post decrease in hypertension (13.5% vs 1%, p = 0.001), sleep apnea (16.7% vs 1.0%, p < 0.001), gastroesophageal reflux disease (13.5% vs 3.1%, p = 0.016), anxiety (7.3% vs 2.1%, p = 0.169), and depression (27.1% vs 4.2%, p < 0.001) were also found.

CONCLUSIONS

Significant sustained reductions in weight and comorbidities, and low rates of long-term complications, a decade or more after completing MBS as an adolescent were found. These findings have important implications for adolescents who may be considering MBS for weight reduction and overall health improvements that extend into adulthood.

Female Patient Perceptions on Financial Incentives to Promote Follow-Up After Bariatric Surgery

INTRODUCTION

Financial incentives to promote recommended behaviors have been applied in many healthcare settings, but to our knowledge, have never been tested as a strategy to improve patient follow-up after bariatric surgery. Given that females make up majority of bariatric surgery patients, our goal was to explore female patient perceptions on the effects of a financial incentive program designed to increase follow-up after bariatric surgery.

METHODS

This was an exploratory qualitative study of patient participants in a pilot program investigating financial incentives. We performed qualitative interviews with female patients to include personal experiences with bariatric surgery, progress toward goals, and concerns related to post-surgical behaviors. The data was analyzed iteratively through inductive thematic analysis.

RESULTS

Twenty-one female patients who had undergone bariatric surgery and enrolled in the financial incentive program participated in this study. Participants had generally positive impressions of the financial incentive program. Participants described the utility of the program in helping to pay for expenses associated with bariatric surgery; feeling that participation was their way of demonstrating that they were compliant with post-surgical recommendations; and that it provided additional motivation. All patients stated that even without the financial incentive they would have continued to follow-up.

CONCLUSIONS

While financial incentives can provide additional motivation for patients following bariatric surgery, they are not the primary reason that patients choose to follow-up. Understanding the motivation of patients who choose to follow-up (or not) may better inform investigations intended to improve follow-up rates after bariatric surgery.

Long-term complications after gastric bypass and sleeve gastrectomy: What information to give to patients and practitioners, and why?

Bariatric surgery is now recognized as the most effective treatment of morbid obesity, leading to durable weight loss and resolution of associated co-morbidities. Roux-en-Y gastric bypass and sleeve gastrectomy are the two most widely used operations today. However, potentially serious medical, surgical, and/or psychiatric complications can occur that raise questions regarding the benefits of this type of surgery. These complications can lead to surgical re-operations, iterative hospitalizations, severe nutritional deficiencies and psychological disorders. Indeed, death from suicide is said to be three times higher than in non-operated obese patients. These results are of concern, all the more because of the high prevalence of patients lost to follow-up (for various and multifactorial reasons) after bariatric surgery. However, better knowledge of post-surgical sequelae could improve the information provided to patients, the preoperative evaluation of the benefit/risk ratio, and, for patients undergoing surgery, the completeness and quality of follow-up as well as the detection and management of complications. The development of new strategies for postoperative follow-up such as telemedicine but also the mobilization of all the actors along the healthcare pathway can make inroads and warrant further study.

Efficacy and safety of endoscopic sleeve gastroplasty and laparoscopic sleeve gastrectomy with 12+ months of adjuvant multidisciplinary support

Background

The laparoscopic sleeve gastrectomy (LSG) and the incisionless endoscopic sleeve gastroplasty (ESG) weight loss procedures require further investigation of their efficacy, safety and patient-centered outcomes in the Australian setting.

Methods

The aim was to examine the 6- and 12-month weight loss efficacy, safety, and weight-related quality of life (QoL) of adults with obesity who received the ESG or LSG bariatric procedure with 12+ months of adjuvant multidisciplinary pre- and postprocedural support. Data were from a two-arm prospective cohort study that followed patients from baseline to 12-months postprocedure from a medical center in Queensland. Percent excess weight loss (%EWL) was the primary outcome. Secondary outcomes were body composition (fat mass, fat-free mass, android:gynoid ratio, bone mineral content) via dual energy X-ray absorptiometry, weight-related QoL, lipid, glycemic, and hepatic biochemistry, and adverse events.

Results

16 ESG (19% attrition; 81.2% female; aged:41.4 (SD: 10.4) years; BMI: 35.5 (SD: 5.2) kg/m²) and 45 LSG (9% attrition; 84.4% female; aged:40.4 (SD: 9.0) years; BMI: 40.7 (SD: 5.6) kg/m²) participants were recruited. At 12-months postprocedure, ESG %EWL was 57% (SD: 32%; p < 0.01) and LSG %EWL was 79% (SD: 24%; p < 0.001). ESG and LSG cohorts improved QoL (19.8% in ESG [p > 0.05]; 48.1% in LSG [p < 0.05]), liver function (AST: − 4.4 U/L in ESG [p < 0.05]; − 2.7 U/L in LSG [p < 0.05]), HbA1c (− 0.5% in ESG [p < 0.05]; − 0.1% in LSG [p < 0.05]) and triglycerides (− 0.6 mmol/L in ESG [p > 0.05]; − 0.4 mmol/L in LSG [P < 0.05]) at 12-months. Both cohorts reduced fat mass (p < 0.05). The ESG maintained but LSG decreased fat-free mass at 6-months (p < 0.05); and both cohorts lost fat-free mass at 12-months (p < 0.05). There were no adverse events directly related to the procedure. The ESG reported 25% mild-moderate adverse events possibly related to the procedure, and the LSG reported 27% mild-severe adverse events possibly related to the procedure.

