Patient preferences and bariatric surgery procedure selection; the need for shared decision-making

From Bands to Bypasses: Navigating Safety of Band Conversions to Roux-en-Y Gastric Bypass and Single Anastomosis Duodenoileostomy Versus Sleeve Gastrectomy

INTRODUCTION

Revisional bariatric surgery is associated with higher perioperative complications over primary procedures. Adjustable gastric bands (AGB) continue to be the most frequently converted bariatric configuration. This study examines trends in current clinical indication and safety profile of the most frequently pursued AGB conversions.

MATERIALS AND METHODS

MBSAQIP data from 2020 to 2022 was retrospectively analyzed in a cohort study examining 30-day postoperative outcomes after AGB conversion to sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), or single anastomosis duodenoileostomy (SADI). Descriptive statistics were used, including multivariable and 2:1 nearest neighbor matching analysis.

RESULTS

This study included 19,335 AGB conversions, of which most were to SG (n = 11,736) followed by RYGB (n = 7442) and SADI (n = 157). While a majority were completed for weight loss, there were differences in distribution of primary indication for each conversion cohort, such as higher proportion of RYGB conversion for gastroesophageal reflux disease (18.7%) compared to SG (7.92%) and SADI (5.10%). Multivariable analysis demonstrates conversion to RYGB has significantly higher odds of 30-day major complications (OR 1.75, p < 0.001), reoperation (OR 2.08; p = 0.001), readmission (OR 1.69; p = 0.001), and emergency department visits (OR 1.50; p = 0.001) over SG. These risks and odds of reintervention (OR 1.75; p < 0.001) remained significantly higher after conversion to RYGB versus SG on matched analysis. None of these risks is significantly different between conversions to SADI versus SG in either multivariable or matched analysis.

CONCLUSIONS

Compared to AGB conversion to SG, single-stage conversion to RYGB had increased odds of perioperative complications while risks of conversion to SADI were not significantly different.

Understanding preferences of patients with obesity for metabolic bariatric surgery: a comprehensive adaptive choice-based conjoint analysis

BACKGROUND

Patient preferences toward metabolic bariatric surgery (MBS) remain inadequately explored.

OBJECTIVE

This study aims to identify and analyze the key factors influencing the decision-making process of patients considering MBS.

SETTING

The research was conducted at the metabolic bariatric surgery clinic of the Medical Research Institute Hospital, Alexandria University, Egypt.

METHOD

Patients with obesity were recruited at the clinic before MBS. The surgical profiles were characterized by attributes including treatment method, recovery and reversibility, treatment tenure, expected weight loss, impact on associated medical problems, risk of complication, side effects, dietary changes, and out-of-pocket costs. Patients engaged in an online survey comprising sociodemographic data, Build Your Own (BYO) section, screening section, and choice tournament section. Adaptive choice-based conjoint analysis was employed to discern the preferences.

RESULTS

Of the 299 respondents, the surgical profiles with the highest preference involved a loss of 80% of excess weight without any recurrence (14.67 [95% CI, 14.10-15.23]), 0% risk of complication (13.74 [95% CI, 13.03-14.45]), and absence of adverse effects (11.32 [95% CI, 10.73-11.91]). K-mean cluster analysis identified 2 distinct groups: "patients prioritize weight loss" group prioritized excess weight loss, surgery availability, and diet change, whereas "patients prioritize avoidance of complications" group focused on the risk of complication, adverse effects, and the surgery mechanism.

CONCLUSIONS

MBS candidates predominantly value weight loss without recurrence, followed by minimization of complication risks and adverse effects, within 3 years postsurgery. Conversely, initial out-of-pocket costs and resolution of medical conditions were deemed the least influential attributes.

Comparison of various prediction models in the effect of laparoscopic sleeve gastrectomy on type 2 diabetes mellitus in the Chinese population 5 years after surgery

BACKGROUND

The effect of bariatric surgery on type 2 diabetes mellitus (T2DM) control can be assessed based on predictive models of T2DM remission. Various models have been externally verified internationally. However, long-term validated results after laparoscopic sleeve gastrectomy (LSG) surgery are lacking. The best model for the Chinese population is also unknown.

METHODS

We retrospectively analyzed Chinese population data 5 years after LSG at Beijing Shijitan Hospital in China between March 2009 and December 2016. The independent t -test, Mann-Whitney U test, and chi-squared test were used to compare characteristics between T2DM remission and non-remission groups. We evaluated the predictive efficacy of each model for long-term T2DM remission after LSG by calculating the area under the curve (AUC), sensitivity, specificity, Youden index, positive predictive value (PPV), negative predictive value (NPV), and predicted-to-observed ratio, and performed calibration using Hosmer-Lemeshow test for 11 prediction models.

RESULTS

We enrolled 108 patients, including 44 (40.7%) men, with a mean age of 35.5 years. The mean body mass index was 40.3 ± 9.1 kg/m 2 , the percentage of excess weight loss (%EWL) was (75.9 ± 30.4)%, and the percentage of total weight loss (%TWL) was (29.1± 10.6)%. The mean glycated hemoglobin A1c (HbA1c) level was (7.3 ± 1.8)% preoperatively and decreased to (5.9 ± 1.0)% 5 years after LSG. The 5-year postoperative complete and partial remission rates of T2DM were 50.9% [55/108] and 27.8% [30/108], respectively. Six models, i.e., "ABCD", individualized metabolic surgery (IMS), advanced-DiaRem, DiaBetter, Dixon et al' s regression model, and Panunzi et al 's regression model, showed a good discrimination ability (all AUC >0.8). The "ABCD" (sensitivity, 74%; specificity, 80%; AUC, 0.82 [95% confidence interval [CI]: 0.74-0.89]), IMS (sensitivity, 78%; specificity, 84%; AUC, 0.82 [95% CI: 0.73-0.89]), and Panunzi et al' s regression models (sensitivity, 78%; specificity, 91%; AUC, 0.86 [95% CI: 0.78-0.92]) showed good discernibility. In the Hosmer-Lemeshow goodness-of-fit test, except for DiaRem ( P <0.01), DiaBetter ( P <0.01), Hayes et al ( P = 0.03), Park et al ( P = 0.02), and Ramos-Levi et al' s ( P <0.01) models, all models had a satifactory fit results ( P >0.05). The P values of calibration results of the "ABCD" and IMS were 0.07 and 0.14, respectively. The predicted-to-observed ratios of the "ABCD" and IMS were 0.87 and 0.89, respectively.

