Weight loss expectations of laparoscopic sleeve gastrectomy candidates compared to clinically expected weight loss outcomes 1-year post-surgery

Patient experience in bariatric surgery: protocol of a French narrative inquiry and qualitative analysis

INTRODUCTION

The quality of hospital care, especially surgery, is traditionally assessed using indicators derived from healthcare databases or safety indicators. Given the growing importance of placing the patient at the heart of care evaluation, the use of questionnaires such as the Patient-Reported Experience Measures and Patient-Reported Outcome Measures has become widespread in recent years. However, these tools-addressing factors such as satisfaction, pain management or wait times-only imperfectly reflect the patient's experience, and all such attempts at patient-centred care quality assessment rely on questions or indicators defined in advance by healthcare providers and health authorities. A biopsychosocial model may allow to better understand the patient experience and to improve care pathways. This study seeks to construct a narrative of the bariatric surgical care journey with instruments from narrative inquiry, propose a metanarrative that can serve as a basis for more sophisticated and reliable patient-focused care quality models and define indicators linked to patients' feelings and stories.

METHODS AND ANALYSIS

To achieve these aims, 16 bariatric surgical patients at the hospital of Créteil, France (Centre Hospitalier Intercommunal de Créteil), will be included and interviewed once before and twice after surgery, at months 3 and 6. Narratives collected will be used to construct a metanarrative intended to encompass all possible narratives. This metanarrative may ultimately inform new patient care quality indicators, furthering care focused on patients and tailored to their needs and predispositions.

ETHICS AND DISSEMINATION

The study is funded by the Group of Clinical Research and Innovation in Île-de-France and was approved by CPP SUD-EST VI Clermont-Ferrand (France) Research Ethics Committee. The results will be submitted for publication in peer-reviewed journals. The patient associations will be approached for the dissemination of the study results.

TRIAL REGISTRATION NUMBER

NCT05092659.

Predicting satisfaction with outcome and follow-up care 5 years after bariatric surgery: A prospective evaluation

Objective

Patient satisfaction is viewed as essential for a successful outcome of bariatric surgery. Few studies have explored long-term satisfaction prospectively. This study aimed to examine pre- and post-surgery predictors for satisfaction with follow-up care, and change in outcome satisfaction from one to 5 years after bariatric surgery.

Methods

A sample of 210 participants was recruited from a single treatment center. Self-reported and medical record data regarding mental and somatic health, body image, follow-up attendance, and weight loss were obtained before, 1 year, and 5 years after surgery.

Results

Over 90% of the participants were satisfied with the results and treatment 1 year after surgery, while 69% had their outcome expectations fulfilled and 62% were satisfied with the follow-up 5 years after surgery. A shift from initial satisfaction to unfulfillment of expectations was predicted by baseline body dissatisfaction, greater percentage of weight regain after initial weight loss, and more discomfort from somatic symptoms 5 years after surgery. In addition to symptom discomfort, worry about surgery predicted satisfaction with follow-up care.

Conclusion

At 5 years, one-fifth of those initially satisfied reported that bariatric surgery had failed to meet their expectations. This suggests that outcome expectations related to weight loss, somatic symptoms, and body image need to be addressed both before and after bariatric surgery.

Women's Reasons to Seek Bariatric Surgery and Their Expectations on the Surgery Outcome - a Multicenter Study from Five European Countries

Purpose

Understanding patients’ reasons for having bariatric surgery and their expectation on surgery outcomes is important to provide the best clinical practice and reduce unrealistic expectations. It is unknown if reasons and expectations differ between countries. We aimed to investigate the reasons for seeking bariatric surgery and expectations of surgical outcomes among patients in five European countries.

Methods

In total, 250 women accepted for bariatric surgery were recruited: 50 women each from Finland, Germany, Norway, Sweden, and the Netherlands. Participants ranked 14 reasons for seeking surgery, and reported the three primary reasons. They also reported expectations on weight loss and impact of surgery vs. lifestyle on weight loss outcomes.

