Patients' perspectives on weight recurrence after bariatric surgery: a single-center survey.

BACKGROUND: Weight recurrence (WR) affects nearly 20% of patients after bariatric surgery and may decrease its benefits, affecting patients' quality of life negatively. Patient perspectives on WR are not well known. OBJECTIVES: Assess patient needs, goals, and preferences regarding WR treatment. SETTING: Single MBSAQIP-accredited academic center, and online recruitment. METHODS: An 18-item, web-based survey was distributed to adults seeking treatment for WR after a primary bariatric surgery (PBS), in addition to online recruitment, between 2021 and 2023. Survey items included somatometric data, questions about the importance of factors for successful weight loss, procedure decision-making, and treatment expectations. RESULTS: Fifty-six patients with > 10% increase from their nadir weight were included in the study. Patients had initially undergone Roux-en-Y gastric bypass (62.5%), sleeve gastrectomy (28.6%), adjustable gastric banding (3.6%), or other procedures (5.3%). When assessing their satisfaction with PBS, 57.1% were somewhat/extremely satisfied, 33.9% somewhat/extremely dissatisfied, while 8.9% were ambivalent. Patients considered the expected benefits (for example, weight loss) as the most important factor when choosing a treatment option for WR. Patient goals included "feeling good about myself" (96.4% very/extremely important), "being able to resume activities I could not do before" (91% very/extremely important), and "improved quality of life" and "-life expectancy" (> 90% very/extremely important). Finally, RBS, lifestyle modification with peer support, and anti-obesity medication were ranked as first treatment options for WR by 40%, 38.8%, and 29.8% of the respondents, respectively. CONCLUSIONS: Patients considered weight loss as the most important factor when choosing treatment modality for WR, with RBS and lifestyle changes being preferred over weight-loss medications. Large prospective randomized trials are needed to counsel this patient population better.

Bariatric Surgeon Perspective on Revisional Bariatric Surgery (RBS) for Weight Recurrence.

BACKGROUND: Weight recurrence (WR) after bariatric surgery occurs in nearly 20% of patients. Revisional bariatric surgery (RBS) may benefit this population but remains controversial among surgeons. OBJECTIVES: Explore surgeon perspectives and practices for patients with WR after primary bariatric surgery (PBS). SETTING: Web-based survey of bariatric surgeons. METHODS: A 21-item survey was piloted and posted on social media closed groups (Facebook) utilized by bariatric surgeons. Survey items included demographic information, questions pertaining to the definition of suboptimal and satisfactory response to bariatric surgery, and general questions related to different WR management options. RESULTS: One hundred ten surgeons from 19 countries responded to the survey. Ninety-eight percent responded that WR was multifactorial, including behavioral and biological factors. Failure of PBS was defined as excess weight loss < 50% by 31.4%, as excess weight loss <25% by 12.8%, and as comorbidity recurrence by 17.4%. Surgeon responses differed significantly by gender (P = .036). 29.4% believed RBS was not successful, while 14.1% were unsure. Nevertheless, 73% reported that they would perform RBS if sufficient evidence of benefit existed. Most frequently performed revisional procedures included conversion of sleeve gastrectomy to Roux-en-Y gastric bypass (RYGB), adjustable gastric band to RYGB, and RYGB revision (21.9% versus 18.2% versus 15.3%, respectively). CONCLUSIONS: This survey demonstrates significant variability in surgeon perception regarding causes and the effectiveness of RBS. Moreover, they disagree on what constitutes a nonsatisfactory response to PBS and to whom they offer RBS. These findings may relate to limited available clinical evidence on best management options for this patient population. Clinical trials investigating the comparative effectiveness of various treatment options are needed.

Social support provided to bariatric surgery patients through a facebook group may improve weight loss outcomes.