CONCLUSION

The prediction model IMS was recommended for clinical use because of excellent predictive performance, good statistical test results, and simple and practical design features.

Outcomes of SADI and OAGB Compared to RYGB from the Metabolic and Bariatric Surgery Quality Improvement Program: The North American Experience

BACKGROUND

Rapid adoption of sleeve gastrectomy (SG) in the last decade aptly reflects the desire of patients and surgeons for alternatives to RYGB and DS. While SG provides good outcomes, other options that address specific patient needs are warranted. Recently approved by ASMBS, SADI, and OAGB have garnered increasing interest due to their single anastomosis technique.

METHODS

Using the Metabolic and Bariatric Surgery Quality Improvement Program database, we examined laparoscopic and robotic cases from 2018 to 2021 to understand the percentage of primary bariatric surgery cases that are SADI and OAGB. We used coarsened exact matching to match patients who underwent SADI or OAGB to patients who underwent Roux-en-Y gastric bypass (RYGB). We examined outcomes of matched patients using logistic regression.

RESULTS

Of the 667,979 patients that underwent bariatric-metabolic surgery, 1326 (0.2%) underwent SADI, and 2541 (0.4%) underwent OAGB. SADI was not identified in the database until 2020. In 2020, there were 487 SADI procedures compared to 839 in 2021. From 2018 to 2021, OAGBs went from 149 to 940. Compared with RYGB, SADI was associated with higher rates of anastomotic or staple line leak (OR 2.21 (95% CI 1.08-4.53)) and sepsis (OR 3.62 (95% CI 1.62-8.12)). Compared with RYGB, OAGB was associated with lower rates of gastrointestinal bleeding (OR 0.29 (95% CI 0.12-0.71)) and bowel obstruction (OR 0.10 (95% CI 0.02-0.39)). Of note, there were no differences between these procedures and RYGB for 30-day mortality.

CONCLUSION

More SADIs and OAGBs are being performed. However, there were higher complication rates associated with the SADI procedure. Further studies will be needed to better understand the key drivers for these outcomes.

Third time's a charm: band to sleeve to bypass

BACKGROUND

Adjustable gastric bands (AGB) are frequently converted to sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) due to weight recurrence or band complications. Such conversions carry a higher-risk than primary procedures. Some patients undergo two conversions-from AGB to SG, and subsequently from SG to RYGB. This presents a unique situation with limited literature on indications and complication rates associated with these double conversions.

METHODS

We examined the 2020-2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use File to evaluate conversions from AGB to SG and then to RYGB. Patient and operative characteristics, along with outcomes, were evaluated. Descriptive statistics were applied.

RESULTS

We identified 276 patients who underwent a conversion from AGB to SG and then to RYGB. The primary reason for the second conversion (SG to RYGB) was gastroesophageal reflux disease (GERD) at 55.1%, followed by inadequate weight loss or weight regain (IWL/WR) at 36.9%. The remaining reasons included dysphagia, nausea, vomiting, or others. Patients converted for IWL/WR demonstrated a higher baseline body mass index and prevalence of sleep apnea compared to other cohorts (both p < 0.001). Meanwhile, patients in the "other reasons" group had the highest rate of open surgical approaches (9.1%) and concurrent lysis of adhesions (p = 0.001 and p = 0.022), with correspondingly higher rates of anastomotic leak, reoperations, serious complications, and mortality.

CONCLUSIONS

Patients undergoing double conversions (AGB to SG to RYGB) do so primarily for GERD or IWL/WR. Further research is required to better define the optimal primary operation for each patient, aiming to reduce the necessity for multiple conversions.

Comparison of various prediction models in the effect of Roux-en-Y gastric bypass on type 2 diabetes in the Chinese population 5 years after surgery

BACKGROUND

Various prediction models of type 2 diabetes (T2D) remission have been externally verified internationally. However, long-term validated results after Roux-en-Y gastric bypass (RYGB) surgery are lacking. The best model for the Chinese population is also unknown.

OBJECTIVES

To evaluate the prediction effect of various prediction models on the long-term diabetes remission after RYGB in the Chinese population and to provide reference for clinical use.

SETTING

A retrospective clinical study at a university hospital.

METHODS

We retrospectively analyzed Chinese population data 5 years after RYGB and externally validated 11 predictive models to evaluate the predictive effect of each model on long-term T2D remission after RYGB.

RESULTS

We enrolled 84 patients. The mean body mass index was 41 kg/m2, and the percentage of excess weight loss (%EWL) was 72.3%. The mean glycated hemoglobin level was 8.4% preoperatively and decreased to 5.9% after 5 years. The 5-year postoperative complete and partial remission rates of T2D were 31% and 70.2%, respectively. The ABCD scoring model (sensitivity, 84%; specificity, 76%; area under the curve [AUC], .866) and the Panuzi et al. [34] study (sensitivity, 84%; specificity, 81%; AUC, .842) showed excellent results. In the Hosmer-Lemeshow goodness-of-fit test, calibration values for ABCD and Panuzi et al. [34] were .14 and .21, respectively. The predicted-to-observed ratios of ABCD and Panuzi et al. [34] were .83 and .88, respectively.

CONCLUSIONS

T2D was relieved to varying degrees 5 years after RYGB in patients with obesity. The prediction models in ABCD and the Panuzi et al. [34] studies showed the best prediction effects. ABCD was recommended for clinical use because of excellent predictive performance, good statistical test results, and simple and practical design features.

