Exploring Patients’ Decision-Making Process in Choosing to Undergo Band or Bypass

An Interview with Drs. Christina C. Wee, Caroline Apovian, Daniel B. Jones, and George L. Blackburn

Bariatric Times. 2013;10(12):14–15.

Christina C. Wee, MD, MPH
Dr. Wee is Associate Professor of Medicine, Harvard Medical School, Associate Section Chief for Research and Director of the Obesity and Health Behaviors Programs in the Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Caroline Apovian, MD, FACP, FACN
Dr. Apovian is Professor of Medicine and Pediatrics, Boston University School of Medicine; Director, Nutrition and Weight Management, Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center, Boston, Massachusetts.

Daniel B. Jones, MD, MS, FACS
Dr. Jones is Professor of Surgery, Harvard Medical School, Vice Chair of Surgery, Office of Technology and Innovation, Chief, Minimally Invasive Surgical Services, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

George L. Blackburn, MD, PhD
Dr. Blackburn is S. Daniel Abraham Professor of Nutrition, Associate Director, Division of Nutrition Harvard Medical School Director, Center for the Study of Nutrition Medicine, Department of Surgery, Beth Israel Deaconess Medial Center, Boston, Massachusetts.

In this interview, Drs. Wee, Apovian, Jones, and Blackburn discuss patient factors associated with undergoing laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass for weight loss. The full article with results was published in the Journal of the American College of Surgeons.[1] Authors Caroline M. Apovian, MD; Karen W. Huskey, MPH; Sarah Chiodi, MPH; Donald T. Hess, MD, FACS; Benjamin E. Schneider, MD, FACS; George L. Blackburn, MD, PhD, FACS; Daniel B. Jones, MD, MS, FACS; and Christina C. Wee, MD, MPH, recruited and interviewed patients seeking bariatric surgery from two academic centers in Boston and conducted multivariable analyses to identify patient perceptions and clinical and behavioral characteristics that correlated with undergoing either procedure. They concluded that patients’ diabetes status, quality of life, eating behavior, ideal weight loss, and willingness to assume mortality risk to lose weight were associated with whether patients proceeded with gastric banding as opposed to gastric bypass and that other clinical factors were less important.

BT: How did the idea for this study come about?

Dr. Wee: This study was part of a larger project to understand patient preferences for undergoing bariatric surgery and the potential barriers that patients faced. This idea for the broader study stemmed from the observation that many patients who are medically eligible for surgery do not actually undergo bariatric surgery. The current paper focuses on one expect of the decision-making process.

BT: Why were Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding the only procedures included?

Dr. Wee: At the time that we were recruiting for the study, 2008 through 2011, Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LABG) were the two most common procedures being performed.

BT: Is there talk of performing another study to include all weight loss surgery options (e.g., sleeve gastrectomy, biliopancreatic diversion with duodenal switch)?

Dr. Wee: No. Sleeve gastrectomy has overtaken gastric banding in popularity, but the biliopancreatic diversion (BPD) with duodenal switch (DS) is not performed much any more.

BT: How educated on weight loss surgery options were the study patients? Was there an educational component to this study where patients were given information and statistics on each procedure?

Dr. Wee: By the time of the interview, patients had already received some education about the risks and benefits. Patients were quoted weight losses for the short-term, ranging from 30 to 80 percent of their excess weight depending on procedures being discussed (i.e., 60–80% EWL for gastric bypass and 30–70% for gastric banding) at the recruitment practices, and while there was discussion about weight regain and recidivism, patients were not explicitly given weight loss estimates for the longer term.

Dr. Jones: Patients receive a lot of education on the procedures. In addition to their own research, all of our patients attended at least two 2-hour information sessions, met with dietitians, nurses, social workers, and bariatricians, and took a written test.

BT: In your experience, how much does a patient’s procedure preference factor into the procedure they ultimately undergo? Is it a joint decision made by both patient and surgeon? For instance, if a patient preferred to undergo LAGB, but you believed that they would do better with RYGB, do you counsel them?

Dr. Wee: This is typically a joint decision. As a primary care physician, I do often express my preference for patients based on their overall profile.

Dr. Jones: Every program and surgeon has a different philosophy. Our program offers band, bypass, and sleeve, and mentions DS as an option they can get elsewhere. In general, we try not to direct patients, but inform them of the risks and benefits of each procedure. For the most part, patients decide what operation is right for them. Insurance companies, however, may restrict options by coverage.

BT: How important is the conversation of preference of procedure and reasons for wanting to undergo surgery?

Dr. Wee: I think this conversation is extremely important. Ultimately, the patients are the ones who reap the benefits or suffer the adverse consequences of the procedure, so in my opinion, their preferences need to be heavily weighted as long as it is an informed and not a misinformed preference.

Dr. Jones: When a patient tells me they want operation “A,” I ask them to explain why and give reasons for why they do not want a different operation. Discussion is usually about risk, dietary restrictions, reversibilitiy, weight loss, dumping, and foreign body.

BT: What is the impact/scientific significance of the study?

Dr. Blackburn: Few data are available on why potential candidates for weight loss surgery choose one procedure over another, or decide against it. Even less is known about its effectiveness in racially diverse populations in the United States, and the value they derive from it.

