Bariatric Surgeons Can’t Cut and Run
No ‘Quick Fix’ for Obesity, So Aftercare Plan Is Crucial
What happens after bariatric surgery is just as important to the final outcome as the surgery itself.
Patients and surgeons alike believe this to be true. It has almost become a mantra. Yet significant challenges remain in putting this belief into practice in the follow-up care surgeons offer, and patients—sometimes—receive.
Recent surveys conducted by market researcher Harris Interactive on behalf of the American Society of Metabolic and Bariatric Surgery (ASMBS) certainly lend support to the contention that aftercare programs improve surgical outcomes. When the group surveyed 208 gastric bypass patients and 201 who underwent gastric banding, they found that patients who followed the guidelines of their provider’s aftercare program lost 35% more weight in the year after surgery. Patients also tended to keep more weight off five years from surgery. In a separate survey of 282 bariatric surgeons, 94% agreed that effective aftercare is just as vital (or more so) in determining success as the decision to undergo surgery. (Ethicon Endo-Surgery sponsored both surveys.)
“The key to improving outcomes is accountability,” said Chris Still, DO, director of the Center for Nutrition and Weight Management Clinic at Geisinger Health Care System in Danville, Pa. “Patients are more motivated to follow through with the changes they need to make if they know that somebody is paying attention. There’s a big difference between telling a patient to come back in three months to see how they are doing, and saying ‘you’ll be coming back next week to see the nutritionist.’ ”
Aftercare an Afterthought?
Yet the same survey also found that nearly half of bariatric surgeons had received no education on follow-up care as part of their surgical training or fellowship. More notably, two-thirds of the surveyed surgeons believe there is no consensus on what a bariatric surgical aftercare program should offer.
“The No. 1 thing you must provide is to make the follow-up meaningful,” said Scott Shikora, MD, ASMBS president and chief of general surgery, bariatric surgery and minimally invasive surgery at Tufts Medical Center, Boston. “Keeping a patient connected to the program is the secret of success. The problem is getting patients to buy into it. Patients may find that the follow-up you are providing doesn’t offer them anything. They’re coming in and seeing you and you ask them ‘how are you doing? Are you doing well, not so well?’ and they’re not leaving feeling inspired. That’s the trick to getting them to come back.”
Like most aftercare programs, Tufts offers postoperative patients regular access to nutritionists, fitness experts and other providers in a group setting led by a behavioral therapist. But Dr. Shikora notes that the format has its limitations. “You have a lot of different people there. Some of them are freshly out of surgery, and some have been out of surgery for years. Although they are structured as post-op support groups, the sessions are also open to people just considering surgery. So there are always people at the sessions who don’t feel you are speaking to them.”
Another limitation is that postoperative education is voluntary. “You can tell patients before surgery that if they don’t comply with the program, they aren’t going into the OR [operating room]. But after surgery, we don’t have that leverage. You have to inspire them to come back,” Dr. Shikora said. “I wish the follow-up in our program was better than it actually is, to be honest. We have an 85% success rate with gastric bypass, which I define as patients losing half of their excess weight and not putting it back on. But we have many, many patients who, for whatever reason, don’t come back, or ultimately come back because they relapsed or didn’t do as well as they should have.”
The follow-up requirements of patients undergoing bariatric procedures are too medically necessary to be handled lackadaisically, Dr. Shikora argued. “With the gastric bypass crowd, the things that are important to them are hair loss and vitamin intake,” Dr. Shikora said. “Then beyond the first year you are dealing with increased appetite and the ability to put some weight on. With the band, you are dealing with much slower weight loss than they might expect, and there is a much higher degree of compliance necessary to achieve it. They don’t always do that.”
Indeed, initially the Tufts team set up its gastric-band readjustment schedules on a once-a-month basis like most programs. “But we found that there were patients who weren’t coming in,” he said. “And sometimes we’d find that they would come in and not need anything done, and we wondered if patients felt that was a wasted visit. We went so far as to have an almost ‘open door’ policy, so patients could come in as frequently as they wanted and every Friday we would do band fills. But that didn’t help. So now we’re trying to just make people understand that during the first couple of months after the procedure they should come in every couple of weeks.”