Laparoscopic Sleeve Gastrectomy versus Laparoscopic Roux-en-Y Gastric Bypass: An Analysis of Weight Loss Using a Multilevel Mixed-Effects Linear Model

Background: Regarding weight loss outcomes, the results published after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y (LRYGB) are conflicting. At this time, no clear evidence exists that outcomes from LSG are similar to those for LRYGB. The main objective of this study was to compare the percent of total weight loss (%TWL) between LRYGB and LSG over the first 2 years using a multilevel mixed-effects linear regression. Methods: Data were collected from a prospectively maintained database of patients who underwent primary laparoscopic bariatric surgery from January 2016 to December 2017 at a French accredited bariatric center. The medical records of 435 consecutive patients were analyzed. %TWL was calculated at each follow-up surgical consultation and used as a repeated outcome variable in our models to assess the long-term %TWL. Due to this hierarchical structure of the data (%TWL at each visit = level 1) within patients (level 2), a multilevel linear regression adjusted for age, sex, preoperative BMI and comorbidities was used. Results: Among the medical records of 435 consecutive patients included, 266 patients underwent LRYGB and 169 underwent LSG. The average %TWL at 2 years was 31.7% for the LRYGB group and 25.8% for the LSG group. The final multivariate model showed that, compared with LRYGB, LSG was associated with a decreased %TWL at over 2 years of follow-up (β: −4.01; CI95%: −5.47 à −2.54; p ≤ 0.001). Conclusion: This observational study suggests that compared with LRYGB, LSG was associated with a decreased %TWL at 2 years using a multilevel model. Further studies are required to confirm the results observed with this statistical model.

Cost-Effectiveness of Surgical Weight-Loss Interventions for Patients With Knee Osteoarthritis and Class III Obesity

OBJECTIVE

Class III obesity (body mass index [BMI] ≥40 kg/m2 ) is associated with worse knee pain and total knee replacement (TKR) outcomes. Because bariatric surgery yields sustainable weight loss for individuals with BMI ≥40 kg/m2 , our objective was to establish the value of Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) in conjunction with usual care for knee osteoarthritis (OA) patients with BMI ≥40 kg/m2 .

METHODS

We used the Osteoarthritis Policy model to assess long-term clinical benefits, costs, and cost-effectiveness of RYGB and LSG. We derived model inputs for efficacy, costs, and complications associated with these treatments from published data. Primary outcomes included quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs), all discounted at 3%/year. This analysis was conducted from a health care sector perspective. We performed sensitivity analyses to evaluate uncertainty in input parameters.

RESULTS

The usual care + RYGB strategy increased the quality-adjusted life expectancy by 1.35 years and lifetime costs by $7,209, compared to usual care alone (ICER = $5,300/QALY). The usual care + LSG strategy yielded less benefit than usual care + RYGB and was dominated. Relative to usual care alone, both usual care + RYGB and usual care + LSG reduced opioid use from 13% to 4%, and increased TKR usage from 30% to 50% and 41%, respectively. For cohorts with BMI between 38 and 41 kg/m2 , usual care + LSG dominated usual care + RYGB. In the probabilistic sensitivity analysis, at a willingness-to-pay threshold of $50,000/QALY, usual care + RYGB and usual care + LSG were cost-effective in 70% and 30% of iterations, respectively.

CONCLUSION

RYGB offers good value among knee OA patients with BMI ≥40 kg/m2 , while LSG may provide good value among those with BMI between 35 and 41 kg/m2 .

Obesity surgery: Which procedure should we choose and why?

In the 70years that bariatric surgery has existed, many different surgical procedures have been developed. Four procedures are officially accepted by all learned societies: adjustable gastric banding (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB) and bilio-pancreatic diversion (BPD). Gastric banding has the lowest short-term surgical risk, but it has the highest re-operation rate. Compared to SG, RYGB presents about twice the risk of early complications. Late complications seem equivalent between the two procedures but studies with follow-up>10years are rarer for SG. SG has become the most commonly performed bariatric procedure worldwide, followed by RYGB, which is still the standard. BPD remains very marginal but the omega gastric bypass, an alternative technique that is still under evaluation, now competes with RYGB. The effectiveness of these different procedures on weight loss remains difficult to compare. SG and RYGB seem to be equivalent for weight loss results and remission of type-2 diabetes (T2DM). Their results are superior to AGB. Procedures that result in greater lengths of intestinal bypass (bilio-pancreatic diversion, omega bypass) seem to have a greater weight-loss effect but are burdened by more side effects. In conclusion, the choice of a procedure is conditioned firstly by the benefit-risk ratio and in relation to patient-related parameters, particularly the body mass index (BMI) and co-morbidities. Long-term results are also linked to factors other than surgery and in particular patient behavioral factors. Obesity is a chronic disease that indicates the need for real long-term medical and surgical management.

A Shared Decision-making Process may Affect Bariatric Procedure Selection and Alter Surgical Outcomes: a Single-unit Retrospective Study

PURPOSE

A shared decision-making (SDM) process centered on the patient perspective may increase understanding and treatment satisfaction. This study aimed to investigate whether SDM would increase the acceptance of bariatric/metabolic surgeries, change treatment decisions, and affect 1-year results.

MATERIALS AND METHODS

This retrospective analysis enrolled 315 consecutive patients with a body mass index between 32.5 and 50 kg/m² and aged 20-65 years who underwent consultation for a primary bariatric/metabolic procedure within 2 years before (pre-SDM) or after (post-SDM) SDM program implementation to assist in the decision to undergo Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) surgery. Consent rate, procedure choice, weight loss, comorbidity remission, etc., were compared between periods and procedures. Statistical tests were two-sided, with p < 0.05 considered significant.

RESULTS

More eligible patients underwent metabolic/bariatric procedures post-SDM than pre-SDM (115/159 [72%] vs. 106/156 [68%]; p = 0.395), and a stronger preference for RYGB post-SDM was observed (71% vs. 62%; p = 0.153). Significantly more patients with diabetes (28 [34.1%] vs. 5 [15.2%]; p = 0.041) chose RYGB over SG post-SDM. Patients who underwent RYGB had a higher diabetes remission rate both pre-SDM (70.0% vs. 58.3%; p = 0.571) and post-SDM (76.2% vs. 66.7%; p = 0.712) than those who underwent SG. While 1-year weight loss was similar between procedures, adherence to nutritional supplementation did not appear to be broadly enhanced post-SDM.