Conclusions

In this setting, the ESG and LSG were safe and effective weight loss treatments for obese adults alongside multidisciplinary support. Patients who elected the ESG maintained fat-free mass at 6-months but both cohorts lost fat-free mass at 12-months postprocedure. Patients who elected the LSG had large and significant improvements to weight-related quality of life. Further well-powered studies are required to confirm these findings.

Trial registration

This study was registered prospectively at the Australia New Zealand Clinical Trials Registry on 06/03/2018, Registration Number ACTRN12618000337279.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01629-7.

Behavioral Interventions to Attenuate Driven Overeating and Weight Regain After Bariatric Surgery

Weight regain after bariatric surgery is associated with problematic eating behaviors that have either recurred after a period of improvement or are new-onset behaviors. Problematic eating behaviors after bariatric surgery have been conceptualized in different ways in the literature, such as having a food addiction and experiencing a loss of control of eating. The intersection of these constructs appears to be driven overeating defined as patients' experiences of reduced control of their eating which results in overeating behavior. The purpose of this review is to define patient experiences of driven overeating through the behavioral expression of emotion-based eating, reward-based eating, and executive functioning deficits-namely impulsivity-which is associated with weight regain after having bariatric surgery. Delineating concepts in this way and determining treatment strategies accordingly may reduce distress related to the inevitable return of increased hunger, cravings, portion sizes, and tolerance for highly palatable foods after surgery. Along with standard behavioral weight maintenance strategies, topics including acceptance, motivation, emotion-based eating, reward-based/impulsive eating, physical activity, and self-compassion are discussed. These concepts have been adapted for patients experiencing weight regain after having bariatric surgery and may be particularly helpful in attenuating driven overeating and weight regain.

Predictors of 30-day follow-up visit completion after primary bariatric surgery: an analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry

BACKGROUND

Adherence to follow-up visits is often unsatisfactory after bariatric surgery.

OBJECTIVES

To identify predictors, including surgery type and preoperative demographics, body mass index (BMI), medical conditions, and smoking status, of 30-day follow-up visit completion.

SETTING

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participating centers (2015-2018).

METHODS

Patients who underwent primary Roux-en-Y gastric bypass or sleeve gastrectomy were included in this analysis. Data were analyzed using weighted logistic regression. Subanalyses included stratification of the sample by sex and age (<45, 45-60, and >60 years).

RESULTS

Patients (n = 566,774) were predominantly female (79.6%), White (72.4%), non-Hispanic (77.9%), and middle-aged (44.5 ± 11.9 years), with a mean BMI of 45.3 ± 7.8 kg/m². More than 95% of patients completed the 30-day visits. In the whole-sample analysis, older age (odds ratio [OR], 1.02) and the presence of non-insulin-dependent diabetes (OR, 1.04), hypertension (OR, 1.03), hyperlipidemia (OR, 1.10), obstructive sleep apnea (OR, 1.15), and gastroesophageal reflux disease (OR, 1.16) were positive predictors of the 30-day visit completion (P_s < .01). Conversely, sleeve gastrectomy procedure (OR, .86), Black race (OR, .87), Hispanic ethnicity (OR, .94), and the presence of insulin-dependent diabetes (OR, .96) and smoking (OR, .83) were negative predictors (P_s < .01). Several differences emerged in subanalyses. For example, in sex stratification, Hispanic ethnicity lost its significance in men. In age stratification, BMI and male sex emerged as positive predictors in the age groups of <45 and 45-60 years, respectively.

CONCLUSION

Although challenged by small effect sizes, this analysis identified subgroups at a higher risk of being lost to follow-up after bariatric surgery.

Peer-supported lifestyle interventions on body weight, energy intake, and physical activity in adults: A systematic review and meta-analysis

There is an increasing interest in peer interventions in the management of chronic conditions, but evidence on peer interventions for body weight is lacking. The aim of this study was to examine the efficacy of peer interventions on body weight, energy intake, and physical activity in adults. Interventions delivered by peer (lay member that participants identify with) were included. We searched 14 databases. Outcomes were combined in the meta-analysis using the inverse variance random-effects model. From 2435 articles, 65 articles were included in the systematic review and meta-analysis (n = 15,673). Peer interventions resulted in significant reduction in weight (mean difference [MD] -1.05 kg; 95% confidence interval [CI] -1.68, -0.43; 95% prediction interval [PI] -3.25, 1.14; 28 studies; 7142 participants), BMI (MD -0.24 kg/m² ; 95% CI -0.44, -0.04; 95% PI -0.92, 0.45; 25 studies; 6672 participants), waist circumference (MD -0.75 cm; 95% CI -1.29, -0.21; 95% PI -1.36, -0.14; 12 studies; 4280 participants), and significant increase in physical activity (SMD 0.20; 95% CI 0.09, 0.32; 95% PI -0.46, 0.86; 41 studies; 10,778 participants) with no significant effect on energy intake. This study suggests peer interventions are effective in reducing waist circumference, but further research is needed to confirm its effect on other obesity-related outcomes.

Five-year attrition, active enrollment, and predictors of level of participation in the Longitudinal Assessment of Bariatric Surgery (LABS-2) study

BACKGROUND

Reporting high-quality bariatric surgery outcomes depends on participant attrition and level of study participation among enrolled participants.

OBJECTIVES

Our aims are to report participant attrition, active enrollment, and level of participation, and to evaluate pre-surgery sociodemographic, physical health, and psychosocial factors as predictors of attrition and level of participation through 5 years.

SETTING

The Longitudinal Assessment of Bariatric Surgery-2 study which enrolled 2458 adults undergoing a first bariatric surgical procedure at 1 of 6 US cites from 2006 through 2009.

METHODS

In-person research assessments were conducted pre-surgery and annually for five years. Extensive retention strategies including offering remote assessments (telephone, email, mail, or a combination) were fully implemented in 2009. Among living participants, including those inactivated, annual follow-up assessments were categorized as in-person, remote or missed through 5 years.