The longitudinal cohort Assessment of Bariatric Surgery (ABS) study is tracking those who are undergoing evaluation for weight loss surgery. Its aims are to understand individual’s perceptions and decision-making processes, and evaluate the long-term effects of surgery on health and quality of life.

Before the ABS study, we knew little about the value patients put on weight loss and their willingness to accept serious risk in pursuit of it. Clinicians and payers have traditionally focused on medical and economic benefits, without taking into account what patients want and expect from bariatric surgery. For example, they may be influenced by obesity’s profound physical and psychosocial consequences, or expect to lose more weight than can be sustained my most people who undergo surgery.

Risk-to-benefit ratios differ widely between procedures, and unrealistic expectations may lead patients to accept more than reasonable surgical risk, beyond that needed for important improvements in comorbidities and health.

Patients seek weight loss surgery for a variety of reasons. The more we learn about their perceptions, preferences, and expectations, the better able we are to target education and help them make informed decisions. Physicians with greater insight are also more likely to select appropriate candidates.

Future studies should evaluate longer-term clinical outcomes and patient satisfaction, attitudes, and actions. The need to identify the factors that drive health value derived by weight loss surgery patients is a high priority.

BT: What have you learned from this study?

Dr. Apovian: What I learned from being a part of the team conducting this study and its analysis is that the reasons patients choose one procedure over another are more complicated than simply weighing risk over benefit. In addition, there are several different types of procedures and, in the future, there will be more procedures and more devices to choose from. Therefore, a clear understanding of the procedure, its mechanism of action, and the postoperative lifestyle change for each procedure need to be explained to the patient in detail and understood completely before a rationale decision can be made.

What we have learned from this study is that in addition to BMI, comorbidities, and quality of life, an additional factor that influences patient decision-making is dysregulated eating and possibly emotional- and stress-related factors leading to dysregulated eating. We need to continue to explore decision -making regarding bariatric surgery procedures and take into account not just genetics and BMI, but also socioeconomic, cultural, and emotional factors that play a role in this process.

It is important to ensure that patients understand each procedure because, in the future, there may be three or more types of surgical and endoscopic procedures available to help people lose weight. It is in the best interest of the patient to first develop an understanding of the procedures and then find a surgeon with expertise in the particular procedure. It may be unlikely that a particular surgeon would specialize in all the procedures given the rapid research and technology moving forward, bringing more options to the table. This paper sheds light on just a few of the factors that need to be addressed regarding patient characteristics. A way of addressing this is to create an algorithm for characteristics of typical patients who would benefit most from each procedure. That way, providers could more quickly assess the patient in front of them and help suggest the best procedure for that patient.

BT: Were you surprised at the results of this study, or are they what you expected?

Dr. Wee: I was surprised that patients who had less control over their eating would choose the less effective surgery, and also how little impact comorbidities other than diabetes have on the choice of procedure.

BT: The study found that one major factor influencing a patient’s decision to undergo one procedure over another was diabetes status. Is this an indication that we should be considering more than BMI when recommending and approving patients for surgery? For instance, LAGB’s indications are based on BMI and the presence of comorbidities. Should these indications, perhaps, focus more on severity of comorbidities?

Dr. Wee: The guidelines are providing the minimum criteria for whom should be considered for bariatric surgery. It is an expectation that clinicians and patients already consider factors, such as severity of comorbidities, when making the decision to undergo surgery. While the benefits are greater when the comorbidities are more severe, the risk of the procedures are also greater in sicker patients. Ultimately, this is nuanced decision and no guideline can take the place of understanding patients’ preferences and their predilection to assume risk.

BT: How can surgeons or anyone working with weight loss surgery candidates learn from these findings?

Dr. Wee: It is important to consider not just the objective clinical markers, but also the more subjective factors, such as the quality of life of the patient and his or her current behaviors and predilections, which one can only understand by talking to the patient.

BT: What do these results contribute to the bariatric surgery body of literature?

Dr. Wee: The answer to this question can be found in the final paragraph of the J Am Coll Surg article:[1]
“In conclusion, our study demonstrates that BMI plays a lesser role than patient preferences and behavioral characteristics in determining whether patients undergo gastric banding or Roux-en-Y gastric bypass. The factors that seem to have the greatest influence on decision making are the presence of type 2 diabetes, how much weight the patient desires to lose, patients’ predilection to assume mortality risk to achieve their ideal weight, and the presence of uncontrolled eating. Future studies should confirm our findings in other bariatric populations and examine the effect of different bariatric procedures on eating behaviors postsurgery.”

BT: Thank you all for taking the time to speak with us about this important study.

References
1.    Apovian CM, Huskey KW, Chiodi S, Hess DT, Schneider BE, Blackburn GL, Jones DB, Wee CC. Patient factors associated with undergoing laparoscopic adjustable gastric banding vs Roux-en-Y gastric bypass for weight loss. J Am Coll Surg. 2013;217(6):1118–1125. Epub 2013 Sep 29.

Funding: No funding was provided in the preparation of this interview.

Financial disclosures: The authors report no conflicts of interest relevant to the content of this interview. 

Category: Interviews, Past Articles