Bariatric Services Research Articles

Severe obesity as a barrier to international travel: a qualitative analysis.

It is unknown whether obesity is a barrier to international travel. The purpose of this qualitative study was to describe the travel experiences of a cohort of severely obese individuals attending a hospital-based bariatric service, to identify their perceived barriers to travel and to generate recommendations that address the needs of severely obese individuals. Semi-structured interviews were conducted with severely obese patients attending a regional, structured, multidisciplinary lifestyle modification programme. Coding and thematic analysis of the transcripts were completed by three independent researchers. A thematic analysis was performed based on examination of the transcribed interviews. Demographic and clinical data such as gender, age and body mass index were also recorded. Twelve patients (six males), with a mean age of 54±5.98years and a mean body mass index of 46.2±8.2kg/m2, agreed to semi-structured interviews (14-52-minute duration). The principal themes emerging from the interviews included obese air traveller embarrassment, physical discomfort on commercial flights, perceived weight bias, challenges in accessing hotel rooms, heat intolerance in warm climates, restricted leisure travel activities and medical co-morbidities. Most of the interviewees perceived a health benefit to travel but regarded obesity as a significant barrier to international travel. These findings highlight the limitations experienced by obese travellers when engaging in international travel. Our results may inform the pre-travel health advice given to obese travellers. They might also serve to raise awareness among operators within the travel industry of the difficulties travellers with severe obesity face.

Variations in bariatric surgical care pathways: a national costing study on the variability of services and impact on costs

BackgroundWe undertook a survey of all bariatric centres in Scotland in order to describe current pre- and post-operative care, to estimate their costs and explore differences in financial impact.MethodsA questionnaire was distributed to each health centre. Descriptive statistics were used to present average cost per patient along with 95% confidence intervals, and the range of costs.ResultsResults show nearly a five-fold difference in costs per patient for pre-operative services (range £226 - £1071) and more than a three-fold difference for post-operative services (range £259 - £896).ConclusionsThere is a lack of evidence base and a clear requirement for the evaluation of bariatric surgical services to identify the care pathways pre- and post-surgery which lead to largest improvements in health outcomes and remain cost-effective.

A350 - Money and motivation: A comparison of excess weight loss (EWL) in insured and uninsured patients undergoing laparoscopic sleeve gastrectomy (LSG)

Background: Patients with obesity undergoing laparoscopic sleeve gastrectomy (LSG) have been shown to experience significant post-operative weight loss. In Australia, the majority of bariatric surgery is performed within private hospitals as few public facilities offer bariatric services. Consequently, the cost of the operation can be high for patients who are not privately insured. The purpose of the study was to compare excess weight loss (EWL) in insured and uninsured patients 6 months post undergoing LSG.

Primary care provider management of patients with obesity at an integrated health network: A survey of practices, views, and knowledge

BackgroundObesity is a serious health problem that affects a wide range of patients and disease processes. ObjectiveThe purpose of this study is to evaluate perceptions, knowledge, and practice habits of primary care providers (PCPs) regarding the care of patients with obesity, including barriers to effective care and their experience with bariatric surgery in our integrated health network. SettingIntegrated health network. MethodsA 16-question survey was distributed electronically to 160 PCPs at our integrated health network. Results were analyzed to identify attitudes, knowledge, practice habits, and bariatric surgery referral patterns while treating patients with obesity. ResultsAmong 160 PCPs, 45 (28.1%) responded. Specialty, sex, patient population, insurance accepted, and practice years of PCPs were reported. Most PCPs reported “always” calculating patient body mass index (88.9%) with only 13.3% “always” discussing the body mass index results. Respondents most frequently prescribed diet and exercise to patients with obesity and rarely prescribed medications, with bariatric surgery referrals falling between the two. PCPs viewed management of obesity as the responsibility of the patient (97.6%) and the PCP (100%). Ninety-three percent felt obesity is a common diagnosis in their practice, but no one correctly identified the prevalence of obesity in our region. Respondents demonstrated adequate knowledge regarding medical consequences of obesity. A majority was able to identify the correct eligibility criteria for bariatric surgery, as well specific medical problems that can improve or be eliminated postoperatively. While 61.9% of respondents were aware of free weight loss and bariatric informational sessions offered, 28.6% reported that they were unfamiliar with existing bariatric surgeons. One respondent was not aware of any bariatric surgery performed. Some PCPs reported prior negative experiences with post-bariatric surgery patients, and thus were hesitant to refer additional patients. ConclusionsPCPs report discussing an obesity diagnosis with patients but are not always using body mass index in that discussion. They most often prescribe lifestyle modification as treatment for patients, which they believe to be most effective to treat obesity. However, they report only one third of their patients are motivated to lose weight. Additionally, they demonstrate appropriate knowledge of indications and benefits of bariatric surgery. A majority of the PCPs is aware of weight loss informational sessions and bariatric services provided within our integrated health network, but almost one third were unable to identify a surgeon, a possible target for improved relationships. Barriers to care include patient motivation and insurance coverage.