RESULTS

By year 5, 1.7% of participants had died and 3.2% had withdrawn or were inactivated by the study staff; thus, attrition was 4.9% (n = 121). Controlling for site and calendar year, missed assessments increased from 14.7%-21.8% between years 1 and 2 and then stayed relatively stable (20.8%-19.6%) for years 3-5. Younger age, male sex, White race, lower body mass index, smoking, illicit drug use, and higher weight loss expectations preoperatively were independently associated with a higher likelihood of a missed versus in-person assessment across follow-up.

CONCLUSION

The LABS-2 participant attrition was low. The percentage of missed assessments did not increase after year 2, perhaps due to implementation of a comprehensive retention plan. Predictors of missed assessments highlight subgroups to target for focused retention efforts.

Are eHealth interventions for adults who are scheduled for or have undergone bariatric surgery as effective as usual care? A systematic review

This systematic review aimed to evaluate the effect of eHealth-delivered interventions for adults who undergo bariatric surgery on postoperative weight loss, weight loss maintenance, eating psychopathology, quality of life, depression screening, and self-efficacy. Six electronic databases were searched, with 14 studies (across 17 reports) included, involving 1633 participants. With substantial heterogeneity, qualitative descriptions have been provided. Interventions were delivered via an online program or internet modules (n = 2), telephone (n = 2), text messages (n = 2), videoconferencing (n = 3), mobile application (n = 1), and audiovisual media (n = 1). Three studies included a combination, including internet modules and telephone (n = 1), wireless fidelity scales, emails, and telephone (n = 1), and a combination of online treatment, weekly emails, and access to a private Facebook group (n = 1). All the eHealth interventions, except for one, implemented behavior change techniques, including self-monitoring, problem solving, social support, goal setting, and shaping knowledge. Both eHealth intervention and control groups lost weight across the included studies, and eHealth was found to be as effective as or more effective than the control for weight loss. Two studies measured weight loss maintenance; both eHealth and control groups regained weight in the longer term. The interventions showed significant improvement on assessment measures for eating psychopathology. In conclusion, when bariatric surgery patients have limited or no access to healthcare teams or require additional support, eHealth may be a suitable option. Future studies implementing eHealth interventions would benefit from reporting intervention components as per the behavior change techniques taxonomy and further consideration of delivering eHealth in a stepped care approach would be beneficial.

Weight Loss Results and Compliance with Follow-up after Bariatric Surgery

PURPOSE

The importance of follow-up (FU) for midterm weight loss (WL) after bariatric surgery is controversial. Compliance to this FU remains challenging. Several risk factors for loss to FU (LtFU) have been mentioned. The aim was therefore to evaluate the association between WL and LtFU 3 to 5 years postoperatively and to identify risk factors for LtFU.

MATERIALS AND METHODS

A single-center cross-sectional study in the Netherlands. Between June and October 2018, patients scheduled for a 3-, 4-, or 5-year FU appointment were included into two groups: compliant (to their scheduled appointment and overall maximally 1 missed appointment) and non-compliant (missed the scheduled appointment and at least 1 overall). Baseline, surgical, and FU characteristics were collected and a questionnaire concerning socio-economic factors.

RESULTS

In total, 217 patients in the compliant group and 181 in the non-compliant group were included with a median body mass index at baseline of 42.0 and 42.9 respectively. Eighty-eight percent underwent a laparoscopic Roux-en-Y gastric bypass. The median percentage total weight loss for the compliant and non-compliant groups was 30.7% versus 28.9% at 3, 29.3% versus 30.2% at 4, and 29.6% versus 29.9% at 5 years respectively, all p>0.05. Age, persistent comorbidities and vitamin deficiencies, a yearly salary <20,000 euro, no health insurance coverage, and not understanding the importance of FU were risk factors for LtFU.

CONCLUSION

Three to 5 years postoperatively, there is no association between LtFU and WL. The compliant group demonstrated more comorbidities and vitamin deficiencies. Younger age, not understanding the importance of FU, and financial challenges were risk factors for LtFU.

Impact of Self-Monitoring on Weight Loss After Bariatric Surgery

BACKGROUND

Weight loss after bariatric surgery varies among patients. Patients who do not comply with self-monitoring are predicted to lose less weight than those who comply with self-monitoring.

OBJECTIVE

To assess the effect of compliance with self-monitoring behavior on long-term %excess weight loss (%EWL) and %total weight loss (%TWL) among patients receiving laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

We used retrospective analysis to evaluate the self-monitoring behavior of patients and their weight changes throughout a 2-year follow-up. The participants were divided into two groups: group 1 consisted of participants who kept self-monitoring behavior records for all follow-ups and group 2 consisted of participants who kept self-monitoring behavior records for only six months of follow-up. Our investigators used telephone interviews to collect the data. By comparing %EWL and %TWL, we assessed the possible relationship between the long-term self-monitoring behavior, weight loss outcome, and operation type.

RESULTS

There were 384 included samples. %EWL was significantly different between group 1 and group 2, and group 1 participants had better outcomes regardless of operational method. In group 2, LRYGB patients had better %EWL outcomes than LSG patients.

CONCLUSIONS

Patients with long-term self-monitoring behaviors have better %EWL and %TWL. Patients in LRYGB group had better weight loss outcomes than the LSG group.

Small bowel obstruction following laparoscopic Roux-en-Y gastric bypass: is it always necessary to operate? A 5-year, high volume center experience

PURPOSE

This study aims to describe the incidence, associated factors, etiology, and management of small bowel obstructions following laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

A retrospective analysis was conducted between January 15 and December 19 using the surgery database of our hospital. Included LRYGB patients were those that evolved with a prolonged length of stay; readmission; emergency room consult; and re-intervention due to small bowel obstruction (SBO) related symptoms with compatible radiological or intraoperative findings. The LRYGB technique implied an antecolic alimentary limb reconstruction and systematic closure of mesenteric defects. Descriptive and analytical statistics were carried out, using a parametric or non-parametric approach as needed.