Results

Mean age and body mass index were 42.9 ± 11.5 years and 45.1 ± 6.2 kg/m², respectively. Weight loss and improved co-morbidity were ranked as the most important reasons. Participants expected to lose between 70.8 and 94.3% of their excessive weight. The expected impact of surgery as a driver of weight loss was higher in Germany and the Netherlands compared to in Finland, Norway, and Sweden where participants expected lifestyle changes to also have an impact.

Conclusion

Weight loss and improved co-morbidities were the main reasons for undergoing bariatric surgery. Expectations on weight loss were generally very high, but expectations of surgery vs. lifestyle as the main driver of weight loss differed between countries. While some patients understand the importance of lifestyle change and maintenance of a healthy lifestyle after surgery in order to obtain a successful weight loss, other may need additional counselling.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-022-06280-w.

Insufficient weight loss after banded vs. non-banded primary gastric bypass surgery: insights from an observational 5 year follow-up study

BACKGROUND

While Roux-en-Y gastric bypass (RYGB) is effective in achieving weight loss and improving obesity-related co-morbidities, insufficient weight loss in the long-term can occur. The goal was to assess whether banded vs. non-banded RYGB reduces the risk of insufficient weight loss at 5-year follow-up.

METHODS

This is a retrospective single-center cohort study from Switzerland. We assessed the 5-year metabolic trajectories in terms of body weight, body mass index, glucose control, lipid profile and blood pressure of two surgical cohorts undergoing identical RYGB procedures with or without banding using a uniform 6.5 cm silastic Fobi band. Insufficient weight loss was defined as < 50% excess weight loss (EWL) at 5 years.

RESULTS

A total of 55 patients receiving banded (Fobi) and 55 patients receiving non-banded (non-Fobi) RYGB were included in the analysis. 5-year follow-up was 91% for both groups. Percentage of EWL at 5 years was 78.11 ± 26.1% and 73.5 ± 27%.3 for the Fobi vs. non-Fobi group (p = 0.368), respectively. Insufficient weight loss (defined as < 50%EWL) at 5 years or last follow-up was significantly higher in the non-Fobi group compared to the Fobi group (19/55 vs. 9/55, respectively, OR = 2.639 (95% CI 1.066, 6.531), p = 0.036). Surrogate markers for cardiometabolic outcomes consistently improved over time, without differences between the groups. During the follow-up period, Fobi-removal was necessary in nine patients (16.3%).

CONCLUSION

Banded-RYGB lowered the odds of insufficient weight loss at 5 years follow-up by approximately 62%. Further research is needed to explore the effect of restriction on eating behaviour and neuroendocrine responses after RYGB.

Nonsurgical weight loss interventions: A systematic review of systematic reviews and meta-analyses

Access to bariatric surgery to treat obesity is limited and has long wait times. Many adults are seeking nonsurgical weight loss support. Our study objective was to conduct a systematic review of nonsurgical weight loss interventions. PubMed, EMBASE, CINAHL, PsycInfo, and the CochraneLibrary were searched. Inclusion criteria were adults 18 + with a BMI > 25 enrolled in minimum a 3-month nonsurgical weight loss intervention. Studies were independently extracted and assessed for quality using A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR2). Pooled analyses were extracted, graded for evidence quality, and summarized. A total of 1065 studies were assessed for eligibility; 815 screened and 236 full-texts assessed. Sixty-four meta-analyses met eligibility criteria: 1180 RCTs with 184,605 study participants. Studies were categorized as diets (n = 13), combination therapies (n = 10), alternative (n = 16), technology (n = 10), behavioral (n = 5), physical activity (n = 6), and pharmacotherapy (n = 3). In 80% of studies, significant weight losses were reported ranging from 0.34-8.73 k in favor of the intervention. The most effective nonsurgical weight loss interventions were diets, either low-carbohydrate or low-fat diets, followed for 6 months; combination therapy including meal replacements plus enhanced support; and pharmacotherapy followed for 12 months. Although significant weight losses were reported for other types of interventions such as physical activity and technology, the majority of studies reported weight losses less than 2 kgs.