Ethnic disparities in rates of publicly funded bariatric surgery in New Zealand (2009-2014).

Publicly funded bariatric surgery in New Zealand (NZ) is steadily on the rise to meet the obesity epidemic. Ethnic disparities in obesity rates exist in NZ with Māori and Pacific people having three to five times higher rates than all other ethnic groups within NZ. Ethnic disparities in rates of bariatric surgery have been reported internationally. This research sought to describe rates of publically funded bariatric surgery by self-identified ethnicity in NZ. Using reported census and hospitalization discharge data from Statistics NZ and the NZ Ministry of Health, we calculated estimate rates of publicly funded bariatric surgery in the morbidly obese population from June 2009 to July 2014. The average number of publicly funded bariatric procedures performed per 1000 morbidly obese patients from June 2009 to July 2014 was 3.0 for European, 1.4 for Māori and 0.7 for Pacific ethnicities. While these data should be interpreted cautiously due to data limitations, the estimated rates may indicate that bariatric services are currently being provided inequitably across the major ethnic groups within NZ. We suggest that further studies should be performed to explore potential patient, healthcare provider and system-level factors that may contribute to ethnic disparities in the rates of publicly funded bariatric surgery in NZ.

Influence of social deprivation on provision of bariatric surgery: 10-year comparative ecological study between two UK specialist centres

ObjectiveTo investigate the effect of residential location and socioeconomic deprivation on the provision of bariatric surgery.DesignRetrospective cross-sectional ecological study.SettingPatients resident local to one of two specialist bariatric units, in different...

A401 - Creation of a Retrocolic, Retrogastric Roux-en-Y Gastric Bypass via the Lesser Sac C. Kenneth Mitchell, JR, MD, FACS, FASMBS Bryan Thomas, MD Jessica Raux, PA-C Roper St. Francis Healthcare Division of Bariatric and Metabolic Services Charleston, SC

A401 - Creation of a Retrocolic, Retrogastric Roux-en-Y Gastric Bypass via the Lesser Sac C. Kenneth Mitchell, JR, MD, FACS, FASMBS Bryan Thomas, MD Jessica Raux, PA-C Roper St. Francis Healthcare Division of Bariatric and Metabolic Services Charleston, SC

Analgesic efficacy of laparoscopic-guided transverse abdominis plane block using liposomal bupivacaine in bariatric surgery

BackgroundPostoperative pain management is a major contributor to recovery and discharge in bariatric surgery. Local anesthetic agents are of particular interest: they're non-sedating and may reduce postoperative pain and hospital length of stay (LOS). DesignResearchers queried the Bariatric Surgery Service Database for patients undergoing laparoscopic weight loss surgery from January 2012–December 2014. Patients were divided between those who did and did not receive liposomal bupivacaine intra-operatively. Measures included demographics, narcotic use, LOS, antiemetic use, and pain scales. ResultsThe liposomal group consisted of 233 patients and the PCA group consisted of 243 patients. The liposomal group had significantly less narcotic use than the PCA group in terms of IV morphine equivalents. This did not translate into a reduction in LOS in the liposomal group. ConclusionsTAP block using liposomal bupivacaine provides effective analgesia comparable to PCA.