RESULTS

Nine hundred forty-one LRYGB were performed. 9.9% were revisional surgeries of patients with a laparoscopic sleeve gastrectomy. During the study period, 36 SBOs occurred, representing 3.8% of operated patients, with no mortality. 58.3% had successful non-operative management, while 41.7% required surgical exploration, of which 73.3% were treated laparoscopically and 20% needed conversion to open surgery. Etiologies of SBO were jejuno-jejunostomy (JJO) related stenosis (22, 61.1%), internal hernias (6, 16.7%), adherences (3, 8.3%), and other diagnoses (5, 13.9%). Regarding JJO stenosis and internal hernias, median time to diagnosis was 8 days (IQR 7-11) and 12 months (IQR 8.7-16) respectively. Previous sleeve gastrectomy, age, or sex was not associated to the incidence of small bowel obstruction.

CONCLUSIONS

LRYGB is safe when performed by experienced surgeons. SBO due to internal hernias were scarce in this series. JJO stenosis could explain most cases of SBO; under this diagnosis, non-surgical management was successful frequently.

Early postoperative follow-up reduces risk of late severe nutritional complications after Roux-En-Y gastric bypass: a population based study

BACKGROUND

Severe nutritional complications can occur following Roux-en-Y gastric bypass (RYGB). Adherence to follow-up visits can reduce the risk of many bariatric surgery complications, but whether this applies to severe nutritional complications is unknown.

OBJECTIVES

Determine the association between adherence to follow-up visits after RYGB and risk of severe nutritional complications.

SETTING

Multicenter publicly-funded Ontario Bariatric Network.

METHODS

Retrospective cohort study of Ontario adults participating in the Ontario Bariatric Registry who underwent RYGB between January 1, 2009, and December 31, 2015. The primary outcome was a severe nutritional complication (hospital admission with malnutrition or nutrient deficiency) occurring 1 year or more after RYGB. The primary exposure was adherence to postoperative follow-up visits, occurring at 3, 6, and 12 months postoperatively, and categorized as perfect (3 visits), partial (1-2 visits), or none. Cox proportional hazards modeling quantified the association between adherence to follow-up visits and the primary outcome using hazard ratios (HR).

RESULTS

In total, 9105 adults (84% female, age 44.7 ± 10.3 yr) met study criteria. Mean preoperative body mass index (BMI) was 48.6 kg/m². First year follow-up attendance was: 51.7% perfect, 31.6% partial, and 16.7% none. Median time in the study was 3.4 years. Severe nutritional complications occurred in 1.1% of patients. Compared with perfect follow-up, patients with no follow-up (HR 3.09, 95% CI 1.74-5.50) and partial follow-up (HR 1.94, 95% CI 1.25-3.03) had an increased risk of severe nutritional complications.

CONCLUSION

Adherence to follow-up visits during the first year after RYGB is independently associated with reduction in the risk of subsequent severe nutritional complications.

Methodological issues in assessing change in dietary intake and appetite following gastric bypass surgery: A systematic review

Gastric bypass surgery is an effective long-term treatment for individuals with severe obesity. Changes in appetite, dietary intake, and food preferences have all been postulated to contribute to postoperative body weight regulation, however, findings are inconsistent. The aim of this systematic review was to evaluate the current literature on changes in dietary intake and appetite following gastric bypass surgery, in the context of the methodology used and the analysis, interpretation, and presentation of results. Four databases were systematically searched with terms related to "gastric bypass surgery," "appetite," and "dietary intake," and 49 papers (n = 2384 patients after gastric bypass) were eligible for inclusion. The evidence indicated that only a reduction in overall energy intake and an increase in postprandial satiety are maintained beyond 6-month post-surgery, whereas relative macronutrient intake and premeal hunger remain unchanged. However, available data were limited by inconsistencies in the methods, analysis, presentation, and interpretation of results. In particular, there was a reliance on data collected by subjective methods with minimal acknowledgment of the limitations, such as misreporting of food intake. There is a need for further work employing objective measurement of appetite and dietary intake following gastric bypass surgery to determine how these mechanisms may contribute to weight regulation in the longer term.

Bariatric Support Groups Predicts Long-term Weight Loss

BACKGROUND

Support groups are an integral part of bariatric surgery (BS) programs yet there is limited evidence for an association between support group attendance and BS weight outcomes.

SETTINGS

University Hospital, Spain.

OBJECTIVES

This study examined the effect of support group attendance on weight loss (WL) at short- and long-term follow-up (FU) following BS.

METHODS

Participants were 531 (mean body mass index (BMI) = 45.8 (5.4) kg/m²; mean age 45.9 (11.1) years, 76.4% females) who underwent BS (Roux-en-Y gastric bypass (RYGB): 233 (43.8%); sleeve gastrectomy (SG): 298 (56.2%)) in our clinic. The bariatric support group program (BSGP) consisted of two subprograms: Novel-BSGP (N-BSGP; first 12 months after surgery) and Experienced-BSGP (E-BSGP; FU between 12 months 5 years after BS).

RESULTS

Three hundred and twenty-three (60.8%) and 129 (24.3%) participants attended at least one session of N-BSGP and E-BSGP, respectively. Linear regression analyses showed that number of sessions attended during year 1 predicted percent total body WL (%TBWL (β = 0.381, p < 0.001)) and percent excess WL (%EWL (β = 0.928, p < 0.001)) at one year and number of sessions attended during years 2-5 were positively related to %TBWL and %EWL achieved at 5 years (%EWL: β = 0.162 (p = 0.014) and %TBWL: β = 0.378 (p = 0.013)) respectively.