"I Want to Lose Weight and it Has to Be Fair": Predictors of Satisfaction After Bariatric Surgery

PURPOSE

Bariatric surgery (BS) is the most effective technique used to help patients with obesity achieve long-term weight loss. Although many patients report high levels of postoperative satisfaction after BS, some remain unsatisfied with their outcome. Studies of factors that predict postoperative satisfaction have yielded varying results. Weight loss has been identified as a predictor of satisfaction after BS, but debate remains concerning the impact of preoperative expectations and psychological variables. Furthermore, the relevance of attribution and perception of equity to postoperative satisfaction has not been evaluated in patients undergoing BS.

MATERIALS AND METHODS

We assessed preoperative expectations and the levels of body dissatisfaction, anxiety, and depression in 80 patients undergoing BS. Satisfaction, attribution, feeling of equity, and psychological variables were evaluated 6 months, 1 year, and 2 years after BS.

RESULTS

Weight loss and equity were the two predictors of satisfaction 6 months after BS. Body dissatisfaction was the main factor predicting satisfaction 1 year after BS, with equity and anxiety having smaller influences. Weight loss and equity were the factors predicting satisfaction 2 years after BS.

CONCLUSION

Our findings support previous results concerning the influence of weight loss on satisfaction after BS. The identification of equity as a factor associated with postoperative satisfaction raises questions regarding the impact of the comparisons made by the patient with others and the consequences of the messages they receive about BS. Moreover, our results underscore the importance of considering the patient's personal experience after BS and not just their weight loss.

Risk of Suicide and Self-harm Is Increased After Bariatric Surgery-a Systematic Review and Meta-analysis

BACKGROUND

Bariatric surgery is endorsed by multiple societies as the most effective treatment for obesity. Psychosocial functioning has also been noted to improve for most patients after bariatric surgery. However, some studies have shown an increase in post-operative suicide risk. The aim of this study was to review the published literature and evaluate the association of bariatric surgery with suicide events and suicide/self-harm attempts in patients who have undergone weight loss surgery.

METHODS

MEDLINE and Embase were searched from inception through January 2018 for retrospective or prospective studies reporting mortality outcomes and self-harm or suicide rates after bariatric procedures. The primary outcome was the pooled event rate with 95% confidence interval (95% CI) for suicide. Secondary outcomes were suicide/self-harm attempts after bariatric surgery compared to same population prior to surgery and to matched control subjects, with the respective calculated odds ratios (OR) and 95% CI.

RESULTS

From 227 citations, 32 studies with 148,643 subjects were eligible for inclusion. The patients were predominantly females (76.9%). Roux-en-Y gastric bypass (RYGB) was the most commonly performed procedure (58.9%). The post-bariatric suicide event rate was 2.7/1000 patients (95% CI 0.0019-0.0038), while the suicide/self-harm attempt event rate was 17/1000 patients (95% CI 0.01-0.03). The self-harm/suicide attempt risk was higher after bariatric surgery within the same population with OR of 1.9 (95% CI 1.23-2.95), and compared to matched control subjects, OR 3.8 (95% CI, 2.19-6.59).

CONCLUSIONS

Post-bariatric surgery patients had higher self-harm/suicide attempt risk compared to age-, sex-, and BMI-matched controls. Various pre- and post-surgical psychosocial, pharmacokinetic, physiologic, and medical factors may be involved.

Association of preoperative hemoglobin with weight loss after bariatric surgery: a retrospective study

BACKGROUND

Despite the known positive correlation between exercise and weight loss after bariatric surgery as well as the established association of hemoglobin level with maximal aerobic power and endurance performance, the correlation between preoperative hemoglobin concentration (pre-Hb) and postoperative weight loss remains unknown.