CONCLUSION

SDM influenced procedure selection toward RYGB, which was more popular than SG among patients with diabetes. Higher diabetes remission was achieved with RYGB, although the results of other effects deserve further study.

Patient perspectives on the usefulness of the MBSAQIP Bariatric Surgical Risk/Benefit Calculator: a randomized controlled trial

BACKGROUND

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Bariatric Surgical Risk/Benefit Calculator uses procedure-specific prediction models to generate individualized surgical risk/outcome estimates. This tool helps guide informed consent and operative selection. We hypothesized that calculator use would influence patient procedure choice.

OBJECTIVE

To assess patient perspectives on the bariatric surgical calculator.

SETTING

A randomized controlled trial at an MBSAQIP-accredited center.

METHODS

During the preoperative bariatric surgical office consultation, patients were randomized into 2 groups: the control group received conventional surgeon-led counseling, whereas surgeons used the risk/benefit calculator to guide decision making for the calculator group. Surveys were completed by patients following consultations to evaluate satisfaction and perceived impact of the risk/benefit calculator on operative selection.

RESULTS

Between 2020 and 2022, 61 patients were randomized to the calculator group and 68 patients to the control group. The percentage of patients whose procedure of choice changed following consultation was similar in the calculator versus control group (44.3% versus 41.2%; P = .723). However, calculator group patients were less likely to perceive surgeon counseling as very important for their decision making (43.3% versus 76.5%; P < .001). Eighty-five percent of calculator group patients rated the calculator as useful or very useful, and only 1.7% found it not very important. The reasons patients changed procedure choice were similar between the groups (P = .091); the most common cause was to improve their anticipated outcome (48.7% versus 54.8%).

CONCLUSIONS

While the risk/benefit calculator was perceived as a helpful tool by most patients, its use did not influence their procedure choice. However, the patient-reported usefulness and importance of the calculator during surgeon counseling suggest that the information provided has weight in patient decision making.

Decision-making in the management of obesity: a scoping review protocol

OBJECTIVE

This scoping review will evaluate the current published literature on decision-making in obesity management.

INTRODUCTION

Obesity is increasing in incidence worldwide. Although indications have been established for a variety of available treatment modalities, treatment selection must also factor in patient preferences, clinician expertise, and resource availability. Such considerations are crucial given the exponential expansion of new surgical techniques and pharmacologic options in the last decade. Although literature exists for decision-making on various obesity management topics, there are no scoping reviews systematically mapping the literature. This scoping review is timely given that the treatment of obesity has evolved into a multidisciplinary endeavor with myriad management decisions that both patients and clinicians must navigate.

INCLUSION CRITERIA

The review will consider for inclusion full-text primary studies, published in English from the year 2000 onwards, pertaining to decision-making in obesity management for health care providers involved in obesity management for patients aged ≥18 years.

METHODS

This scoping review will be conducted in accordance with the JBI methodology for scoping reviews. Embase (Elsevier), MEDLINE (PubMed), Scopus (Elsevier), Web of Science (Clarivate), CINAHL Complete (EBSCO), PsycINFO (EBSCO), and Cochrane Central (Wiley) will be systematically searched using a predefined strategy. Two independent reviewers will conduct a 3-tiered screen of identified articles, with a third reviewer resolving disputes. Data extraction will be performed using a predefined, yet flexible form. Descriptive summaries and mapping will be provided for included studies. Available evidence and knowledge gaps will be identified and summarized as they relate to specific concepts, populations, and contexts in obesity management decision-making.

A survey of values and related factors among 200 guardians of children with epilepsy

OBJECTIVES

Epilepsy is a common disease in the pediatric neurology department; as it a chronic disease, many years are spent seeing doctors and taking drugs. The objective of the study is to understand the values of parents to help doctors to more effectively communicate and to improve patient compliance.

STUDY DESIGN

The study was designed to investigate guardians' values of children with epilepsy and analyze the relevant factors that may affect these values and the correlation of the guardians' values and medical decision making.

METHODS

Two hundred guardians (93 men and 107 women) of children with epilepsy from three hospitals in Wuhan, China, were selected at random and investigated by means of interview survey. Statistical analysis by ratio was conducted on the general data, whereas statistical analyses by Pearson and Spearman rank correlation were conducted for the relative factors.

RESULTS

A high educational level among male guardians indicated a strong tendency to read up on epilepsy, which influenced their care given. A high educational level among female guardians indicated better capability to take care of child patients and follow directions for antiepileptic drug administration. Female guardians were more likely to see the same doctors during a long disease period than male guardians.

CONCLUSION

The guardians' values were influenced by many factors, such as gender, education, and duration of disease. Guardians' values need to be considered as they are helpful for doctors in decision-making.

The Bariatric Experience Long Term (BELONG): Factors Related to Having Bariatric Surgery in a Large Integrated Healthcare System

PURPOSE

Bariatric surgery is the most effective treatment for severe obesity, but currently, only 1-2% of all eligible patients undergo surgery each year. This study examined which factors were associated with a patient receiving bariatric surgery after referral in a real-world healthcare setting.

MATERIALS AND METHODS

The current study used the baseline survey and electronic medical record (EMR) data from the Bariatric Experience Long Term (BELONG) study (n = 1975). Predictors of who did (n = 1680) and who did not (n = 295) have surgery were analyzed using multivariate logistic regression.

RESULTS

Participants (n = 1975; 42.4% response rate) were primarily women (84%) and either non-Hispanic Black or Hispanic (60%). In the fully adjusted multivariate model, the strongest predictors of having surgery were being a woman (OR = 3.17; 95% CI = 2.15, 4.68; p < .001) and losing at least 5% of their body weight in the year before surgery (OR = 3.16; 95% CI = 2.28, 4.38; p < .001). The strongest predictors of not having surgery were a ≥ BMI 50 kg/m2 (OR = .39; 95% CI = .27, .56; p < .001) and having a higher physical comorbidity burden (OR = .84; 95% CI = .75, .94; p = .004).

CONCLUSIONS

Practices such as 5-10% total weight loss before surgery and selection of patients with safer operative risk profiles (younger with lower comorbidity burden) may inadvertently contribute to under-utilization of bariatric surgery among some demographic subpopulations who could most benefit from this intervention.