Influence of morbid obesity on physical capacity, knee-related symptoms and overall quality of life: A cross-sectional study.

To evaluate the impact of morbid obesity on physical capacity, joint-related symptoms, and on the overall quality of life. Cross-sectional study carried out at a university hospital, enrolling 39 individuals admitted to a bariatric surgery service. Physical capacity was assessed by Six-Minute Walk Test (SMWT) and the Borg rating of perceived exertion (RPE). Knee-related symptoms were evaluated by Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Lysholm Score. Quality of life was evaluated by Short Form 36 Health Questionnaire (SF-36). On SMWT, the mean distance walked was 374.1±107.5 m. The mean Borg score was 12.9±2.4. KOOS questionnaire found the following scores: pain (64.3±24), other symptoms (67.2±25.5), function in daily living (60.4±26.8), function in sport and recreation (28.5±32.2), knee-related quality of life (35.9±33.5), mean Lysholm scale score (55.3±25.4). SF-36 provided the following scores: physical functioning (41±27.4), physical role functioning (34.6±39.2), bodily pain (45.7±23.6), general health perceptions (63.1±26.2), vitality (53.5±12.1), social role functioning (52.6±29.3), emotional role functioning (41±44.9), mental health (55±27.7). Obesity led to significant loss of physical capacity, gait impairment, knee-related symptoms, and a negative impact on the overall quality of life.

A needs assessment of bariatric surgery services in Saudi Arabia

Background: Obesity in Saudi Arabia is a serious problem; 30% of men and 44% of women are obese, and these levels are anticipated to rise. Fortunately, obesity is amenable to surgical intervention. However, we do not know if Saudi Arabia has enough bariatric surgery services. The literature has already determined the number of bariatric surgeons and the number of bariatric surgeries annually in Saudi Arabia but has not investigated whether these services are sufficient for the size of the Saudi population. Objective: The objective of this study was to determine if Saudi Arabia needs more bariatric services. Materials and Methods: The research was conducted by an email survey of 31 bariatric surgeons in Saudi Arabia. Likert scale based questionnaire was used to obtain opinions about the need for more bariatric surgeons. Results: This study found that Saudi Arabia does need more bariatric surgery services. Totally, 55% of the respondents agreed that Saudi Arabia needs more bariatric surgery services, 65% agreed that Saudi Arabia’s need for such services will increase in the next 10 years, 54% mentioned they had a long waiting list for bariatric surgery. Conclusion: The results of this study showed that Saudi Arabia needs more bariatric surgery services. Therefore, hospitals in Saudi Arabia and the government should invest more in bariatric services.

Unmet need for bariatric surgery

IntroductionWith the rising prevalence of severe obesity and type 2 diabetes (T2D), bariatric surgery offers a clinical and cost-effective treatment for carefully selected patients. Despite this, the provision of surgical services varies significantly between countries. ObjectiveTo inform health service planning by estimating the number of people who would potentially benefit from bariatric surgery. SettingNationally representative sample of community-dwelling older adults. MethodsWe applied two separate evidence-based criteria sets for eligibility for bariatric surgery. For the first set of criteria, we considered those with body mass index≥40 kg/m2 or≥35 kg/m2 and one or more of the following: T2D, hypertension, previous myocardial infarction, or sleep apnea. For the second set of criteria, we considered patients with T2D and body mass index≥35 kg/m2, with one or more of the following: previous myocardial infarction, elevated urine albumin-creatinine ratio, retinopathy, neuropathy, or peripheral vascular disease. Prevalence estimates were applied to census figures for 2011, estimating absolute numbers meeting the criteria. ResultsAmong adults aged≥50 years, 7.97% (95% confidence interval [CI]: 7.23, 8.78), representing 92,573 people (95% CI: 83,978, 101,981), met criteria one and 0.97% (95% CI: 0.73, 1.28), representing 11,231 people (95% CI: 8471, 14,890), met criteria two. With fewer than 1/100,000 population publicly funded surgeries taking place annually, current service provision meets much less than 0.1% of the need. ConclusionsWhile many adults who fulfill the eligibility criteria for bariatric surgery may not want or require it, the current level of need for bariatric surgical services is not being met. A strategy to develop and expand the provision of bariatric care is urgently needed.