OBJECTIVE

This study aimed at assessing the association of pre-Hb with postoperative percentage weight loss (%WL) at 3, 6, 12, and 24 months after surgery.

SETTING

A single tertiary referral center.

METHODS

Outcomes of 282 patients undergoing laparoscopic sleeve gastrectomy at the 4 timepoints within a 24-month follow-up period were assessed. The primary study endpoint was the relationship between pre-Hb and postoperative %WL at 12-month follow-up.

RESULTS

The 282 patients had a mean preoperative body mass index of 39.0 ± 4.5 kg/m² with a slight female predominance (57.4%). Follow-up data were available for 221 of 282 (78.4%) patients (mean %WL: 30.9% ± 6.6%) at 1 year. Pearson's correlation showed that pre-Hb correlated positively with post-Hb (r = 0.778, P < .001) and %WL (r = .237, P < .001) at 12-month follow-up but not at 24 months (r = .145, P = .331). Multiple linear regression analyses including baseline variables of age, sex, preoperative body mass index, and diabetes revealed that pre-Hb, age, and preoperative body mass index were independent predictors of %WL. There was no evidence of multicollinearity among these variables.

CONCLUSION

The present study showed a potential positive relationship between pre-Hb and postoperative weight loss. More well-designed, large-scale studies are warranted to clarify the effect of hemoglobin level on postoperative weight loss in this patient population.

Patients' Preoperative Estimate of Target Weight and Actual Outcome after Bariatric Surgery

BACKGROUND

Evidence about the impact of psychological factors on weight loss after bariatric surgery is scarce. This study explores whether patients' preoperative estimate of target weight influences actual weight loss for different types of bariatric procedures.

METHODS

Patients eligible for bariatric surgery were instructed twice on how to calculate their expected target weight. They were divided into three groups based on their percentage excess weight loss (%EWL) and percentage total body weight loss (%TBWL). Weight loss 12 and 24 months after surgery was analyzed for each group and per type of surgery.

RESULTS

Six hundred fifty-six patients participated in this study. Types of surgery performed were the Roux-en-Y gastric bypass (RYGB, 75%), sleeve gastrectomy (SG, 8.1%), REDO-RYGB (12.5%), and laparoscopic adjustable gastric banding (LAGB, 4.4%). Data of 622 and 410 patients were available for analysis at 12 and 24 months, respectively. Surprisingly, 415 patients (63.3%) overestimated their expected weight loss as opposed to our calculation, based on our own historic data. One hundred thirty-four patients (20.4%) estimated their weight loss correctly and 107 patients (16.3%) underestimated their weight loss. There was a significant higher %EWL 12 months after RYGB surgery for patients who overestimated their weight loss compared to those who estimated their weight loss correctly (p = 0.001). After 24 months and for other types of procedures, no statistically significant differences were found between the three groups.

CONCLUSION

Despite instructions on how to calculate target weight, the majority of patients overestimated their weight loss. Actual %EWL 12 months after RYGB surgery might be influenced by setting a low target weight.

Is there a Reason Why Obese Patients Choose Either Conservative Treatment or Surgery?

BACKGROUND

The effects of bariatric surgery on excess weight loss (EWL) and comorbidities are proven. Still, a significant number of patients prefer conservative therapy (ConsP).

OBJECTIVES

The goal of this study was to examine why ConsP and patients awaiting bariatric surgery (SurgP) choose which therapy, and to define the differences in their expectations.

SETTING

Prospective study, 1 university hospital, 1 general hospital, Germany.

METHODS

ConsP and SurgP were asked to complete a questionnaire. Statistical analysis including all patients and a BMI-matched cohort was performed using the chi-square and Wilcoxon rank-sum test.

