Influence of Patient Choice on Outcome of Bariatric Surgery

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.

Sleeve gastrectomy or gastric bypass: a "post-code" lottery? A comprehensive national analysis of the utilization of bariatric surgery in Switzerland between 2011-2017

BACKGROUND

Sleeve gastrectomy (SG) recently became the most frequently performed bariatric surgery (BS) worldwide, overtaking the long-time standard Roux-en-Y gastric bypass (RYGB). Main indications for one or the other procedure show large inter-center variations and warrant further investigations.

OBJECTIVES

The aim of this study was to identify the influencers of primary BS selection in Switzerland.

SETTING

Switzerland.

METHODS

Retrospective analysis of all hospitalizations in Switzerland January 1, 2011 through December 31, 2017 with anonymized data provided by the Swiss Federal Statistical Office. BS procedures were identified based on ICD-10 and national surgical codes. Statistical analyses were performed with R.

RESULTS

During the study period 27,375 BS were performed. The annual BS caseload doubled over time, whereas inpatient complications decreased (∼-33%). RYGB was the prevailing procedure, although its annual proportion decreased from 80% to 70% over 7 years. Meanwhile, use of SG increased from 14% to 23%. Primary RYGB and SG had similar rates of inpatient mortality (∼.05%) and morbidity (8.0 versus 7.4%, P =.148), with the exception of higher ileus rates following RYGB (.7 versus .1%, P < .001). Patient-related factors favoring the indication of SG were male sex, extremes of age, and metabolic co-morbidities , while gastroesophageal reflux disease and private insurance-favored RYGB. Strikingly, differences between geographic regions outweighed patient-related factors in procedure selection: inhabitants of German- and Italian-speaking areas had higher likelihood (OR 4.6; 3.9, P < .001) to receive SG than those in French-speaking areas.

CONCLUSION

Geographic differences in primary BS procedure selection indicate a lack of objective rationales. Long-term risk-benefit and cost-effectiveness analyses are needed to assist evidence-based decision making.

How Effective Is the Multidisciplinary Team Approach in Bariatric Surgery?

BACKGROUND

Multidisciplinary team (MDT) meetings are widely recommended in the management of bariatric surgery patients; however, there is limited evidence for their effectiveness. The aims of this study were to evaluate the decision-making process of a single-day bariatric MDT clinic and secondly to evaluate whether these MDT decisions were implemented.

METHODS

This was a retrospective observational study analysing MDT treatment decisions from February 2012 to June 2013 using an MDT proforma. The decision-making process of the MDT meeting was investigated by assessing the alterations in management plan between the surgeon and the rest of the MDT. Adherence to MDT decisions was also assessed.

RESULTS

Decisions regarding 200 consecutive patients were analyzed. There was MDT agreement for 55%, and patients were listed for surgery on the day of the MDT. There was MDT disagreement regarding 45%, with conflicting opinions expressed by surgeons in 33/200 (17%), anaesthetists in 60/200 (30%) and dieticians in 65/200 (33%). The MDT plan was instigated in 78% and the most common reason for failure was patients failing to attend for further assessment. By the end of the study, 85% of patients underwent bariatric surgery, 11.5% declined further input, 2.5% chose further weight loss and 1% were removed from waiting list.

CONCLUSION

Use of a single-day MDT clinic format resulted in a change in plan for a significant number of patients. This can be interpreted as improved quality of care for these patients, and we conclude the MDT approach is valuable.

Rethinking Patient and Medical Professional Perspectives on Bariatric Surgery as a Medically Necessary Treatment

The prevalence of class 3 obesity (body mass index ≥40 kg/m²) is 7.7% of the United States adult population; thus, more than 25 million people may be medically appropriate for consideration of bariatric surgery as therapy for severe obesity. Although bariatric surgery is the most effective therapy for patients with severe obesity, the surgery is performed in less than 1% of patients annually for whom it may be appropriate. Patients' and medical professionals' misperceptions about obesity and bariatric surgery create barriers to accessing bariatric surgery that are not given adequate attention and clinical consideration. Commonly cited patient barriers are lack of knowledge about the severity of obesity, the perception that obesity is a lifestyle problem rather than a chronic disease, and fear that bariatric surgery is dangerous. Medical professional barriers include failing to recognize causes of obesity and weight gain, providing recommendations that are inconsistent with current obesity treatment guidelines, and being uncomfortable counseling patients about treatment options for severe obesity. Previous research has revealed that medical professional counseling and accurate perception of the health risks associated with severe obesity are strong predictors of patients' willingness to consider bariatric surgery. This article reviews patient and medical professional barriers to acceptance of bariatric surgery as a treatment of medical necessity and offers practical advice for medical professionals to rethink perspectives about bariatric surgery when it is medically and psychologically appropriate.