Considering how common serious adverse effects like regurgitation are in the patient population, banding patients were naturally expected by the Tufts team to be motivated to schedule regular follow-ups. “You’d think so,” Dr. Shikora said. “It’s the same thing you see with patients taking blood pressure medication. Having high blood pressure doesn’t make you feel bad, but sometimes the medication does. It’s not enough for us to just offer a program. Getting patients back here physically is half the battle. There is a drop-off in each year after surgery. A lot of patients do come back in the first year because they are motivated. But as time goes by, more and more drop out.”
Meeting Patient Needs
Surgeons answering the Harris survey estimated that roughly one-third of their patients was not adequately compliant with follow-up. For its part, Tufts is reassessing its much-lauded aftercare program in order to catch more problems earlier. One of the ideas being considered is to emphasize the metabolic testing component of the follow-up visits. With this new emphasis, it is hoped that the medical necessity of monitoring the physical changes in the postsurgical period will be clearer to patients.
“We’d call them metabolic follow-ups,” Dr. Shikora said. “We would be looking at the patient with a more critical eye, looking at any ongoing issues that pose a risk of relapse. These consultations would be looking for changes in behavior, if there is anything stressful happening to them, as well as changes in diet and other issues that if not acted upon could lead to failure. Progress is not just a matter of weight loss. We should be able to show them that things are improving: ‘look here, your diabetes is fading away.’ I’m being vague,” he added, “because I’m not really sure that there is a right answer yet. Although our program is generally successful, we will continue evaluating what we do to make it better.”
Although modern bariatric surgical techniques have been demonstrated to be effective in eliminating weight from the body, a key aspect of successful aftercare is addressing what might be weighing on the patient’s mind. The postsurgical period can be fraught with challenges ranging from serious psychosocial issues to relatively benign jitters.
Patients know they need to get exercise, for example, but many find the fitness culture a bit alien. “They’re intimidated by the equipment, even the sorts of things you can use at home,” said Alan Wittgrove, MD, the medical director of Wittgrove Bariatric Center in La Jolla, Calif. Dr. Wittgrove performed the first laparoscopic gastric bypass procedure in 1993. “Our exercise coordinator tries to work individual by individual to find out what their roadblocks are. Likewise, in the preoperative period the psychologist assesses patients to identify red flags that might mean the patient won’t do as well. We have a support group just for emotional issues.”
The Perils of Success
The dramatic weight loss seen postoperatively also can herald new problems that an effective aftercare program must address. For some, fears of regaining weight can become phobias. Reduced stomach capacity means that a patient’s days of overeating are at an end, but this carries life-altering ramifications in itself. Among many obese people, overeating is a singular pleasure or a way to cope with stress. Filling that emotional void by other means can lead to new unhealthy behaviors. “Although it is often dramatically overstated, there is an issue known as addiction transference—more wine or cigarettes in place of food,” Dr. Shikora said.
Surgery can also have a profound effect on a patient’s home life that can be largely invisible to clinicians despite its negative effect on outcomes, said Tracy Martinez, RN, the program director of the Wittgrove Center’s aftercare program. “Surgery alters patients’ relationships,” she said. “We find that good relationships tend to get better, but stressed relationships can get more stressed. Sometimes patients are mistreated. Their perceived self-worth is very low. So they take abuse, either physical or verbal, and experience neglect from their partner. Then, after surgery, they are feeling healthier and more productive, and they don’t want to put up with that anymore. Relationship challenges are something that we can talk to patients about beforehand.”
Obesity is a chronic disease that likely placed limits on the patient’s life well before they presented for surgery. The effects are not as easy to shake as the excess pounds postoperatively. “One of the things you see is the patient who has been morbidly obese since they were an adolescent, who never went through normal dating and socialization at a young age. Now they are 26 or 28, more appealing to the opposite sex, and have been asked out on a date for the first time in their lives,” Ms. Martinez said. “Some of our female patients—79% of our patients are female—will look in the mirror and see somebody who is 290 lb when in fact they weigh 187. So we encourage them to take a picture of themselves once a month, because when you see a picture, the changes start connecting with the brain.”
The Wittgrove Center runs two monthly support groups. One is a multidisciplinary discussion session with different guest speakers covering specific topics. About 50 patients attend. “Sometimes we’ll have a plastic surgeon talking about reconstructive surgery, or someone speaking on women’s health, stress management or surviving the holidays,” Ms. Martinez explained. Other patients benefit from a second monthly group session run by the program psychologist, where there might be seven or eight people. “These are the people who are struggling,” Ms. Martinez said. “I purposely do not go to that session and neither does Dr. Wittgrove. For one, psychological matters lie outside the scope of our expertise, and this also allows the patient privacy to discuss personal problems. It might be a sexual matter, or a patient may feel that they have somehow disappointed Dr. Wittgrove. That’s not uncommon.”