RESULTS

Overall, 151 patients participated in this study (50 ConsP, 101 SurgP, 69.4% females). The mean age was 41.1 years (SD ± 12.2 years). ConsP had a significant lower body mass index (BMI, 44.7 kg/m² vs. 49.3 kg/m², p < 0.01). The educational level was significantly higher in ConsP. SurgP suffered significantly more often from depression (21.6% vs. 36.6%, p = 0.02) and joint pain (45.1% vs. 68.7%, p = 0.02). ConsP completed significantly more diets that were supervised by physicians or considered well-structured (56.3% vs. 31.0%, p = 0.04). SurgP considered their chosen therapy a last resort significantly more often (p < 0.01). A BMI-matched analysis between ConsP and SurgP revealed no significant differences in the prevalence of comorbidities but showed that fear of surgery plays a major role in the decision-making processes of obese patients.

CONCLUSION

A higher BMI and a greater prevalence of comorbidities had driven patients to seek a more radical solution for their obesity, i.e., surgery. The BMI-matched analysis suggests that fear of surgery is a relevant factor in why obese patients do not decide to undergo bariatric surgery lightly.

Morbidity and health-related quality of life of patients accessing laparoscopic sleeve gastrectomy: a single-centre cross-sectional study in one province of Canada

Background

In Canada, severe obesity (BMI ≥ 35 kg/m²) affects 5% or 1.2 million adults. Bariatric surgery is the only effective treatment for severe obesity, but the demand for publicly funded procedures is high and capacity limited. Little is known in Canada about the types of patients undergoing these procedures, especially laparoscopic sleeve gastrectomy (LSG). The study objective is to examine the socio-demographic profile, morbidity and HRQoL of patients accessing LSG in one Canadian province.

Methods

Health status and HRQoL were examined in patients (n = 195) undergoing LSG. HRQoL was assessed using the EQ-5D-3L, SF-12v2 and the Impact of Weight on Quality of Life-lite questionnaire.

Results

Mean age and BMI were 44 and 49 kg/m² and most were women (82%). Pre-surgery, comorbidities were sleep apnea (65%), dyslipidemia (48%), hypertension (47%) and osteoarthritis (44%). Patients reported impaired HRQoL with 44-67% reporting problems in mobility, usual activities, pain and anxiety/depression. Physical health was impaired more than mental health. There were few socio-demographic differences between women and men, but significant differences in comorbid conditions such as sleep apnea, dyslipidemia, hypertension and gout exist (p < .05). Women reported fewer problems with self-care (9.5% vs. 25.0%, p < .05), and better overall health (VAS 61.5 vs. 52.0, p < .05) and General Health (39.3 vs. 32.9, p < .05), but greater impairment in self-esteem (27.3 vs. 44.1, p < .01) and sexual life (49.2 vs. 63.6, p < .05).

Conclusions

Before LSG, patients reported significant morbidity and impaired HRQoL. Although baseline characteristics were similar between men and women, gender specific differences were observed in comorbid profile and HRQoL.

Communication between the obese patient and bariatric surgeon

Communication between the bariatric surgeon and the obese patient is very important as it influences the expectations of patients with regard to surgery, aim of the surgery and the understanding of the mechanisms of failure of surgery. Furthermore, the incidence of certain psychopathology in these patients makes it necessary for the surgeon to have the ability to communicate to the patient the need for motivation and the maintenance of healthy life habits. Although the topic is subjective, in this article we review several useful recommendations to optimize communication before and after surgery. Finally, we emphasize the need to create workshops to train the bariatric surgeon in these issues that we consider so important.

Evidence-based decision-making 5: Translational research

The delay in turning research into practice for the benefit of patient care has been compared to a "leaky pipeline." In the early 2000s, this delay raised concerns among governmental agencies and other sponsors of health services in many countries. Facilitating the translation of basic and clinical research into clinical practice through evidence-based decision-making and improving population health is now a major goal of health research investment agencies. Translational research or knowledge translation has emerged to bridge the gaps between basic and clinical research, and between clinical research and clinical practice. Various frameworks and definitions of translational research are presented. We present an example of an Integrated Knowledge Translation Team in Bariatric Care, and explain how an integrated knowledge translation (iKT) approach was created at the program's inception. This led to evidence-based decision-making and subsequent practice change in one area of the health care system. Real-world successes and challenges in moving research to practice are discussed.

