Team Approach to the Bariatric Surgical Patient: When to Refer and How

Obesity is increasing at epidemic rates. Recent National Health and Nutrition Examination Survey data reveal that approximately 15% of American adults aged 20 years and older have a body mass index (BMI) > 35 kg/m², meeting criteria for grades 2 and 3 obesity (Table, page 4).¹ Although the rate of obesity increase has lessened, the prevalence of morbid (severe/grade 3/morbid; BMI > 40 kg/m²) and super (grade 4; BMI > 50 kg/m²) obesity is increasing at higher rates.²

Click here for a larger view of this image.

In addition to exploring strategies to reduce this trend, developing effective methods to achieve and maintain beneficial weight loss is a major public health focus. Data from numerous studies suggest that bariatric surgery is the most effective weight-loss therapy for people with grade 3 obesity.³ Management of the bariatric surgery patient requires a coordinated team approach, involving the primary care physician (PCP), surgeon, dietitian, and psychologist.

Types of Bariatric Surgery

Bariatric surgical procedures are categorized by function into restrictive, primarily malabsorptive, and combined restrictive and malabsorptive. Restrictive procedures include laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG). Malabsorptive procedures achieve their effect by allowing food to bypass parts of the small intestine, and are typically associated with the highest complication rates among bariatric procedures. Combined procedures include Roux-en-Y gastric bypass (RYGB), which is the most commonly used procedure.

Qualifying Patients for Bariatric Surgery

Physicians see patients with a BMI > 40 kg/m² or > 35 kg/m² with a comorbid medical disease every day. When considering a patient load of 15 to 20 patients per day, most PCPs will see 2 to 3 patients in that category daily, and endocrinologists will see 3 to 6 patients with morbid obesity per day. These patients should be considered for a referral to a bariatric surgeon when:

• other attempts at weight loss have failed;
• it is believed that the individual patient would benefit from bariatric surgery;
• the patient agrees and wants to consider bariatric surgery;
• the patient understands the risks and benefits of bariatric surgery.

The option of bariatric surgery should be discussed with the patient early in the course of weight management. Many patients may not be appropriate for bariatric surgery, but mentioning that the patient has a serious weight problem for which an option is weight loss surgery will help patients understand the severity of their medical condition.

Patients who are extremely obese are likely to benefit from surgery because the significant risks associated with their morbid obesity outweigh the risks of bariatric surgery. The prevalence of weight-related comorbidities in patients with morbid obesity can have severe repercussions on their health and longevity.⁴ In a study comparing outcomes in 189 patients with morbid obesity who were denied bariatric surgery with 587 who underwent laparoscopic RYGB, baseline comorbidities in the denied cohort included diabetes (20%), sleep apnea (20%), abnormal lipids (34%), hypertension (51%), and gastroesophageal reflux disease (GERD), a precursor to esophageal cancer (62%). Patients who underwent surgery had significantly lower BMIs at follow-up compared with patients denied surgery (P < .001). In addition, during the 3-year follow-up the incidence of new-onset diabetes, hypertension, obstructive sleep apnea, GERD, and lipid disorders was significantly greater in the group of patients who were denied surgery (P < .001 for all).

Despite the fact that physicians in practices may see more than 100 patients per month who qualify for bariatric surgery, the number of patients who undergo these procedures is often significantly lower. On a national scale, approximately 100,000 bariatric surgeries are performed annually, representing < 1% of people who qualify.^5-7 Patients choose not to undergo surgery for a variety of reasons. Physicians should engage their patients in a discussion to address issues that may be resolvable. Patients may fear surgery, or they may not perceive themselves as candidates, believing that their weight is not that excessive. Access to care can be an issue, if the patient does not have insurance that will cover the procedure. Others may erroneously consider surgery to be an easy solution to their weight problems.