CONCLUSION

We observed a significant beneficial effect of a post-surgical support group program on short- and long-term body WL after BS.

The impact of patient-reported outcomes on loss to follow-up care after bariatric surgery

BACKGROUND

High rates of attrition to post-bariatric surgical care continue to be common, despite recommendations for lifelong follow-up. There is little available work focusing on the etiology of attrition to post-bariatric surgical follow-up. Patient-reported outcomes (PROs) are metrics of patients' perceptions of their own health and have been used for their predictive value in other specialties. The relationships between PROs and loss to follow-up have not been explored.

METHODS

PRO data from patients who met the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) definition of loss to follow-up at 1-year postoperatively were reviewed and compared to patients who were compliant with 1-year follow-up. Patient-reported outcomes measurement information system (PROMIS) measures are routinely collected pre- and postoperatively at our institution using a series of validated computer-adaptive tests that assess depression, satisfaction with social roles, pain interference, and physical function. A series of univariate logistic regressions tested whether baseline PROs or change in PROs from baseline to 6-month postoperatively predicted loss to follow-up at 1 year.

RESULTS

Neither baseline PROs nor change in depression, satisfaction with social roles, pain interference, or physical function were significant predictors of loss to follow-up. Similarly, patient state of residence, Charlson Comorbidity Index, BMI, and percent excess weight loss were not significant predictors of follow-up attrition.

CONCLUSION

The PROs in this study were not significant predictors of loss to follow-up at 1-year postoperatively. The rate of bariatric procedures continues to increase nationally, so does the potential for late post-surgical complications. Given the potential impact of loss to follow-up on adverse late post-surgical outcomes, there is a need to facilitate long-term post-surgical follow-up and more investigation is needed to identify and intervene on underlying causes of bariatric patient follow-up attrition.

Self-Pay Payer Status Predicts Long-Term Loss to Follow-Up After Bariatric Surgery

PURPOSE

In spite of widespread recommendations for lifelong patient follow-up with a bariatric provider after bariatric surgery, attrition to follow-up is common. Over the past two decades, many programs have sought to expand access to care for patients lacking insurance coverage for bariatric surgery by offering "self-pay" packages; however, the impact of this financing on long-term follow-up is unclear. We sought to determine whether payer status impacts loss to follow-up within 1 year after bariatric surgery.

MATERIALS AND METHODS

Records of 554 consecutive patients undergoing bariatric surgery who were eligible for 1-year post-surgical follow-up between 2014 and 2019 were retrospectively reviewed. Multiple logistic regression examined the relationship between demographics, psychological variables, payer status, and loss to follow-up.

RESULTS

Self-pay status more than tripled the odds of loss to follow-up (OR = 3.44, p < 0.01) at 1 year following surgery. Males had more than double the odds of attrition (OR = 2.43, p < 0.01), and members of racial and ethnic minority groups (OR = 2.51, p < 0.05) were more likely to experience loss.

CONCLUSIONS

Self-pay patients, males and members of racial and ethnic minority groups, may face additional barriers to long-term access to postoperative bariatric care. Further investigation is greatly needed to develop strategies to overcome barriers to and disparities in long-term post-surgical care for more frequently lost groups.

Where Are My Patients? Lost and Found in Bariatric Surgery

PURPOSE

Follow-up is a cornerstone of the success of bariatric surgery. However, adherence to monitoring decreases over time. The reasons for non-compliance with follow-up still remain unclear.

MATERIALS AND METHODS

This is a retrospective, single-center, cohort study, including all patients undergoing bariatric surgery between 2014 and 2017. Patients lost to follow-up were called back and questioned about the reasons of non-adherence. Patients followed and lost to follow-up were compared in terms of weight loss.

RESULTS

Overall, 29.7% of patients were lost to follow-up. After a callback, we obtained information on 89.9% of patients. The first reason of non-attendance was considering follow-up as unnecessary (29.5%). Almost a quarter of patients (24%) discontinued follow-up due to geographic distance, while 23.3%, 18.6%, and 14.0% of patients explained the lack of follow-up due to family, professional, or health problems. Only 7.0% declared to renounce to follow-up because of poor weight loss. Percentage of excess weight loss at 3 and 5 years after surgery was respectively 73.6% and 81.2% in attendant patients, and 70.7% and 68.4% in non-adherent patients (p = ns). Despite a greater weight loss in the group of patients regularly followed, the difference with patients lost to follow-up remained not significant in multivariate analysis.

CONCLUSIONS

Follow-up is of crucial importance in the management of bariatric patients. Follow-up disruption is associated to individual patient choice and external constraints. In order to improve the quality of long-term care, care providers will probably need to adapt to these constraints, diversifying the offer of care.

Weight loss after bariatric surgery: a comparison between delayed and immediate qualification according to the last resort criterion

BACKGROUND

In the Netherlands, patients only qualify for bariatric surgery when they have followed a 6-month mandatory weight loss program (MWP), also called the "last resort" criterion. One of the rationales for this is that MWPs result in greater weight loss.

OBJECTIVES

To determine weight loss during MWPs and the effect of delayed versus immediate qualification on weight loss 3 years after bariatric surgery.

SETTING

Outpatient clinic.

METHODS

This is a nationwide, retrospective study with prospectively collected data. All patients who underwent a primary bariatric procedure in 2016 were included. We compared weight loss between patients who did not qualify according to the last resort criterion at screening (delayed group) with patients that qualified (immediate group).