Body shape expectations and self-ideal body shape discrepancy in women seeking bariatric surgery: a cross-sectional study

Background

Postoperative body shape expectations (BSE) of bariatric surgery candidates remain relatively unexplored, and may have important implications for weight loss outcomes, treatment satisfaction, and education.

Methods

The ‘Silhouette Figure Rating Scale’ was administered to 69 consecutive female candidates. Self-perceived current and goal body shape and postoperative BSE in four categories; “dream, “happy”, “acceptable”, and “disappointed” were examined.

Results

The mean age and BMI of the sample was 43.4 ± 8.9 years and 48.8 ± 7.0 kg/m². Self-ideal body shape discrepancy of 4.1 ± 1.3 silhouettes was reported, indicating body image dissatisfaction. 53% incorrectly identified the silhouette associated with their actual BMI. Goal body shape (4.3 ± 0.8 silhouettes) corresponded to a BMI figure 23.1 kg/m²- 26.2 kg/m². The postoperative “dream” (4.1 ± 1.0 silhouettes), “happy” (5.0 ± 0.8 silhouettes), “acceptable” (5.3 ± 1.0 silhouettes), and “disappointed” (6.9 ± 1.0 silhouettes) BSE corresponded to silhouettes that were thinner than the thinnest silhouette clinically expected based on a 56.1% excess weight loss 1-year after laparoscopic sleeve gastrectomy (LSG) or a 22.3% to 47.2% total body weight loss.

Conclusions

Women seeking bariatric surgery experience body image dissatisfaction and misperceive their actual body size. BSE do not correspond with evidence-based LSG weight loss outcomes.

Early postoperative weight loss predicts maximal weight loss after sleeve gastrectomy and Roux-en-Y gastric bypass

Background

Previous studies show that ‘poor responders’ to Roux-en-Y gastric bypass (RYGBP) may be identified on the basis of early postoperative weight loss. Early identification of poor responders could allow earlier provision of postoperative behavioural and/or intensive lifestyle interventions and enhance their maximal weight loss. Our aim was to investigate whether early postoperative weight loss predicts the maximal weight loss response after RYGBP and sleeve gastrectomy (SG).

Methods

We undertook a retrospective cross-sectional study of 1,456 adults who underwent either RYGBP (n = 918) or SG (n = 538) as a primary procedure in one of two European centres. Postoperative weight loss was expressed as weight loss velocity (WLV) and percentage weight loss. Linear regression analyses were performed to determine the association of early postoperative weight loss with maximal %WL, including adjustment for baseline variables.

Results

There was marked variability in maximal %WL following both RYGBP (mean 32.9 %, range 4.1–60.9 %) and SG (mean 26.2 %, range 1.1–58.3 %). WLV 3–6 months postoperatively was more strongly associated with maximal %WL (r² = 0.32 for RYGBP and r² = 0.26 for SG, P < 0.001 for both) than either WLV 0–6 weeks or 6 weeks to 3 months postoperatively (r² = 0.14 and 0.10 for RYGBP, respectively; r² = 0.18 and 0.21 for SG, respectively; P < 0.001 for all). Multiple linear regression analysis, including baseline variables of age, sex, preoperative BMI, type 2 diabetes, ethnicity, and bariatric centre, revealed that 3–6 month WLV was an independent predictor of maximal %WL in both SG and RYGBP groups (standardised β-coefficients 0.51 and 0.52, respectively; P < 0.001 for both).

Conclusions

There is a marked variability in weight loss response following RYGBP and SG. Early postoperative weight loss can be used to identify patients whose predicted weight loss trajectories are suboptimal. Early targeting of poor responders with more intensive postoperative lifestyle and behavioural support could potentially enhance their weight loss response.