Comparative Safety of Sleeve Gastrectomy and Gastric Bypass: An Instrumental Variables Approach

OBJECTIVE

To compare the safety of sleeve gastrectomy and gastric bypass in a large cohort of commercially insured bariatric surgery patients from the IBM MarketScan claims database, while accounting for measurable and unmeasurable sources of selection bias in who is chosen for each operation.

SUMMARY OF BACKGROUND DATA

Sleeve gastrectomy has rapidly become the most common bariatric operation performed in the United States, but its longer-term safety is poorly described, and the risk of worsening gastroesophageal reflux requiring revision may be higher than previously thought. Prior studies comparing sleeve gastrectomy to gastric bypass are limited by low sample size (in randomized trials) and selection bias (in observational studies).

METHODS

Instrumental variables analysis of commercially insured patients in the IBM MarketScan claims database from 2011 to 2018. We studied patients undergoing bariatric surgery from 2012 to 2016. We identified re-interventions and complications at 30 days and 2 years from surgery using Comprehensive Procedural Terminology and International Classification of Disease (ICD)-9/10 codes. To overcome unmeasured confounding, we use the prior year's sleeve gastrectomy utilization within each state as an instrumental variable-exploiting variation in the timing of payers' decisions to cover sleeve gastrectomy as a natural experiment.

RESULTS

Among 38,153 patients who underwent bariatric surgery between 2012 and 2016, the share of sleeve gastrectomy rose from 52.6% (2012) to 75% (2016). At 2 years from surgery, patients undergoing sleeve gastrectomy had fewer re-interventions (sleeve 9.9%, bypass 15.6%, P < 0.001) and complications (sleeve 6.6%, bypass 9.6%, P = 0.001), and lower overall healthcare spending ($47,891 vs $55,213, P = 0.003), than patients undergoing gastric bypass. However, at the 2-year mark, revisions were slightly more common in sleeve gastrectomy than in gastric bypass (sleeve 0.6%, bypass 0.4%, P = 0.009).

CONCLUSIONS AND RELEVANCE

In a large cohort of commercially insured patients, sleeve gastrectomy had a superior safety profile to gastric bypass up to 2 years from surgery, even when accounting for selection bias. However, the higher risk of revisions in sleeve gastrectomy merits further exploration.

Patient Satisfaction With Decision Making Does Not Correlate With Patient Centeredness of Surgeons

BACKGROUND

High-quality decision making is important in patient-centered care. Although patient involvement in decision making varies widely, most patients desire to share in decision making. The Press-Ganey Patient Satisfaction survey includes questions that measure patients' perceptions of their providers' efforts to involve them in decision making (PGDM). We hypothesized that higher PGDM scores would correlate with higher scores on a validated measure of patient centeredness.

MATERIALS AND METHODS

Surgical providers at a university hospital who routinely receive Press-Ganey scores received a survey that included the Patient-Practitioner Orientation Scale (PPOS), a validated tool that measures the provider's orientation toward patient centeredness on a continuous six-point scale: score ≥5 = high, 4.57-5 = moderate, and <4.57 = low and includes nine-item "caring" or "sharing" subscales. We compared PPOS scores to PGDM scores, averaged from April 2015 to January 2016.

RESULTS

Eighty-six of 112 (75%) of surgical providers responded to the survey. Fifty-two (46%) had PGDM scores available and 26% achieved a perfect score on the PGDM. The overall PPOS scores were low, with a mean of 4.2 (SD = 0.5). The PPOS was not correlated with the PGDM, correlation coefficient (rs) = -0.07 (CI: -0.34-0.21, P = 0.63). Similarly, the two subscales of the PPOS did not correlate with the PGDM with rs = -0.15 (CI: -0.41-0.13, P = 0.29) for "caring" and rs = -0.04 (CI: -0.31-0.23, P = 0.76) for "sharing".

CONCLUSIONS

Although surgical providers scored low in patient centeredness using the PPOS, over one-quarter (26%) of them rank in the top 1% on the PGDM. No correlation was found between providers' patient centeredness and their patients' perceptions of efforts to include them in decision making.

Validating Risk Prediction Models of Diabetes Remission After Sleeve Gastrectomy

INTRODUCTION

Many risk prediction models of diabetes remission after bariatric and metabolic surgery have been proposed. Most models have been created using Roux-en-Y gastric bypass cohorts. However, validation of these models in sleeve gastrectomy (SG) is limited. The objective of our study is to validate the performance of risk prediction models of diabetes remission in obese patients with diabetes who underwent SG.

METHOD

This retrospective cohort study included 128 patients who underwent SG with at least 1 year follow-up from Dec 2011 to Sep 2016 as the validation cohort. A literature review revealed total 11 models with 2 categories (scoring system and logistic regression), which were validated by our study dataset. Discrimination was evaluated by area under the receiver operating characteristic (AUC) while calibration by Hosmer-Lemeshow test and predicted versus observed remission ratio.

RESULTS

At 1 year after surgery, 71.9% diabetes remission (HbA1c < 6.0 off medication) and 61.4% excess weight loss were observed. Individual metabolic surgery, ABCD, DiaRem, Advanced-DiaRem, DiaBetter, Ana et al., and Dixon et al. models showed excellent discrimination power (AUC > 0.8). In calibration, all models overestimated diabetes remission from 5 to 30% but did not lose their goodness of fit.

CONCLUSION

This is the first comprehensive external validation of current risk prediction models of diabetes remission at 1 year after SG. Seven models showed excellent predicting power, and scoring models were recommended more because of their easy utility.