RESULTS

In total 2628 patients were included. Mean age was 44.4 years, 81.3% were female, and baseline BMI was 42.3 kg/m². Roux-en-Y gastric bypass (RYGB) was the most frequently performed surgery (77.0%), followed by sleeve gastrectomy (15.8%) and banded RYGB (7.3%). The delayed group (n = 831; 32%) compared with immediate group (n = 1797; 68%), showed less percentage of total weight loss (%TWL) during the MWP (1.7% versus 3.9%, P < .001) and time between screening and surgery was longer (42.3 versus 17.5 wk, P < .001). Linear mixed model analysis showed no significant difference in %TWL at 18- (P = .291, n = 2077), 24- (P = .580, n = 1993) and 36-month (P = .325, n = 1743) follow-up.

CONCLUSION

This study shows that delayed qualification for bariatric surgery compared with immediate qualification does not have a clinically relevant impact on postoperative weight loss 3 years after bariatric surgery.

Correlates related to follow-up in a community engagement program in North Central Florida

AIMS

This analysis identifies the correlates of 60- and 120-day telephone-based study follow-ups among community-dwelling adults in North Central Florida.

METHODS

Six thousand three hundred and forty participants were recruited by Community Health Workers from the University of Florida's community engagement program with a face-to-face baseline and two phone follow-ups assessing indicators of health.

RESULTS

Physical disability versus none (adjusted odds ratio [aOR], 1.5; 95% confidence interval [CI], 1.2─1.9), high trust in research versus none (aOR, 1.5; 95% CI, 1.1─2.1), history of research participation versus none (aOR, 1.6; 95% CI, 1.3─2.0), having health insurance versus none (aOR, 1.4; 95% CI, 1.1─1.7), interest in research participation versus none (aOR, 1.8; 95% CI, 1.3─2.7), and no drug use versus drug use (aOR, 0.5; 95% CI, 0.3─0.9) significantly predicted completion of follow-up.

CONCLUSIONS

Health and social factors such as disability, insurance, history of and interest in research, trust and no drug use significantly predicted completing two follow-ups. These findings can facilitate efforts to minimize attrition in the research enterprise.

The Optimal Nutritional Programme for Bariatric and Metabolic Surgery

PURPOSE OF REVIEW

Bariatric surgery is the most effective treatment for severe and complex obesity; however, the risk of developing nutrient deficiencies varies based upon the type of surgery, degree of malabsorption, and level of nutrition intervention. There are numerous factors that can impact the nutrition status of a patient during their pre- and postoperative journey. We review the critical components and considerations needed in order to provide optimal nutrition care for patients with bariatric surgery.

RECENT FINDINGS

A dietitian, specializing in bariatric surgery, is the best equipped healthcare provider to prepare and support patients in achieving and maintaining optimal nutrition status. We present best practices for both the pre- and postoperative nutrition-related phases of a patient's journey. The dietitian specialist is integral in the assessment and ongoing nutrition care of patients with bariatric surgery. Further consideration should be given to enable access for lifelong follow-up and monitoring.

Improving Access to Bariatric Surgery for Rural and Remote Patients: Experiences from a State-Wide Bariatric Telehealth Service in Australia

BACKGROUND

The state of Queensland, Australia, is large (1.85 million km²). The provision of bariatric care across the state is difficult as most major hospitals are concentrated in the capital city of Brisbane. We implemented a state-wide telehealth service to improve access for rural patients in a public bariatric service. We report our early experiences with this service.

METHODS

We reviewed all patients seen in the Bariatric Telehealth Clinic from 2017 to 2019. Patients underwent consultation through video-link software at their local hospital with the multidisciplinary team in Brisbane (surgeon, dietician and clinical nurse). Distances from Brisbane and number of visits were calculated. Telehealth patients were contacted by phone to complete a survey regarding their experiences. This was a 17-question Likert-style survey with scores from 1 (strongly disagree) to 5 (strongly agree).

RESULTS

A total of 85 new patients underwent their initial consultation via telehealth. Each patient had a variable number of in-person as well as telehealth consultations both before and after surgery. Mean distance from telehealth consultation site to Brisbane was 614 km (range 149-2472 km). In total, 41 (48%) completed the survey. With regard to telehealth saving time and money, improving access to bariatric care, and desire to use telehealth again, the mean score was 4 out of 5 or higher for all questions (i.e., agree or strongly agree). There was no identifiable post-operative complication that was caused or exacerbated by telehealth.

CONCLUSION

Bariatric surgical telehealth appointments are feasible and preferred by most patients residing in rural and remote locations. Each consultation avoids significant travel time and cost for the patient and health service, with no obvious adverse outcomes. Telehealth improves equity and access to specialist services for rural and remote patients.

Impact of Routine and Long-Term Follow-Up on Weight Loss after Bariatric Surgery

BACKGROUND

Weight loss after bariatric surgery varies among patients. Patients who do not complete long-term follow-up are considered to loose less weight than those with regular follow-up visits.

OBJECTIVE

To evaluate the influence of patients' follow-up compliance on long-term excess weight loss (%EWL) and total weight loss (%TWL) after bariatric surgery, comparing results between gastric bypass (GB) and sleeve gastrectomy (SG).

METHODS

Patients with up to 5 years of follow-up data after bariatric surgery were included in this retrospective analysis. Patients were divided in 2 groups: those in group 1 who had attended every scheduled postoperative appointment and those in group 2 who had been lost to follow-up before 1 year and were later contacted by telephone. %EWL and %TWL were compared to determine the possible relationship between type of surgery and regularity of the follow-up.

RESULTS

A total of 385 patients were included. A significant difference in EWL was observed at 5 years in the SG group (78% for group 1 versus 39% for group 2; p = 0.02) and GB group (75% for group 1 versus 62% for group 2; p = 0.01). No significant differences between surgeries were found when comparing long-term EWL in group 1 patients 77% for SG versus 75% for GB. For group 2 patients, GB achieved greater EWL than SG; p = 0.005. %TWL patients in group 2 showed significant differences in all periods of study (p < 0.05).