Penny Wise, Pound Foolish?
The cost of running these aftercare services is borne by the facility, rather than by patients—a common arrangement. Although clinicians and patients alike swear by them, insurance companies have yet to show similar enthusiasm.
“These procedures will not be as effective without an aftercare program,” said Dr. Wittgrove. “It’s very expensive to try to do all this and still eke out a living. The insurance companies will allow a patient to have the surgery because it pays for itself in a few years because of all the comorbid conditions it treats, such as diabetes and hypertension. But they won’t cover follow-up.”
Insurers’ reluctance to pay for aftercare is perhaps most pernicious in the case of gastric banding, where the need for postoperative adjustments is common and may be long-term. “Absolutely, it is counterintuitive,” Dr. Wittgrove said. “The band doesn’t work if you don’t have fills, but they won’t pay for them.”
Dr. Shikora echoes the necessity of viewing bariatric surgery as a long-term commitment by all involved parties. “This is not like taking out a gallbladder that doesn’t grow back so you cure the patient,” he said. “Obesity does not get better because we staple or band the stomach. Surgery is only a tool—and it’s not a perfect tool. Patients can still fail. You have to stay on your guard forever so you don’t relapse. It’s a lifelong commitment.”
The problem in obtaining insurance coverage is that there is scant evidence to show that surgical outcomes are significantly impaired if patients do not have access to aftercare, even if the experience of patients points strongly in that direction. The Harris poll, for example, found that bariatric surgical patients who enrolled in aftercare programs lost more weight and found compliance easier. Among gastric banding patients in particular, the more elaborate the aftercare program, the more weight they lost.
“We know that part of favorable outcomes is secondary to having effective follow-up,” Dr. Wittgrove said. “We have data from places that have good programs. But nobody performing bariatric surgery without an aftercare program is tracking down their patients three years later to see how they’re doing. You’d be amazed how common it is to have zero follow-up. An HMO [health maintenance organization] will farm out the surgery and then the patient is turned back over to their HMO and disappears. By not paying for it, the system encourages not following-up. We don’t charge our patients for the nonclinical side of aftercare because we want to have follow-up to improve our patients’ chances. With transplantation and cardiac surgery, follow-up is a given,” he said. “They have multidisciplinary programs that provide perpetual care.”
To further this goal, Dr. Wittgrove’s office sends patients’ primary care physicians all pertinent records to include them as part of the care team—something that is necessary for maintaining aftercare for out-of-state patients.
“Primary care providers by themselves are unlikely to have the time or the experience to offer the follow-up patients need,” Dr. Still said. “I would recommend that surgeons who don’t have access to a full-fledged aftercare program take advantage of commercially available support groups, such as Weight Watchers. Patients find that online chatrooms can also offer useful support. Other Web sites provide a means for the patient to assist with electronic medical records.”
One size may not fit all, but effective aftercare suits all patients. “Nobody has to imitate my program,” Dr. Wittgrove said. “But you do have to develop a program—one you can run without bankrupting your practice and also represents your patient population. I think a surgeon should not be doing bariatric surgery without an aftercare program. An aftercare program should be a multidisciplinary program, with involvement by a behavioral therapist and dieticians, and it should be offered to patients on a regular basis forever. Anything less than that is unacceptable.”
Bariatric Surgery Aftercare: Sabrina’s Story
In Fall 2005, Sabrina C’s physician was recommending bariatric surgery. But her doctor wasn’t recommending it to her. He was recommending it to her father.
“My father and I have the same doctor,” says the 30-year-old Web designer from Franklin, Mass. “Dad wasn’t ready for it, but he thought I was and he told me about it.”
Her father’s own reluctance to undergo surgery is not uncommon. At many bariatric surgical practices, female patients outnumber males four to one. “What we see is men seek bariatric surgery when their doctor has told them that they need to lose weight or they’re not going to see their kids grow up,” notes Tracy Martinez, RN, aftercare program director at Wittgrove Bariatric Center in La Jolla, Calif. “Women come in much sooner. They can’t play with their kids, or can’t bear a child because of their abnormal hormone levels. It’s a different motivation entirely.”