Shared Decision Making and Choice for Bariatric Surgery

: The number of people undergoing bariatric surgery is increasing every year, and their expectations for surgery often differ greatly. The purpose of this study was to develop a patient-centered decision-making aid to help people define their weight loss goals and assist them in discussing their surgical treatment with surgeons. Before the operation, the patients were asked to read the shared decision-making text and conduct a self-assessment. After the operation, we evaluated the program using survey questionnaires. A total of 103 patients were formally included in this study. The results show that patients were very satisfied with the use of patient decision aids (PDAs), with a score of 4.3 points (±0.6), and the postoperative decision-making satisfaction was also very high, at 4.4 points (±0.5), while the postoperative regret score was low, at 1.6 points (±0.6). Their satisfaction with surgical decision making and decision regret were statistically significantly negatively correlated (r = -0.711, p < 0.001). The experience of using PDAs was statistically significantly negatively correlated with decision regret (r = -0.451, p < 0.001); the experience of PDA use was statistically positively correlated with decision satisfaction (r = 0.522, p < 0.001). Patient decision aids are a means of helping patients make informed choices before they seek to undergo bariatric surgery.

Impact of self-efficacy on risk aversion in the context of surgical weight loss decision scenarios

Obesity is prevalent among a third of US adults and a leading indicator for many chronic diseases. Self-efficacy is important for non-surgical weight loss interventions, but there is less information about the role of self-efficacy in the candidacy phase when there are discussions of side effects and decisions for uptake. This study conducted an experiment set within an online survey assessing risk aversion towards bariatric surgery as a weight loss intervention. The survey asked about hypothetical weight loss scenarios for bariatric surgery among a national probability-based sample of US adults aged 18 years and older. Participants answered their willingness to achieve different weight loss amounts within the context of bariatric surgery in varying risk scenarios. The analysis utilized a repeated-measures linear mixed model. A three-way interaction demonstrated that participants were more willing to take risks under ideal weight loss conditions even with the risk of death, particularly when considering self-efficacy (𝛽 = 1.20, P = .05). Margin projections showed that those with lower self-efficacy were more likely to take risks overall. This trend was significant for those with a body mass index of 30 and above in scenarios presenting one's ideal weight as the outcome of bariatric surgery. Adding a measure of self-efficacy within patient assessments could identify those eligible patients who are most likely to adopt bariatric surgery, particularly among those who may have negative post-surgical outcomes due to low self-efficacy levels. Addressing self-efficacy by way of providing support resources in tandem with candidacy consultations may enhance quality of life and post-surgical outcomes.

What Makes Bariatric Operations Difficult-Results of a National Survey

Background and objective: The most commonly performed bariatric procedures include laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), and one anastomosis gastric bypass-mini gastric bypass (OAGB-MGB). A study comparing the degree of difficulty among those procedures could serve as a guide for decision making in bariatric surgery and further improve training programs for general surgery trainees. The aim of this study was to compare the subjective level of technical difficulty of LSG, LRYGB, and OAGB-MGB as perceived by surgeons and surgical residents. Materials and Methods: An anonymous internet-based survey was designed to evaluate the subjective opinions of surgeons and surgical residents in training in Poland. It covered baseline characteristics of the participants, difficulty of LSG, OAGB-MGB, LRYGB and particular stages of each operation assessed on a 1-5 scale. Results: Overall, 70 surgeons and residents participated in our survey. The mean difficulty degree of LSG was 2.34 ± 0.89. The reinforcing staple line with sutures was considered most difficult stage of this operation (3.17 ± 1.19). The LRYGB operation had an average difficulty level of 3.87 ± 1.04. Creation of the gastrojejunostomy was considered the most difficult stage of LRYGB with a mean difficulty level (3.68 ± 1.16). Responders to our survey assessed the mean degree of difficulty of OAGB-MGB as 2.34 ± 0.97. According to participating surgeons, creating the gastrojejunostomy is the most difficult phase of this operation (3.68 ± 1.16). Conclusion: The LSG is perceived by surgeons as a relatively easy operation. The LRYGB was considered to be the most technically challenging procedure in our survey. Operative stages, which require intra-abdominal suturing with laparoscopic instruments, seem to be the most difficult phases of each operation.

Patient Preferences for Bariatric Surgery: Findings From a Survey Using Discrete Choice Experiment Methodology

Importance

Surgical options for weight loss vary considerably in risks and benefits, but the relative importance of procedure-associated characteristics in patient decision making is largely unknown.

Objective

To identify patient preferences for risks, benefits, and other attributes of treatment options available to individuals who are candidates for bariatric surgery.

Design, Setting, and Participants

This discrete choice experiment of weight loss procedures was performed as an internet-based survey administered to patients recruited from bariatric surgery information sessions in the State of Michigan. Each procedure was described by the following set of attributes: (1) treatment method, (2) recovery and reversibility, (3) time that treatment has been available, (4) expected weight loss, (5) effect on other medical conditions, (6) risk of complication, (7) adverse effects, (8) changes to diet, and (9) out-of-pocket costs. Participants chose between surgical profiles by comparing attributes. Survey data were collected from May 1, 2015, through January 30, 2016, and analyzed from February 1 to June 30, 2016.

Main Outcomes and Measures

Estimated relative value of risks and benefits for leading weight-loss surgical options and marginal willingness to pay for procedure attributes. A latent class analysis identified respondent subgroups.

Results

Among the 815 respondents (79.9% women; mean [SD] age, 44.5 [12.0] years), profiles of hypothetical procedures that included resolution of medical conditions (coefficient for full resolution, 0.229 [95% CI, 0.177 to 0.280; P < .001]; coefficient for no resolution, -0.207 [95% CI, -0.254 to -0.159; P < .001]), higher total weight loss (coefficient for each additional 20% loss, 0.185 [95% CI, 0.166 to 0.205; P < .001]), and lower out-of-pocket costs (coefficient for each additional $1000, -0.034 [95% CI, -0.042 to -0.025; P < .001]) were most likely to be selected. Younger respondents were more likely than older respondents to choose treatments with higher weight loss (coefficient for loss of 80% excess weight 0.543 [95% CI, 0.435-0.651] vs 0.397 [95% CI, 0.315-0.482]) and were more sensitive to out-of-pocket costs (coefficient for $100 out-of-pocket costs, 0.346 [95% CI, 0.221-0.470] vs 0.262 [95% CI, 0.174 to 0.350]; coefficient for $15 000 in out-of-pocket costs, -0.768 [95% CI, -0.938 to -0.598] vs -0.384 [95% CI, -0.500 to -0.268]). Marginal willingness to pay indicated respondents would pay $5470 for losing each additional 20% of excess body weight and $12 843 for resolution of existing medical conditions, the most desired procedure attributes. Latent class analysis identified the following 3 unobserved subgroups: cost-sensitive (most concerned with costs); benefit-focused (most concerned with excess weight loss and resolution of medical conditions); and procedure-focused (most concerned with how the treatment itself worked, including recovery and reversibility).