Surgical candidates should understand the risks and benefits of bariatric surgery. Significant benefits include the fact that more than one-half of those accepting bariatric surgery will lose 50% or more of their excess body weight. In addition, weight-related comorbidities are usually improved or resolved after bariatric surgery. A recent meta-analysis demonstrated complete resolution of diabetes in 78.1% of patients following bariatric surgery.⁸ Results from another meta-analysis that included more than 40,000 control and surgical patients with 2.5 to 10 years of follow-up data indicated that bariatric surgery reduced the risk of global mortality (odds ratio [OR], 0.55), all-cause mortality (OR, 0.70), and cardiovascular mortality (OR, 0.58) compared with either clinic-based or community-based control patients who did not undergo surgery.⁹

When patients have reached the stage where they will opt for surgery, specific risks are more appropriately left to the surgeon to explain. General practitioners should still remain versed about these risks. Overall, bariatric surgery is a safe surgery with a low mortality rate that compares favorably with the 30-day mortality of 0.55% following laparoscopic cholecystectomy and 1% following total hip arthroplasty.¹⁰ Reports have compared complication and mortality rates from several sources and suggest a decreasing incidence of adverse outcomes. Between 2001-2002 and 2005-2006, complication rates decreased significantly for inpatient (23.6% vs. 14.8%), 30-day overall (33.7% vs. 25.5%), and 180-day overall (41.7% vs. 32.8%) data sets, despite increases in patient age and comorbidities.¹¹ Perioperative mortality rates have also decreased, reported at 0.4% (95% confidence interval [CI], 0.01%-2.1%) for gastric banding, and 1.0% (95% CI, 0.5%-1.9%) for gastric bypass in 2 meta-analyses of randomized trials and observational studies that were published prior to 2002.¹² More recently, a longitudinal study of almost 5,000 patients reported overall 30-day mortality of 0.2%: 0% for gastric banding, 0.2% for laparoscopic gastric bypass, and 2.1% for open gastric bypass.¹³

Motivation to lose weight is often considered to be an important component of successful weight loss and a qualifier for surgery.¹⁴ However, results from a recent study evaluating the relationship between preoperative Readiness To Change (RTC) scores and 2-year outcomes in 204 bariatric surgery patients failed to reveal an association between RTC and weight loss, compliance, or surgical complications.¹⁵ Surgery may physiologically facilitate a commitment to losing weight. If excessive eating was an issue prior to surgery, the patient will clearly be uncomfortable eating large meals postoperatively.

Counseling the Patient for Bariatric Surgery

Discussion of bariatric surgery should be part of the overview of options to manage morbid obesity, and should begin well before discussing a specific patient's eligibility. This counseling should incorporate the approach described in the National Institutes of Health (NIH) guidelines.¹⁶ Patients should begin with diet and lifestyle changes, followed by weight loss medications when appropriate. If these interventions are unsuccessful, qualified patients should be advised to consider weight loss surgery. If the patients initially state that they are not interested, the seriousness of their condition should be explained to them.

Patients should be referred to a dietitian at the beginning of the weight loss program. Patients with diabetes should be referred to a certified diabetes educator. The patient can undergo a trial of adopting a proper dietary approach to weight loss, helping them become accustomed to the diet that they will be required to maintain if they undergo bariatric surgery. They can learn tools for appetite control and ways to enhance satiety. After RYGB, the stomach empties faster than normal in some patients, which can cause cramping and diarrhea. An “anti-dumping diet” is commonly prescribed, which is based on having 6 to
8 small meals per day following diet restrictions and general eating habit principles.¹⁷ Learning about this diet before surgery can facilitate its acceptance postoperatively.

Psychologists are another important member of the patient management team, particularly when evaluating the patient for bariatric surgery. Psychologists are more likely than other team members to discover contraindications for surgery such as alcohol or substance abuse. Psychologists also can determine if the patient has realistic expectations about postsurgical outcomes. Most patients expect to have significantly more weight loss than what is realistically achievable. A survey of 284 bariatric surgery candidates had them define their weight loss objectives as “dream,” “happy,” “acceptable,” and “disappointed.”¹⁸ The perceived “disappointed” weight loss amount was 49% of body weight, which is consistent with what is considered to be successful weight loss. Therefore, patients should be guided to have realistic weight loss expectations prior to undergoing surgery, and should be counseled that even modest weight loss can produce significant health benefits.

The psychologist can also help ensure that the patient understands the risks for surgery and necessary follow-up required. Patients must understand that there can be adverse consequences of failure to attend regularly scheduled follow-up visits. For example, health issues can result from lack of adherence to taking micronutrient supplements, which will go undetected if follow-up visits are ignored.