Patient experiences of a bariatric group programme for managing obesity: A qualitative interview study.

People with obesity experience a range of physical and psychological ill-health outcomes. This study examined patients' experiences of a group-based programme for the management of morbid obesity delivered within the UK National Health Service. The focus of the study was on the emerging dynamic of the group and patients' perceptions of its impact on health outcomes. A qualitative interview study was conducted and involved patients recruited from a Tier 3 bariatric service in South West England. Verbatim transcripts were analysed using thematic analysis. Twenty patients (12 females) with a BMI≥35kg/m2 participated in a semi-structured one-to-one interview. Participants had been registered with the bariatric service for at least 6months. None of the participants had had bariatric surgery. Most participants felt that they had benefited from participating in the group programme and talked about the group as a resource for lifestyle change. Participants' narratives centred on the emergence of a sense of self based upon their participation in the group: establishing psychological connections to other patients, or shared social identity, was regarded as a key mechanism through which the programme's educational material was accessed, and underpinned the experience of social support within the group. Through interaction with other patients, involving the sharing of personal experiences and challenges, participants came to experience their weight 'problem' through a collective lens that they felt empowered them to initiate and sustain individual lifestyle change. Bariatric care groups have the potential to support lifestyle change and weight loss and may help address the psychological needs of patients. Nurturing a sense of shared social identity amongst patients with morbid obesity should be a core aim of the care pathway and may provide the foundation for successful translation of dietetic content in group programmes. Statement of contribution What is already known on this subject? Services for people with obesity who require specialist care are often supported by group-based bariatric programmes. There are no specific guidelines for the organization of bariatric groups beyond the recommendation for lifestyle interventions delivered by a multidisciplinary care team. Research with other health conditions suggests that the psychological connections formed between participants in bariatric programmes may play an important role in structuring programme effectiveness. What does this study add? Establishing psychological connections with other patients underpins bariatric patients' group experience. Shared social identity structures behaviour change in patients on bariatric programmes. Nurturing shared social identity should be a core aim of the bariatric care pathway.

Liver failure following biliopancreatic diversions: a narrative review.

Occurrences of liver failure following jejunoileal bypass were extensively reported in the past and were one of the main factors that led to abandonment of this procedure. The newer predominantly malabsorptive procedures called biliopancreatic diversions (BPDs) have also been implicated in several cases of acute and subacute liver failure. The aim here was to review the current available evidence on occurrences of liver failure following BPDs. Narrative review; bariatric surgery service of a public university hospital. A review of the literature was conducted through an online search of medical databases. Associations between BPDs and liver failure have only infrequently been reported in the literature. However, they appear to be more than merely anecdotal. The pathophysiological mechanisms remain obscure, but they seem to be related to rapid weight loss, protein malnutrition, deficits of hepatotrophic factors, high circulating levels of free fatty acids and bacterial overgrowth in the bypassed bowel segments. Reversal of the BPD may ameliorate the liver impairment. Although infrequent, liver failure remains a concern following BPDs. Careful follow-up is required in individuals who undergo any BPD.

Fragilities of bariatric health tourism in an environment devoid of a formal bariatric service

Fragilities of bariatric health tourism in an environment devoid of a formal bariatric service

The effect of the Ontario Bariatric Network on health services utilization after bariatric surgery: a retrospective cohort study.