CONCLUSION

Bariatric surgery patients who attended all scheduled follow-up appointments experienced significantly greater long-term EWL and TWL than those who did not. GB has apparent increased benefits for weight loss in long-term follow-up when compared with SG for patients who did not attend long-term follow-up. Therefore, continued long-term follow-up of bariatric patients should be encouraged to increase postoperative weight loss results.

Predictors and Consequences of Loss to Follow-up after Vascular Surgery

BACKGROUND

Loss to follow-up (LTF) after surgery impacts quality of care and can adversely affect short- and long-term clinical outcomes. This study identifies modifiable factors contributing to LTF after vascular surgery and the factors' effect on short- and long-term clinical outcomes.

METHODS

This is a retrospective single-center cohort study of 440 consecutive adult patients who underwent carotid endarterectomy, infrainguinal bypass, percutaneous lower extremity revascularization, or endovascular aortic aneurysm repair at Northwestern Memorial Hospital between November 2011 and November 2013. Twenty-six patients who died within 9 months after surgery were excluded because of competing risks with the study end points. Demographics, medical history and medications, hospitalization and procedure-related factors, and postoperative complications were collected from the medical record. The primary end point was LTF 1 month after surgery (LTF1M), defined as lack of an in-person outpatient visit with a vascular surgeon 1 month after the index procedure. Secondary outcomes were LTF 1 year after surgery (LTF1Y), defined as lack of an in-person outpatient visit with a vascular surgeon between 9 and 22 months after discharge, and overall 5-year survival.

RESULTS

Overall LTF1M and LTF1Y rates were 27.3% and 46.8%, respectively. Kaplan-Meier analysis revealed no difference in survival based on the LTF1M status (P = 0.72), but patients who were LTF1Y had significantly worse survival at 5 years (P < 0.001). Seeing a nonvascular surgeon specialist at our institution (odds ratio (OR) 0.58, 95% confidence interval (CI): 0.35-0.94, P = 0.03) and having a reintervention (OR 0.17, 95% CI: 0.08-0.37, P < 0.001) were associated with decreased LTF1Y in a multivariable model. Overall mortality was more likely with LTF1Y (hazard ratio (HR) 3.27, 95% CI: 1.86-5.76, P < 0.001) and less likely with seeing another specialist at our institution (HR 0.38, 95% CI: 0.20-0.75, P = 0.005).

CONCLUSIONS

LTF rates after vascular surgery are high and associated with poor long-term outcomes. Patients who did not see a nonvascular surgeon specialist at our institution had higher rates of LTF1Y and worse overall mortality, suggesting that improved integration of care can improve LTF and survival.

Travel distance reduces follow-up compliance but has no effect on long-term weight loss success in bariatric patients

BACKGROUND

Patients seeking bariatric surgery are traveling longer distances to reach Bariatric Centers. The purpose of this study was to evaluate the impact of travel distance on adherence to follow-up and outcomes after bariatric surgery.

METHODS

A retrospective review of all consecutive patients who had undergone bariatric surgery from June 2013 to May 2014 was performed, and the patients were divided into two groups: those who traveled 50 miles or less and those who traveled more than 50 miles. Primary outcome assessed was the influence of distance on post-operative follow-up attrition over 4-year period. Secondary outcomes assessed were excess weight loss, length of stay (LOS), complications and readmission rates.

RESULTS

A total of 228 patients underwent bariatric surgery with 4 years of follow-up available. Of these, 145 patients traveled 50 miles or less and 83 patients traveled greater than 50 miles. Patient demographics were similar between the two groups. Those who traveled more had statistically higher probability of attrition up to 3-year follow-up mark. There was no difference in percent excess weight loss at each follow-up visit between the two cohorts. Furthermore, there was no difference in readmission rates (2% vs 5%), minor complications (14% vs 10%), major complications (3% vs 2%) and LOS (2.6 days vs 2.6).

CONCLUSION

The distance patients traveled for bariatric surgery did not affect their weight loss success, length of stay, postsurgical complications or readmission rate. Despite the lack of influence on postoperative outcomes, follow-up compliance was statistically affected by distance.

Exploring isolation, self-directed care and extensive follow-up: factors heightening the health and safety risks of bariatric surgery abroad among Canadian medical tourists

PURPOSE

This article explores first-hand accounts of Canadian bariatric patients' experiences of seeking and obtaining weight loss surgery abroad through the practice of medical tourism. While researchers have identified many of the challenges and associated health and safety risks imposed on patients by engaging in medical tourism generally, little is known about the specific challenges experienced by Canadians seeking bariatric surgery abroad.

METHOD

To better understand these challenges, we conducted thematic analysis on interviews conducted with 20 former Canadian bariatric tourists.

RESULTS

Our analysis illuminated three key challenges Canadians face in obtaining bariatric care: (1) stigma and isolation from friends, family and medical professionals; (2) self-directed navigation of domestic and destination health care systems; and (3) challenges with obtaining adequate follow-up care in Canada.

CONCLUSIONS

While these challenges identified by participants may occur in other forms of medical tourism, it appears that these challenges are occurring simultaneously in cases of bariatric tourism by Canadians. These challenges appear to work in conjunction to heighten the health and safety risks potential Canadian bariatric tourists may be exposed to. Unless structural changes occur to increase domestic availability of bariatric surgery, Canadians are likely to continue seeking this care abroad.

A Specialized Medical Management Program to Address Post-operative Weight Regain in Bariatric Patients

INTRODUCTION

Although bariatric surgery results in massive weight loss, weight regain over time up to as much as 25% is not uncommon. Weight regain in this population often leads to long-term weight loss failure and non-compliance in clinical follow-up and program recommendations.