Patients taking psychiatric medications that are associated with weight gain have an additional risk that requires counseling. In 1 study, nearly two-thirds of bariatric surgery candidates had a psychiatric diagnosis, more than one-half of whom were receiving treatment.¹⁹ Almost one-third were recommended for additional counseling prior to surgery. Depression is also common among bariatric surgery candidates, with reported prevalence rates reaching 30% or more.²⁰ A recent study that included a 4-year postsurgical follow-up revealed that patients with a comorbid mental diagnosis at baseline lost significantly less weight than those without depressive or anxiety disorders.²¹

Discussion

Is the terminology associated with obesity a deterrent to seeking appropriate treatment?

John Morton, MD, MPH, FACS: There is certainly a stigma associated with being obese. Although every chronic illness is morbid, the term “morbidly obese” is pejorative. Therefore, it may be preferable to soften the terminology when talking with the patient; in fact, morbid obesity is increasingly being replaced by grade 3 or class 3, extreme, or clinically severe obesity. However, International Classification of Diseases (ICD) criteria and insurance billing codes continue to use this nomenclature.

On the other hand, it is important for patients to know that they are obese and that it has significant health outcomes. Once a BMI of 30 kg/m² is reached, it is very difficult to lose weight and maintain the weight loss.

Very few conditions require 6 months or more of medically-based treatment prior to qualification. Is this a barrier to bariatric surgery?

Robert Kushner, MD, FACP: There is attrition during the 6 months leading up to surgery, and it is rarely due to the patient achieving weight loss success and no longer needing surgery. This period has been perceived as an important time period during which the patient can accept and implement the lifestyle changes and compliance requirements that they must fulfill after they have the surgery. Surgery then provides some physiological reinforcement. There are no studies that have explored a potential relationship between the extent of compliance during the presurgical interval with weight loss maintenance postsurgery.

Is there a relationship between weight loss during the 6-month preoperative period and postsurgical outcomes?

Morton: Studies of the relationship of presurgical weight loss to postoperative outcomes have produced conflicting results.^22,23 After a retrospective chart review showed a significant correlation between preoperative weight loss and 1-year postoperative weight loss,²⁴ a randomized controlled trial was performed, dividing patients into 2 preoperative groups, one requiring a 10% weight loss, and the other with no weight loss requirements.²⁵ Follow-up data were available for 26 and 35 patients, respectively. Initial BMI was similar between the 2 groups. However, preoperatively the weight loss group had a significantly lower BMI than the non-weight loss group (P = .0027). Operative time was significantly less in the weight loss group (P = .0084), and complication rates were similar. Although weight loss after 3 months was significantly greater in the weight loss group (P = .0267), it was similar in the 2 groups 6 months after surgery. Resolution of comorbidities was also similar between the 2 groups.

What is your experience with attitude changes during the 6-month trial of medical therapy?

Ken Fujioka, MD: Patients who fail the 6-month medical therapy period often change their opinions, and accept that surgery may be their best, and at times, their only option. However, it is crucial to be sensitive in approaching the patients. If patients are not encouraged to consider bariatric surgery before the trial of medical therapy begins, they may have a firm negative response if it is offered as an option at the end of therapy. In fact, patients may leave the practice of physicians who delay counseling about surgery as an option until after medical therapy has failed. Hearing about surgery for the first time while they are in a failure mindset may be frightening or offensive to many patients. In the beginning, physicians should acknowledge that they are not thinking about surgery, but that it may become a viable option. If medical therapy fails, that does not signify the end of their options. Knowing they may have another option may help motivate compliance with medical therapy. Unfortunately, research has not been done to test this theory.

References

1. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999-2008. JAMA. 2010;303(3):235-241.

2. Sturm R. Increases in morbid obesity in the USA: 2000-2005. Public Health. 2007;121(7):492-496.

3. Kushner RF, Noble CA. Long-term outcome of bariatric surgery: An interim analysis. Mayo Clin Proc. 2006;81(10 suppl):S46-S51.

4. Al Harakeh AB, Burkhamer KJ, Kallies KJ, Mathiason MA, Kothari SN. Natural history and metabolic consequences of morbid obesity for patients denied coverage for bariatric surgery. Surg Obes Relat Dis. 2010;6(6):591-596.