BACKGROUND: Patients' social support has been shown to impact outcomes after bariatric surgery. We have previously shown that a Facebook group administered by bariatric providers offers an effective alternative social support mechanism to in-person support groups, with higher patient participation. Our aim was to determine whether participation in this Facebook group could improve patient outcomes after bariatric surgery. METHODS: After institutional board approval, our center's Facebook group members were electronically surveyed about their perceived value of group participation and their Facebook group usage frequency. We also collected patient age, sex, insurance, preoperative weight, type of procedure, hospital stay, postoperative complications, and weight loss from the electronic medical record. To assess the impact of Facebook group participation we compared patient outcomes between "frequent users" (those checking the Facebook group's activity at least once a week), "infrequent users", and a control group of all patients operated on during the year prior to the establishment of the Facebook group. The groups were compared after adjusting for potential confounding factors. RESULTS: 250 out of 1400 Facebook group patients responded to the survey (18%). 195 patients were frequent and 55 were infrequent users. Outcomes were compared with 211 control patients. The groups did not differ in their baseline characteristics apart from their sex. Frequent users had a higher weight loss compared to the other groups up to 2 years postoperatively but no difference in the overall complications. On multivariable analysis, frequency of Facebook use was the main factor associated with 0.5-, 1-, and 2-year weight loss. CONCLUSION: Frequent participation in a Facebook support group after bariatric surgery was associated with improved early weight loss outcomes. If additional longer-term studies confirm our findings, offering similar social support groups may become essential after bariatric surgery, especially during times of social isolation when in-person social support meetings may not be feasible.

High-risk bariatric candidates: does red-flagging predict the post-operative course?

BACKGROUND: Standards for preoperative bariatric patient selection include a thorough psychological evaluation. Using patients "red-flagged" during preoperative evaluations, this study aims to identify trends in long-term follow-up and complications to further optimize bariatric patient selection. METHODS: A multidisciplinary team held a case review conference (CRC) to discuss red-flagged patients. A retrospective chart review compared CRC patients to control patients who underwent bariatric surgery in the same interval. Patients under 18 years old, undergoing revisional bariatric surgery, or getting band placement were excluded. High-risk characteristics causing CRC inclusion, preoperative demographics, percent follow-up and other postoperative outcomes were collected up to 5 years postoperatively. If univariate analysis revealed a significant difference between cohorts, multivariable analysis was performed. RESULTS: Two hundred and fifty three patients were red-flagged from 2012 to 2013, of which 79 underwent surgery. After excluding 21 revisions, 3 non-adult patients, and 6 band patients, 55 red-flagged patients were analyzed in addition to 273 control patients. Patient age, sex, initial BMI, ASA, and co-morbidities were similar between groups, though flagged patients underwent RYGB more frequently than control patients. Notably, percent excess BMI loss and percent follow-up (6 months-5 years) were similar. In multivariable analysis, minor complications were more common in flagged patients; and marginal ulcers, endoscopy, and dilation for stenosis were more common in flagged versus control patients who underwent RYGB. Perforation, reoperation, revision, incisional hernia, and internal hernia were statistically similar in both groups, though reoperation was significantly more common in patients with multiple reasons to be flagged compared to controls. CONCLUSION: Bariatric patients deemed high risk for various psychosocial issues have similar follow-up, BMI loss, and major complications compared to controls. High-risk RYGB patients have greater minor complications, warranting additional counseling of high-risk patients.

How are bariatric patients coping during the coronavirus disease 2019 (COVID-19) pandemic? Analysis of factors known to cause weight regain among postoperative bariatric patients.

BACKGROUND: The global coronavirus disease 2019 (COVID-19) pandemic is wreaking havoc on society. Bariatric patients are more prone to severe infection due to their high body mass index (BMI) and are more vulnerable to the effects of isolation, such as depression or disruption of their health habits. OBJECTIVES: To quantify the impact of self-quarantine on bariatric patients and self-quarantine's relationship with weight gain. SETTING: Academic hospital, United States. METHODS: A 30-item survey examining several known contributors to weight regain was distributed among the postoperative bariatric patients of our clinic. Changes in eating habits, exercise, depression, social support, loneliness, and anxiety were studied, among others. RESULTS: A total of 208 patients completed the survey (29.3% response rate). A large percentage of patients reported increases in their depression (44.2%), loneliness (36.2%), nervousness (54.7%), snacking (62.6%), loss of control when eating (48.2%), and binge eating (19.5%) and decreases in their social support (23.2%), healthy food eating (45.5%), and activity (55.2%). Difficulty in accessing vitamins was reported by 13%. Patients more than 18 months out of surgery regained more than 2 kg during an average of 47 days. Risk factors for weight regain were found to be loss of control when eating, increases in snacking and binge eating, reduced consumption of healthy food, and reduced physical activity. CONCLUSION: Bariatric patients are negatively affected by the COVID-19 pandemic and subsequent social isolation on many levels. This patient population is vulnerable to crisis situations; thus, additional intervention is needed to address behaviors that lead to weight regain.