METHODS

We analyzed early weight outcomes at 3 and 6 months of 48 bariatric patients referred to an individualized, multidisciplinary medical management program at the Center for Obesity Medicine (COM) to address weight regain in 2015 and compared to a group of matched non-bariatric patients. The medical management center, under the direction of a medical obesity specialist and complementary to the surgical program and multidisciplinary team, addressed weight regain with intensive lifestyle (diet, activity, anti-stress therapy, behavioral counseling, sleep) and with medical intervention (one or more anti-obesity medications).

RESULTS

According to early findings, the average percentage post-operative weight regain of patients entering the weight management program was 20% above nadir and time since surgery averaged 6 years (range = 1 to 20 years) with a mean weight loss of - 2.3 kg after 3 months and - 4.4 kg at 6 months into the program. Individuals most successful with weight loss were those treated with anorexigenic pharmaceuticals. Weight and percent weight loss were significantly greater for the non-surgical than the surgical patients at 3 and 6 months (p < 0.05).

CONCLUSIONS

A medically supervised weight management program complementary to surgery is beneficial for the treatment of weight regain and may prove important in assisting the surgical patient achieve long-term weight loss success.

Pre-operative Bariatric Clinic Attendance Is a Predictor of Post-operative Clinic Attendance and Weight Loss Outcomes

AIM

Our primary aim was to determine whether non-attendance at pre-operative clinics were associated with non-attendance at post-operative clinics and its influence on weight loss. We also sought to examine the relationship between gender, ethnicity and post-operative clinic attendance with respect to weight loss post-bariatric surgery.

METHODS

A retrospective audit was performed for patients undertaking the bariatric surgery program at the Auckland City Hospital between 2013 and 2016.

RESULTS

One hundred and eighty-four patients completed our program, with a mean age of 46.1 years. Mean weight at commencement was 133.3 kg, with a BMI of 47.4. At 2 years follow-up (n = 143), excess weight loss was 70.8% following RYGB and 68.0% following LSG (p = 0.5743). More patients attended all pre-operative than post-operative clinics (67.4% vs 37.5% p = < 0.001). One pre-operative clinic non-attendance was associated with less weight loss at 2 years and it increases the risk of missing at least 50% of post-operative clinics with a risk ratio of 2.73, p = 0.005. Non-attendance of at least 50% of post-operative clinics was also associated with less weight loss at 2 years (33.4 kg vs 44.3 kg, p = 0.040). Although Maori and Pacific Islanders more frequently missed > 50% of post-operative clinics, weight loss was similar between European, Maori and Pacific Islander populations (2-year weight loss 44.2 kg vs 40.74 kg vs 44.1 kg, respectively, p = 0.8192).

CONCLUSION

Pre-operative clinic non-attendance helps predict post-operative clinic non-attendance. Missing any pre-operative clinics and at least 50% of scheduled post-operative clinics is associated with poorer weight loss outcomes.

Long-term micronutrient surveillance after gastric bypass surgery in an integrated healthcare system

BACKGROUND

The number of patients undergoing bariatric surgery in the United States is growing. While gastric bypass surgery is an important tool in the management of obesity, it requires lifelong metabolic monitoring and medical management. Data describing compliance with recommended laboratory follow-up are limited, particularly in long-term and primary care settings.

OBJECTIVES

To evaluate postoperative follow-up laboratory testing for patients after laparoscopic Roux-en-Y gastric bypass (LRYGB).

SETTING

Academic-affiliated community hospital.

METHODS

A review of patients who underwent LRYGB from 2001 to 2016 was performed. The location of patients' follow-up care and compliance with recommended laboratory testing were determined from patient records. Compliance was analyzed at 1-year intervals.

RESULTS

One thousand four hundred ninety patients underwent LRYGB. Five years after their surgical date, patients were more likely to follow-up with primary care than bariatric surgery clinic (369 versus 159 patients). At 5 years postoperative, 82%, 85%, and 68% of patients that followed-up with primary care did not have a vitamin D, parathyroid hormone, or vitamin B12 test, respectively. Patients that followed-up in bariatric clinic were slightly more likely to have recommended labs completed. At 5 years postprocedure, 81%, 55%, and 48% did not have a vitamin D, parathyroid hormone, or vitamin B12 test, respectively.

CONCLUSION

Most patients do not have the recommended laboratory testing completed, regardless of where their follow-up care occurred. This study identified a gap in long-term postoperative care for patients who have undergone gastric bypass surgery. Further studies will be necessary to develop interventions aimed at improving adherence to recommended monitoring after LRYGB.

The use of telemedicine for delivering healthcare to bariatric surgery patients: A literature review

Introduction Bariatric weight loss surgery is one of the most effective treatments for severe obesity. Research shows that the availability of healthcare services pre and post bariatric surgery improves behavioural change and weight loss outcomes. The aim of this systematic review is to assess the evidence relating to the use of telemedicine for providing health services to bariatric surgery patients. Methods A search was conducted using PubMed, EMBASE, CINAHL, PsycNET and SCOPUS. Original research relating to telemedicine for bariatric surgery patients published in peer-reviewed journals were included. Results Database search returned 258 references and a total of 10 studies were included in the review. Six studies assessed use, feasibility and acceptance of telemedicine by patients/practitioners. Studies also examined the use of telemedicine for weight loss, changes in physical activity, diet/eating or other behavioural changes. Two studies were randomised controlled trials; one showed a significant difference in outcomes between intervention and control group. Discussion This review suggests that telemedicine may be a potential method for providing healthcare services to bariatric surgery patients. However, the current evidence base does not allow for definitive conclusions.