5. Nguyen NT, Masoomi H, Magno CP, Nguyen XM, Laugenour K, Lane J. Trends in use of bariatric surgery, 2003-2008. J Am Coll Surg. 2011;213(2):261-266.

6. Belle SH, Berk PD, Courcoulas AP, et al; Longitudinal Assessment of Bariatric Surgery Consortium Writing Group. Safety and efficacy of bariatric surgery: Longitudinal assessment of bariatric surgery. Surg Obes Relat Dis. 2007;3(2):116-126.

7. Livingston EH. The incidence of bariatric surgery has plateaued in the U.S. Am J Surg. 2010;200(3):378-385.

8. Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: Systematic review and meta-analysis. Am J Med. 2009;122(3):248-256.

9. Pontiroli AE, Morabito A. Long-term prevention of mortality in morbid obesity through bariatric surgery. A systematic review and meta-analysis of trials performed with gastric banding and gastric bypass. Ann Surg. 2011;253(3):484-487.

10. Khuri SF, Henderson WG, DePalma RG, Mosca C, Healey NA, Kumbhani DJ; Participants in the VA National Surgical Quality Improvement Program. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg. 2005;242(3):326-341.

11. Encinosa WE, Bernard DM, Du D, Steiner CA. Recent improvements in bariatric surgery outcomes. Med Care. 2009;47(5):531-535.

12. Maggard MA, Shugarman LR, Suttorp M, et al. Meta-analysis: Surgical treatment of obesity. Ann Intern Med. 2005;142(7):547-559.

13. Longitudinal Assessment of Bariatric Surgery (LABS) Consortium, Flum DR, Belle SH, et al. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;361(5):445-454.

14. Norris L. Psychiatric issues in bariatric surgery. Psychiatr Clin North Am. 2007;30(4):717-738.

15. Dixon JB, Laurie CP, Anderson ML, Hayden MJ, Dixon ME, O'Brien PE. Motivation, readiness to change, and weight loss following adjustable gastric band surgery. Obesity. 2009;17(4):698-705.

16.NIH Consensus Development Conference Consensus Statement. Gastrointestinal surgery for severe obesity. 1991;9(1):1-22. http://consensus.nih.gov/1991/1991GISurgeryObesity084PDF.pdf. Accessed October 21, 2011.

17.Mayo Clinic. Dumping syndrome. http://www.mayoclinic.com/health/dumping-syndrome/DS00715/DSECTION=lifestyle%2Dand%2Dhome%2Dremedies. Accessed September 29, 2011.

18. Kaly P, Orellana S, Torrella T, Takagishi C, Saff-Koche L, Murr MM. Unrealistic weight loss expectations in candidates for bariatric surgery. Surg Obes Relat Dis. 2008;4(1):6-10.

19.Sarwer DB, Cohn NI, Gibbons LM, et al. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obes Surg. 2004;14(9):1148-1156.

20. Franks SF, Kaiser KA. Predictive factors in bariatric surgery outcomes: What is the role of the preoperative psychological evaluation? Primary Psychiatry. 2008;15(8):74-83.

21. Legenbauer T, De Zwaan M, Benecke A, Muhlhans B, Petrak F, Herpertz S. Depression and anxiety: Their predictive function for weight loss in obese individuals.Obes Facts. 2009;2(4):227-234.

22. Still CD, Benotti P, Wood GC, et al. Outcomes of preoperative weight loss in high-risk patients undergoing gastric bypass surgery. Arch Surg. 2007;142(10):994-998.

23. Fujioka K, Yan E, Wang HJ, Li Z. Evaluating preoperative weight loss, binge eating disorder, and sexual abuse history on Roux-en-Y gastric bypass outcome. Surg Obes Relat Dis. 2008;4(2):137-143.

24. Alvarado R, Alami RS, Hsu G, et al. The impact of preoperative weight loss in patients undergoing laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2005;15(9):1282-1286.

25. Alami RS, Morton JM, Schuster R, et al. Is there a benefit to preoperative weight loss in gastric bypass patients? A prospective randomized trial. Surg Obes Relat Dis. 2007;3(2):141-145.