In 2009, the Ontario Bariatric Network was established to address the exploding demand by Ontario residents for bariatric surgery services outside Canada. We compared the use of postoperative hospital services between out-of-country surgery recipients and patients within the Ontario Bariatric Network. We conducted a population-based, comparative study using administrative data held at the Institute for Clinical Evaluative Sciences. We included Ontario residents who underwent bariatric surgery between 2007 and 2012 either outside the country or at one of the Ontario Bariatric Network's designated centres of excellence. The primary outcome was use of hospital services in Ontario within 1 year after surgery. A total of 4852 patients received bariatric surgery out of country, and 5179 patients underwent surgery through the Ontario Bariatric Network. After adjustment, surgery at a network centre was associated with a significantly lower utilization rate of postoperative hospital services than surgery out of country (rate ratio 0.90, 95% confidence interval [CI] 0.84 to 0.97). No statistically significant differences were found with respect to time in critical care or mortality. However, the physician assessment and reoperation rates were significantly higher among patients who received surgery at a network centre than among those who had bariatric surgery out of country (rate ratio 4.10, 95% CI 3.69 to 4.56, and rate ratio 1.84, 95% CI 1.34 to 2.53, respectively). The implementation of a comprehensive, multidisciplinary provincial program to replace outsourcing of bariatric surgical services was associated with less use of postoperative hospital services by Ontario residents undergoing bariatric surgery. Future research should include an economic evaluation to determine the costs and benefits of the Ontario Bariatric Network.

Guidelines for the follow-up of patients undergoing bariatric surgery.

Bariatric surgery can facilitate weight loss and improvement in medical comorbidities. It has a profound impact on nutrition, and patients need access to follow-up and aftercare. NICE CG189 Obesity emphasized the importance of a minimum of 2 years follow-up in the bariatric surgical service and recommended that following discharge from the surgical service, there should be annual monitoring as part of a shared care model of chronic disease management. NHS England Obesity Clinical Reference Group commissioned a multi-professional subgroup, which included patient representatives, to develop bariatric surgery follow-up guidelines. Terms of reference and scope were agreed upon. The group members took responsibility for different sections of the guidelines depending on their areas of expertise and experience. The quality of the evidence was rated and strength graded. Four different shared care models were proposed, taking into account the variation in access to bariatric surgical services and specialist teams across the country. The common features include annual review, ability for a GP to refer back to specialist centre, submission of follow-up data to the national data base to NBSR. Clinical commissioning groups need to ensure that a shared care model is implemented as patient safety and long-term follow-up are important.

Patient Perspectives About Follow-Up Care and Weight Regain Following Sleeve Gastrectomy.

Weight regain following sleeve gastrectomy is an increasingly recognised and important problem. Similar to other centres, we have noticed an association between the onset of weight regain and discharge from the bariatric service. We aimed to elucidate this further from the patient perspective. Patients at least 2years from sleeve gastrectomy, who had experienced weight regain, were invited to participate in a focus group discussion. Participants were asked to complete a demographic survey and discussions were audio-recorded. Transcripts underwent content analysis using an inductive approach. Thirty-eight participants participated in one of seven focus group discussions. The majority of participants were female, European and satisfied with the surgery and follow-up care. Participants described positive and negative aspects of the surgery, their follow-up care and causes of weight regain. Important emergent themes included the desire for more support, that is delivered within the overarching principles of providing individualised, specialised care by providers that maintain good rapport and assist in maintaining motivation. Furthermore, this follow-up support may be delivered in non-traditional ways rather than conventional face-to-face consultations. Explorative focus group discussions in a group of patients who had regained weight following sleeve gastrectomy revealed a desire for more support after discharge from the bariatric service.