High Rates of Nicotine Use Relapse and Ulcer Development Following Roux-en-Y Gastric Bypass.

PURPOSE: Given that smoking is known to contribute to gastrojejunal anastomotic (GJA) ulcers, cessation is recommended prior to laparoscopic Roux-en-Y gastric bypass (LRYGB). However, smoking relapse rates and the exact ulcer risk remain unknown. This study aimed to define smoking relapse, risk of GJA ulceration, and complications after LRYGB. MATERIALS AND METHODS: We performed a retrospective cohort study of patients who underwent primary LRYGB during 2011-2015. Initially, three patient categories were identified: lifetime non-smokers, patients who were smoking during the initial visit at the bariatric clinic or within the prior year (recent smokers), and patients who had ceased smoking more than a year prior to their initial clinic visit (former smokers). Smoking relapse, GJA ulcer occurrences, reinterventions, and reoperations were recorded and compared. RESULTS: A total of 766 patients were included in the analysis. After surgery, 53 (64.6%) recent smokers had resumed smoking. Out of these relapsed smokers, 51% developed GJA ulcers compared with 14.8% in non-relapsed recent smokers, 16.1% in former smokers, and 6% in lifetime nonsmokers (p < 0.001). Furthermore, relapsed smokers required more frequently endoscopic reinterventions (60.4%) compared with non-relapsed smokers (20.8%, p < 0.001), former smokers (20.7%, p < 0.001), and lifetime non-smokers (15.4%, p < 0.001). Additionally, relapsed smokers required a reoperation (18.9%) more often than non-relapsed recent smokers (5.7%, p < 0.001) and lifetime non-smokers (1.3%, p < 0.001). CONCLUSION: Smokers relapse frequently after LRYGB, and the majority experience GJA complications. They should be counseled about this risk preoperatively and directed towards less ulcerogenic procedures when possible. Alternatively, longer periods of preoperative smoking abstinence might be needed.

Facebook groups provide effective social support to patients after bariatric surgery.

BACKGROUND: Social support after bariatric surgery is considered essential. Unfortunately, patient participation in such groups tends to be limited threatening their effectiveness. Facebook groups may provide a social support option that attracts more participation. The aim of this study was to describe our experience with the administration of a Facebook social support group and evaluate its perceived value by our bariatric patients. METHODS: After IRB approval, all Facebook group posts since its establishment in 2015 were reviewed and a thematic analysis was undertaken. Group members also completed a survey related to their Facebook group experience and its perceived value. Responses were collected using 5-point Likert scales. In addition, 30 members were phone interviewed using open-ended questions and their responses were analyzed. RESULTS: Over 4 years, the group accumulated 12,507 posts, 104,053 comments, and 197,594 reactions. On average, members check the group page more than once per day. Ten common themes were identified in the submitted posts: questions, motivation related, education related, diet related, physical activity related, current status updates, sharing failures, social, random/humorous and other. Members reported that the group helped them do well with their procedure (3.3/5) particularly due to the motivation of others' successful stories (3.5/5) and made them feel understood (3.9/5) even though it offered limited help controlling their eating habits (2.7/5). The phone interviews suggested that the Facebook group offered constant support, was simple to use, and provided the sole social support for many patients. They most appreciated the motivational posts that kept them on track and the assistance/comments of clinical staff. In contrast, they disliked repeated questions/spam and negative stories shared by some members. CONCLUSIONS: Facebook groups can provide effective social support to patients after bariatric surgery. Peers educate, answer questions, and motivate patients by sharing their positive experiences. Whether this online connectedness also positively impacts patient outcomes requires further study.

Can a brief assessment of social support predict outcomes after bariatric surgery?

