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Post-Surgical Care Critical To Optimal Weight Loss After Bariatric Surgery

Ruzanna Harutyunyan's picture

Those patients who were most compliant with surgeon recommendations after bariatric surgery lost 35 percent more weight the first year and tend to keep more weight off even after five years, according to new patient and bariatric surgeon surveys conducted by Harris Interactive, for the American Society for Metabolic & Bariatric Surgery (ASMBS).

The survey of 208 gastric bypass patients and 201 gastric band patients found that on average compliant patients lost more than 123 pounds the first year, while the less compliant lost 92 pounds. At the five year mark, compliant bariatric surgery patients lost more than 127 pounds while less compliant patients lost 100 pounds. Bariatric surgeons also place a high value on follow-up care programs. In a separate survey of 282 bariatric surgeons, 94 percent said follow-up care is just as or even more important to successful outcomes than the surgery itself. Both surveys were sponsored by Ethicon Endo-Surgery, Inc.

"While surgeons have always understood the importance of follow-up care, this survey helps quantify how much of a difference it really makes," said Scott Shikora, MD, ASMBS President and Chief of General Surgery, Bariatric Surgery and Minimally Invasive Surgery at Tufts Medical Center in Boston. "Compliance can mean the difference between a good result and a great result."

Surgeons typically recommend post-surgical activities including regular exercise, nutritional counseling, maintaining a food diary, psychological counseling, diet modification, keeping doctor's appointments and participation in support groups. However, 66 percent of surgeons believe there is no consensus on what constitutes bariatric surgery follow-up care. About half (48%) say they did not receive bariatric surgery follow-up care education as part of their training or fellowship.

Surgeons believe regular exercise (67%), changing eating habits (58%) and support group attendance (34%) are the most difficult components of aftercare for patients and that while both groups of patients face compliance challenges after surgery, gastric band patients have a more difficult time with it than gastric bypass patients (59% vs. 49%). In addition, surgeons indicate that missed doctor appointments, insurance issues and long-distance travel are the reasons they do not see their patients more often.

"Techniques in bariatric surgery are consistent, but follow-up care tends to vary from bariatric program to bariatric program," said Alan Wittgrove, MD, a past president of the ASMBS and medical director of the Wittgrove Bariatric Center and Scripps Memorial Hospital in La Jolla. "There are a lot of good programs out there but there is a need to standardize follow-up care so patients can achieve the best outcomes possible."

Gastric band patients who participated in five or more components of aftercare lost 30 percent more weight and reported having a significantly better quality of life than gastric band patients who participated in four or less. Compliant gastric bypass patients also lost more weight than their less compliant counterparts, but their success was not linked to any specific number of post-surgical activities. Gastric bypass patients (77%) indicated greater ease in complying with doctor recommendations than gastric band patients (66%).

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It's not only what patients and surgeons do after surgery that can determine success. The vast majority of surgeons have patients engage in educational activities, nutritional counseling, medically supervised diet and exercise programs, support groups, and goal setting prior to surgery. Patients who felt prepared were twice as likely (39% vs. 18%) to say compliance after surgery was easy than those who felt "very or somewhat" unprepared for surgery. Surgeons believe commitment to diet, exercise and making lifestyle changes are the most important factors that patients should know about to succeed after surgery.

According to the survey, surgeons believe patients choose gastric bypass over gastric banding because it results in more weight loss (51%), they knew someone who had it (40%), to lose weight more quickly (34%) and for "better comorbidity resolution" (23%). They say patients choose gastric banding over bypass because it's less invasive (63%), safer (59%), reversible (55%), results in fewer complications (41%) and because they knew someone who had it (25%).

Life Before Surgery

On average, patients tried 24 diets and exercise programs before surgery and have been obese for about 20 years. Two-thirds (67%) of patients reported having an average of five obesity-related conditions. They considered bariatric surgery for about three years before deciding to have surgery and about one-quarter of them were denied insurance coverage about three times before getting approval. About 60 percent of patients report that their health worsened during this waiting period. Improving their health (25%), losing weight (20%) and resolving disease (17%) were top reasons patients opted for bariatric surgery while only 3 percent said they wanted surgery for cosmetic reasons. Almost three times as many patients thought they were more likely to die from obesity (64%) than from bariatric surgery (24%).

Surgeons say most patients come on their own accord (44%) or are referred from a primary care practitioner (36%). Most patients come to the surgeon requesting a specific type of procedure (68%).

About the Surveys

Online surveys were conducted in April and May 2008 among 282 surgeons and 409 patients (208 gastric bypass surgery patients and 201 gastric band surgery patients).

Bariatric and general surgeons who performed bariatric surgery for at least three years, and at least 100 surgeries during their career were recruited from the ASMBS, the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), and Harris Interactive's Physician Panel and the American Medical Association (AMA) master file. Patients who had gastric bypass or gastric banding surgery in the previous one to five years were recruited from Harris Interactive's Chronic Illness Panel, general population panel and eRewards Patient data were weighted to be representative of U.S. obese adults ages 18 and older. Propensity score weighting was also used to adjust for respondents' propensity to be online. Because the sample is based on those who agreed to participate in the online survey, no estimates of theoretical sampling error can be calculated. A full methodology is available.

The survey sponsor, Ethicon Endo-Surgery, a Johnson & Johnson company, develops and markets advanced medical devices for minimally invasive and open surgical procedures, focusing on procedure-enabling devices for the interventional diagnosis and treatment of conditions in general and bariatric surgery, as well as gastrointestinal health, gynecology and surgical oncology.