Experience of a specialist emergency bariatric surgical service

BackgroundBariatric surgery is associated with late and procedure-specific acute surgical complications. There is very little evidence available regarding the volume, nature, and outcomes of acute surgical admissions directly stemming from bariatric surgery. Centralization of bariatric elective services in the United Kingdom may have an adverse impact on the ability of local services to manage such unpredictable complications. To address this potential problem, we set up a comprehensive and specialist emergency bariatric service. ObjectivesThe aim of this study was to quantify and characterize the workload of a specialist emergency surgical bariatric service. SettingUniversity National Health Service hospital. MethodsOver 2 years, we prospectively collected data on demographic characteristics, management, and outcomes of all acute surgical admissions related directly to previous bariatric surgery. ResultsBetween December 2011 and November 2013, 69 patients had 71 emergency admissions due to a surgical emergency directly related to previous bariatric surgery. Thirty-seven (54%) had undergone primary bariatric surgery at our institution, 13 (19%) at a different National Health Service hospital, 16 (23%) at private U.K. hospitals, and 3 (4%) at private overseas hospitals. Forty-four endoscopic or surgical interventions were required, of which 17 (39%) were performed on nights or weekends and within 12 hours of admission. Of 27 operations, 25 (93%) were completed laparoscopically. Median length of stay was 2 days, there were no mortalities, and there was 1 readmission within 30 days. ConclusionsThere is a significant volume of late bariatric surgical emergencies, many requiring urgent intervention. These may be effectively managed by a specialist bariatric service.

Adolescent weight history and adult cognition: before and after bariatric surgery

BackgroundCognitive deficits occur in a subset of individuals with obesity. Deficits can be reversed with bariatric surgery, though cognitive recovery is not equally exhibited across patients. Recent work has found that obesity during adolescence portends medical complications in adulthood; it is unknown if obesity in adolescence predicts adult cognition or cognitive recovery after weight loss surgery. ObjectivesThe present study examines the relationship between weight history and cognitive function in obese adults undergoing bariatric surgery. SettingAcademic medical centers with bariatric care services. MethodsSeventy-eight bariatric surgery patients (mean age = 43.2 years) enrolled in an ancillary study to the Longitudinal Assessment of Bariatric Surgery (LABS) project completed a questionnaire recalling weight history at age 18. Cognitive testing was completed preoperatively and at 12-month follow-up. ResultsWeight status at age 18 was linked to performance in several aspects of cognition. Higher body mass index at age 18 predicted poorer preoperative verbal fluency (B = –.26, P = .045) as well as postoperative cognitive recovery in attention (B = –.30, P = .01) at 12-month follow-up. ConclusionHigher body mass index at age 18 predicts verbal fluency performance in adults with obesity, as well as postoperative recovery of attention after bariatric surgery. The mechanisms underlying this connection are not fully clear, though findings may reflect effects of obesity on the brain during a crucial period of neural maturation or duration of obesity and cumulative impact of co-morbidities on cognition. Future work examining possible causal factors involved in these relationships is needed.

PSYCHOLOGICAL PROFILE OF PATIENTS ELIGIBLE FOR BARIATRIC SURGERY.

Background: The psychologist who works in bariatric surgery has a role to receive, evaluate, prepare and educate the patient who will undergo the surgical procedure. Psychological evaluation becomes important in so far as allows us to obtain data on personal and familiar history and allow tracing of possible psychopathology. Aim: To collect data on psychological evaluations of patients in a bariatric surgery service of a public hospital in order to describe the psychological profile of patients in this service. Method: Data were collected from 827 patients between 2001 and 2015, using data from an interview, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI) and Binge Eating Scale (BES). Results: The mean age of patients before surgery was 39 years+/- 10, the mean BMI was 51 kg/m²+7, and most patients (81%) were female. The average score on the BDI was 14.8+8 and women had significantly higher scores than men. On the BAI the average score was 11+8 and on the ECAP was 14+8, both with no difference between groups. Conclusions: Psychosocial characteristics of the patients points to the significant presence of indicators of depression, with low levels of anxiety and binge eating.