Conclusions and Relevance

Candidates for bariatric surgery identified costs, expected weight loss, and resolution of medical conditions as the most important characteristics of weight loss surgery decisions. Other information, such as risk of complications and adverse effects, were important to patients but less so.

Comparative Effectiveness and Safety of Bariatric Procedures for Weight Loss: A PCORnet Cohort Study

BACKGROUND

There has been a dramatic shift in use of bariatric procedures, but little is known about their long-term comparative effectiveness.

OBJECTIVE

To compare weight loss and safety among bariatric procedures.

DESIGN

Retrospective observational cohort study, January 2005 to September 2015. (ClinicalTrials.gov: NCT02741674).

SETTING

41 health systems in the National Patient-Centered Clinical Research Network.

PARTICIPANTS

65 093 patients aged 20 to 79 years with body mass index (BMI) of 35 kg/m2 or greater who had bariatric procedures.

INTERVENTION

32 208 Roux-en-Y gastric bypass (RYGB), 29 693 sleeve gastrectomy (SG), and 3192 adjustable gastric banding (AGB) procedures.

MEASUREMENTS

Estimated percent total weight loss (TWL) at 1, 3, and 5 years; 30-day rates of major adverse events.

RESULTS

Total numbers of eligible patients with weight measures at 1, 3, and 5 years were 44 978 (84%), 20 783 (68%), and 7159 (69%), respectively. Thirty-day rates of major adverse events were 5.0% for RYGB, 2.6% for SG, and 2.9% for AGB. One-year mean TWLs were 31.2% (95% CI, 31.1% to 31.3%) for RYGB, 25.2% (CI, 25.1% to 25.4%) for SG, and 13.7% (CI, 13.3% to 14.0%) for AGB. At 1 year, RYGB patients lost 5.9 (CI, 5.8 to 6.1) percentage points more weight than SG patients and 17.7 (CI, 17.3 to 18.1) percentage points more than AGB patients, and SG patients lost 12.0 (CI, 11.6 to 12.5) percentage points more than AGB patients. Five-year mean TWLs were 25.5% (CI, 25.1% to 25.9%) for RYGB, 18.8% (CI, 18.0% to 19.6%) for SG, and 11.7% (CI, 10.2% to 13.1%) for AGB. Patients with diabetes, those with BMI less than 50 kg/m2, those aged 65 years or older, African American patients, and Hispanic patients lost less weight than patients without those characteristics.

LIMITATION

Potential unobserved confounding due to nonrandomized design; electronic health record databases had missing outcome data.

CONCLUSION

Adults lost more weight with RYGB than with SG or AGB at 1, 3, and 5 years; however, RYGB had the highest 30-day rate of major adverse events. Small subgroup differences in weight loss outcomes were observed.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute.

Microvascular Outcomes in Patients With Diabetes After Bariatric Surgery Versus Usual Care: A Matched Cohort Study

Background

Bariatric surgery improves glycemic control in patients with type 2 diabetes mellitus (T2DM), but less is known about microvascular outcomes.

Objective

To investigate the relationship between bariatric surgery and incident microvascular complications of T2DM.

Design

Retrospective matched cohort study from 2005 to 2011 with follow-up through September 2015.

Setting

4 integrated health systems in the United States.

Participants

Patients aged 19 to 79 years with T2DM who had bariatric surgery (n = 4024) were matched on age, sex, body mass index, hemoglobin A1c level, insulin use, diabetes duration, and intensity of health care use up to 3 nonsurgical participants (n = 11 059).

Intervention

Bariatric procedures (76% gastric bypass, 17% sleeve gastrectomy, and 7% adjustable gastric banding) compared with usual care.

Measurements

Adjusted Cox regression analysis investigated time to incident microvascular disease, defined as first occurrence of diabetic retinopathy, neuropathy, or nephropathy.

Results

Median follow-up was 4.3 years for both surgical and nonsurgical patients. Bariatric surgery was associated with significantly lower risk for incident microvascular disease at 5 years (16.9% for surgical vs. 34.7% for nonsurgical patients; adjusted hazard ratio [HR], 0.41 [95% CI, 0.34 to 0.48]). Bariatric surgery was associated with lower cumulative incidence at 5 years of diabetic neuropathy (7.2% for surgical vs. 21.4% for nonsurgical patients; HR, 0.37 [CI, 0.30 to 0.47]), nephropathy (4.9% for surgical vs. 10.0% for nonsurgical patients; HR, 0.41 [CI, 0.29 to 0.58]), and retinopathy (7.2% for surgical vs. 11.2% for nonsurgical patients; HR, 0.55 [CI, 0.42 to 0.73]).

Limitation

Electronic health record databases could misclassify microvascular disease status for some patients.

Conclusion

In this large, multicenter study of adults with T2DM, bariatric surgery was associated with lower overall incidence of microvascular disease (including lower risk for neuropathy, nephropathy, and retinopathy) than usual care.

Primary Funding Source

National Institute of Diabetes and Digestive and Kidney Diseases.

Management of Slipped Gastric Bands via Creation of a De Novo Tunnel and Band Replacement: a Single-Centre Experience

BACKGROUND

A lack of clarity remains over the optimal strategy for the management of laparoscopic adjustable gastric band (LAGB) slippage, which, although rare (around 3% in our experience), can when acute result in obstruction, gastric erosion or ischaemia. Typically, slipped bands are removed acutely. The aim of this study was to explore outcomes following immediate or delayed resiting of slipped LAGBs in a single centre, comparing simple repositioning with retunnelling and replacement.

METHODS

A retrospective analysis of computerised records, notes and prospectively maintained bariatric databases was undertaken to identify all patients with a slipped LAGB in a single centre.