Patient preferences regarding bariatric/metabolic procedures: a survey of Korean obese candidates for surgery

Purpose

The objective of this study was to survey potential candidates for bariatric/metabolic surgery for procedure preferences.

Methods

Questions asked were divided into 5 categories: (1) demographic and anthropometric data, comorbidities, and favored surgery; (2) awareness of safety, effectiveness, and complications of each type of surgery; (3) discordances in opinion between self-selected and medically recommended procedures; and (4, 5) reasons for/against particular surgery.

Results

From 1 October to 15 November 2018, 104 respondents adequately responded and were included in the analysis. The number (%) of female respondents was 79 (76.0%). The number (%) of respondents by decade was 17 (16.3%) in their 20s, 65 (62.5%) in their 30s, 19 (18.3%) in their 40s, and 3 (2.9%) in their 60s, respectively. Mean body mass index was 37.1 ± 6.3 kg/m². Comorbidities were type 2 diabetes in 34 (32.7%) and hypertension in 35 (33.7%). The most favored procedure was sleeve gastrectomy (SG) in 78 (75.0%), adjustable gastric band (AGB) surgery in 12 (11.5%), Roux-en-Y gastric bypass (RYGB) in 6 (5.8%), and gastric plication (GP) in 8 (7.7%). Major reasons for choosing procedures were; “adjustable” for AGB, “stomach sparing” for GP, “excellent weight loss” for SG, and “comorbidity resolution” in RYGB.

Conclusion

Candidates for bariatric/metabolic surgery favored SG followed by AGB, GP, and RYGB, and their choices were compatible with current evidence-based clinical practice.

Mid-term bariatric surgery outcomes for obese patients: does weight matter?

INTRODUCTION

Studies have attempted to identify prognostic indicators for successful outcomes following bariatric surgery for obesity. The aim of this study was to determine whether the degree of obesity affects outcomes in patients who are morbidly obese (basal metabolic index, BMI, 40-49.9 kg/m²), super-obese (BMI 50-59.9 kg/m²) and super-super-obese (BMI greater than 60 kg/m²) undergoing restrictive or malabsorptive bypass procedures.

MATERIAL AND METHODS

Retrospective analysis of a prospectively maintained database was undertaken to include all consecutive laparoscopic adjustable gastric bands (LAGB), laparoscopic sleeve gastrectomies (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures since 2010. Patients with at least two years of follow-up were included. At each visit, the patient's weight, BMI, excess weight loss and comorbidity status were recorded.

RESULTS

A total of 353 patients (75% women) were included in the analysis; 65 (18.4%) underwent LAGB; 70 (19.8%) LSG and 218 (61.8%) LRYGB. At presentation, the median BMI for the morbidly obese sub-group was 47.2 kg/m² for LAGB, 46.4 kg/m² for LSG and 46.6 kg/m² for LRYGB (P = 0.625); for the super-obese sub-group it was 53.2 kg/m² for LAGB, 52.9 kg/m² for LSG and 52.4 kg/m² for LRYGB (P = 0.481); and for the super-super-obese sub-group 66.9 kg/m² for (LAGB, 66.7 kg/m² for LSG and 61.5 kg/m² for LRYGB (P = 0.169). Percentage of excess weight loss at the end of two years was significantly higher in the morbidly obese and super-morbidly obese sub-groups undergoing LRYGB (median 68.5% and 69.5%, respectively; P < 0.001) than in the sub-groups undergoing LAGB and LSG. This was also reflected in the reduction of BMI achieved with bypass in the two sub-groups (P < 0.001). Complete diabetes remission was significantly higher in the morbidly obese and super-morbidly obese sub-groups undergoing LRYGB treatment (P < 0.05). Sleep apnoea, asthma and exercise tolerance had significantly improved in the super-morbidly obese undergoing LRYGB (P < 0.05). There was no significant difference between the three treatment groups in remission of hypertension; dyslipidaemia; gastro-oesophageal reflux disease and depression in all three BMI sub-groups.

CONCLUSION

The mid-term results for weight loss and resolution of obesity-related comorbidities is best achieved in super-obese patients undergoing LRYGB, without any significant increase in complications with this procedure as compared with LAGB and LSG.