Sabrina became motivated. When she attended her first educational session at Tufts Medical Center in Boston, the 5’11” Sabrina weighed 375 lb. Wary of invasive surgery, she was considering laparoscopic gastric banding. “But I just knew I could so out-eat a gastric band that it wasn’t worth it,” she says. “I went home and tried dieting again.”
She put on more weight.
A month later, Sabrina went back to learn about gastric bypass surgery and was enrolled in Tuft’s six-week preoperative program in November 2005. “My mother went to the pre-op consultations with me. She wasn’t on board with me getting surgery.”
Sabrina’s success with the preoperative weight-loss regimen initially did not assuage these maternal concerns. “My mother was asking me, ‘You lost 37 lb, so why can’t you lose the next 100?’ But losing the weight was a real struggle. I would not eat, and then I would eat everything.”
By the time Sabrina underwent laparoscopic gastric bypass in April 2006, mother and daughter were equally enthusiastic. “In pre-op class, we discussed how to eat the way we would after surgery. We did chewing exercises. We talked about how the surgery was going to change us. Mom was amazed.” Sabrina says. “They didn’t treat me like I was patient number 952. The nutritionist I was seeing back then is no longer at Tufts. She moved to Maryland. But I still keep in touch with her.”
After surgery, Sabrina found the behavioral therapy offered at Tufts to be the most helpful. “It keeps people honest,” she says. “When you go to group, you want to see the friends you have made and not have gained 5 lb.”
Now Sabrina finds she is mentoring fellow patients at earlier stages of the process in group sessions and at a Yahoo chatroom called Small Bites. “I try to let others know how I did it,” Sabrina says.
Besides providing emotional support, Sabrina finds that her online community allows patients to keep each other abreast of what to expect after surgery, including potentially serious complications. “Someone might post ‘Ooh, my right side really hurts. Did this happen to anyone else?’ and seven people will respond that that is where the camera goes during the procedure, so that’s why it hurts,” she reveals. “When you lose weight rapidly, it causes your gallbladder to produce extra stones. Many of us have had our gallbladders out. So when somebody mentions a strange pain, we’re telling them to get it checked out.”
Another online service Sabrina uses, Fitday.com, provides her with an interactive diet diary that tracks the calories, fat and protein she’s getting. “We need to eat about 70 g of protein a day. That’s a lot,” she says. “I’m not a huge protein drink fan—I have this thing about texture. I also don’t like chicken; it’s a head thing. I try to eat things like hummus and fish.”
This informal connection with other patients is important for “keeping it real,” she says. “For me, surgeons can tell me something medical, and it’s like ‘whatever.’ Being able to talk to people my own age who are also mothers of two really helps me.”
The world outside aftercare is sometimes less supportive. “I lost 165 lb the first year, but I didn’t tell people why,” Sabrina recalls. “You get a lot of negative input—‘why are you getting surgery?’ A lot of people at work who are bigger had that response. I opened up to them first because I thought I’d be lying to them if I let them think I was just dieting,” she says. “But one person said how they were just waiting for me to regain weight. It’s like they don’t want a person to join the other side.”
Sabrina’s weight currently fluctuates between 204 and 210 lb. “I’m trying to be realistic. I don’t ever want to get over 220, but if I could get down to 199 I’d be stoked.”
Sabrina’s last insurance provider refused to pay for the postoperative behavioral therapy offered by Tufts, and she had to stop attending when money got tight. (The larger group sessions she still attends are free of charge.) “They gave me the runaround because it was a ‘mental health issue,’ ” she says. Sabrina’s new provider agreed to cover the sessions, and she looks forward to attending them again.
“I’ve been given a second chance,” she says. “I don’t want to make the same mistakes I made before. I know part of my situation is genetic, but some of it is … well, I like chocolate.”
Sabrina is unwavering in her conviction that the support she received postoperatively made her surgery worthwhile. “I have two sisters-in-law who underwent gastric bypass at a different hospital. They’ve never seen a doctor again,” she says. “When I told them everything I had to go through, they thought I was crazy for doing it! Of course they lost weight in the beginning, but one of them has gained it all back, if not more,” she adds. “I really think it’s because there was no program to prepare her for what was going to happen, and there was nobody there for her afterward. I think she thought that surgery was going to be a fix-all.”
The original article appeared in General Surgery News
ISSUE: DECEMBER 2008 | VOLUME: 35:12