RESULTS

Thirty-two patients required operative intervention following a diagnosis of slipped LAGB (median time from initial LAGB insertion to slippage 2.9 years). Two (6%) patients underwent band removal and 30 (94%), band revision surgery (25 immediately and five at a planned but expedited procedure).Twenty-four (77%) patients underwent insertion of a new LAGB via a de novo retrogastric tunnel, five (21%) of which required further future operative intervention; whereas, six (23%) patients underwent repositioning of the existing LAGB within the same tunnel, five (83%) of which underwent further operative intervention (log-rank test p = 0.0001). Following LAGB revision, there was no significant further change in BMI (median + 1 kg/m²; range - 13 to + 10 kg/m²).

CONCLUSION

Resiting of slipped LAGBs is safe and maintains weight loss. Although a significant risk of future operative intervention remains, this can be reduced via the creation of a de novo retrogastric tunnel for band resiting.

Primary experience of bariatric surgery in a newly established private obesity center

Objectives:

To assess the outcomes of different types of bariatric surgeries in a single newly established private obesity center.

Methods:

Retrospectively, we included patients who were entered in the registry for bariatric surgeries in the Obesity Unit, Riyadh National Hospital, Riyadh, Saudi Arabia between January 2013 and September 2014, and completed one year of follow up. Baseline characteristics, percent excess weight loss, and safety data were collected and analyzed.

Results:

A total of 79 patients were included. Based on the type of surgery, patients were divided into 3 groups: laparoscopic Roux-en-Y gastric bypass (RYGB), laparoscopic minigastric bypass (MGBP), and laparoscopic vertical sleeve gastrectomy (SG). After one year, RYGB and MGB patients lost more weight than SG patients. No mortality, or leak were reported and one patient had reoperation after revision laparoscopic RYGB for bleeding. There was one readmission, while 4 patients visited the emergency room for vomiting and dehydration (2 patients), anemia (one patient), and port site infection (one patient).

Conclusion:

Bariatric surgeries are safe when carried out by an experienced bariatric surgeon in the private sector. The outcome of this series is similar to the published results from large international obesity databases.

Systematic review of risk prediction models for diabetes after bariatric surgery

BACKGROUND

Diabetes remission is an important outcome after bariatric surgery. The purpose of this study was to identify risk prediction models of diabetes remission after bariatric surgery.

METHODS

A systematic literature review was performed in MEDLINE, MEDLINE-In-Process, Embase and the Cochrane Central Register of Controlled Trials databases in April 2015. All English-language full-text published derivation and validation studies for risk prediction models on diabetic outcomes after bariatric surgery were included. Data extraction included population, outcomes, variables, intervention, model discrimination and calibration.

RESULTS

Of 2330 studies retrieved, eight met the inclusion criteria. Of these, six presented development of risk prediction models and two reported validation of existing models. All included models were developed to predict diabetes remission. Internal validation using tenfold validation was reported for one model. Two models (ABCD score and DiaRem score) had external validation using independent patient cohorts with diabetes remission assessed at 12 and 14 months respectively. Of the 11 cohorts included in the eight studies, calibration was not reported in any cohort, and discrimination was reported in two.

CONCLUSION

A variety of models are available for predicting risk of diabetes following bariatric surgery, but only two have undergone external validation.

Assessment of perioperative complications following primary bariatric surgery according to the Clavien-Dindo classification: comparison of sleeve gastrectomy and Roux-Y gastric bypass

BACKGROUND

Laparoscopic Roux-Y gastric bypass (LRYGBP) is the gold-standard procedure for the treatment of morbid obesity. It has been reported to be somewhat more efficient and durable than laparoscopic sleeve gastrectomy (LSG). However, it is considered more invasive and, therefore, more hazardous. There is a lack of unity in complication reporting following bariatric surgery. Thus, there is a possible misconception regarding the relative safety of the two major bariatric procedures performed worldwide. This may have contributed to a shift in practice with LSG gaining momentum "at the expense" of LRYGBP. The aim of this study was to evaluate the relative safety of primary LSG and LRYGBP according to the Clavien-Dindo complication grading system.

METHODS

A total of 2651 and 554 patients underwent primary LSG and LRYGBP, respectively at three high-volume centers. Thirty-day perioperative complications were recorded and graded. Length of hospital stays (LOS) and readmission rates were collected as well.

RESULTS

Complications occurred in 110 (3.7%) and 24 (4.3%) patients following LSG and LRYGBP, respectively (p = 0.9). No significant difference was found between the groups regarding overall and complication-grade-specific rates. Individual complication types were unevenly distributed, but not significantly so. Patients with complications were older than those without (47 and 43 years, respectively; p = 0.01). Gender was not a risk factor for complication. Median LOS and readmission rates were not significantly different.

CONCLUSIONS

LSG and LRYGBP are equally safe, at least in the perioperative period. Acknowledging and conveying this finding to surgeons and patients alike is important and might cause a pendulum shift in the distribution of bariatric procedures performed.

[Patient selection as the key to success of metabolic surgery]

BACKGROUND

The indications for bariatric interventions consist of the objectives to improve the quality of life and to prolong survival by remission of obesity-associated comorbidities. Until now the selection criteria for patients to undergo surgery which allow a prediction of therapeutic success are obscure.

OBJECTIVE

The aim of the study was to identify the prerequisites for selection of overweight and obese patients to undergo bariatric surgery.

RESULTS

Obesity per se is a proven indication for bariatric surgery due to the associated increase in mortality; however, not all obese patients can be considered for weight reduction surgery. A decisive factor for patient selection is the evidence of behavioral change regarding nutrition, composition and frequency of meals as well as increased ambulation. In patients with psychiatric diseases and behavioral disorders responsible for obesity a specific therapy is mandatory as well as intensive counseling and adherence to a lifelong follow-up.

DISCUSSION

It seems that therapeutic success on a long-term basis is only guaranteed by behavioral changes. Preoperative multimodal therapy does not influence the outcome but it seems possible that such treatment may contribute to increased adherence to the behavior necessary for therapeutic success. Nevertheless, such treatment must not constitute a barrier against bariatric surgery. However, patients who are not willing to change their pathological behavior do not qualify for weight-reducing surgery because otherwise therapeutic success is questioned.