Social support is important to optimize bariatric surgery outcomes, but limited tools exist for brief and effective assessment preoperatively. The aims of the study were to determine the extent to which two ratings of social support can predict bariatric surgery outcomes, and to examine any associations between these two methods.In this retrospective study, patients were included for whom the Cleveland clinic behavioral rating system (CCBRS) and Flanagan quality of life scale (FQoLS) scores were obtained as part of their preoperative psychosocial evaluation. They were followed up for 6 to 24 months after bariatric surgery. Linear and logistic regressions were performed with patients' CCBRS and FQoLS scores as independent variables, and percent excess weight loss (%EWL), length of stay (LOS), complications, readmissions and loss to follow-up as dependent variables. The prediction of CCBRS ratings from FQoLS social support items was also evaluated. A total of 415 patients were included in the analysis. There were significant associations between the CCBRS and three of the four relevant FQoLS self-ratings. As CCBRS and FQoLS scores increased, complications decreased significantly. The CCBRS alone additionally predicted decreased length of hospital stay and approached significance for predicting decreased readmission rates. There were no associations between %EWL and behavior ratings. The degree of patients' social support is associated with important bariatric surgery outcomes. It is possible to obtain this valuable information via the administration of brief assessments prior to bariatric surgery.

Do Mandated Weight Loss Goals Prior to Bariatric Surgery Improve Postoperative Outcomes?

BACKGROUND: Most patients pursuing bariatric surgery undergo mandated preoperative weight management programs. The purpose of this study was to assess whether preoperative mandated weight loss goals lead to improved perioperative morbidity, postoperative weight loss, and resolution of comorbidities. METHODS: Data from patients who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB), and laparoscopic sleeve gastrectomy (LSG) between October 2012 and October of 2015 was reviewed. Patients were divided in two groups: those with BMI of 35-45 were not required to achieve a weight loss goal prior to surgery (no-WLG group) while those with BMI > 45 were given a weight loss goal proportionate to their weight (WLG group). Body mass index (BMI), history of diabetes mellitus type-II (DM-II), hypertension (HTN), hyperlipidemia (HLD), and obstructive sleep apnea (OSA) were recorded at baseline and 4 years postoperatively. Length of hospital stay (LOS) and reinterventions were considered proxies for postoperative morbidity. RESULTS: A total of 776 patients, 81.4% LRYGB, were included in the study (age 45.1 ± 11.9). There was no difference in %ΔBMI, DM-II, HDL, HTN, LOS, or reinterventions among the two groups at 4 years postoperatively in both LRNY and LSG patients. This lack of difference persisted even when patients with similar BMI (43-45 vs 45.01-47) were compared. CONCLUSION: WLG group did not have decreased perioperative morbidity, nor improved weight loss and comorbidity resolution 4 years after surgery. While these findings should also be confirmed by multicenter trials, they question the value of mandated WLG prior to bariatric surgery as they seem ineffective and may limit patient access to surgery.

A behavioral rating system predicts weight loss and quality of life after bariatric surgery.

BACKGROUND: Bariatric surgery represents the most effective intervention for severe obesity available today; however, significant variability in postoperative outcomes exists. Effective tools that predict postoperative outcomes are needed for decision-making and patient counseling. OBJECTIVES: We hypothesized that a validated behavioral assessment tool, the Cleveland Clinic Behavioral Rating Scale (CCBRS), would predict excess weight loss, health-related quality of life, depression, anxiety, and alcohol use after bariatric surgery. SETTING: Hospital in the United States. METHODS: A prospective observational study with 2-year planned follow-up was conducted with patients who completed a psychological clinical interview, the Short Form 36 (SF-36) v.2 Health Survey and brief self-report questionnaires measuring depression (PHQ-9), anxiety (GAD-7), and alcohol use (AUDIT) preoperatively. At the conclusion of the preoperative psychological evaluation, the psychologist completed the CCBRS. All questionnaires were readministered at 6, 12, 18, and 24 months after surgery. Generalized estimating equations were used to assess whether any CCBRS ratings predicted surgery outcomes. RESULTS: One hundred seventy-nine patients (113 Roux-en-Y gastric bypass and 66 sleeve gastrectomy) were included in the analyses. SF-36 scores, PHQ-9 scores, and the AUDIT total scores improved significantly after surgery, while GAD-7 scores did not change appreciably. Higher preoperative CCBRS ratings predicted higher SF-36 scores, and lower PHQ-9, GAD-7 and AUDIT scores. The CCBRS social support rating predicted higher postoperative percent excess weight loss. CONCLUSION: A behavioral rating scale (CCBRS) completed before bariatric surgery predicted postoperative weight loss, quality of life, depression, and anxiety. Therefore, this tool may prove useful in patient counseling and expectation management before surgery.