Is it Time for a Paradigm Shift in Postoperative Follow-up?

| April 1, 2022 | 0 Comments

Jennifer C. Seger, MD, FOMA, is the Co-clinical Editor of Bariatric Times; Diplomate, American Board of Obesity Medicine; Medical Director, Bariatric Medical Institute of Texas, San Antonio, Texas.

Dear Readers,

Aristotle said, “We are what we repeatedly do. Excellence then is not an act, but a habit.” 

When I think about our patients and what sets apart the ones with long-term success from others, it all seems to revolve around the quality of follow-up care, support, and healthy habit changes. 

Beginning in 2007, the Surgical Review Corporation, which at the time accredited bariatric surgery programs, introduced the Bariatric Outcomes Longitudinal Database (BOLD) (precursor to the current Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program [MBSAQIP]), and an attempt was made to standardize postoperative follow-up care for bariatric surgical patients at one month, three months, six months, one year, and annually thereafter.

Many surgical practices still subscribe to this plan today since this was the way surgeons were taught, and it’s generally still accepted as the norm. This logic is not surprising; after all, surgeons are trained to operate, and they frequently get to cure diseases in the operating room (OR). Think about appendicitis or cholecystitis. These common ailments never return after the surgical intervention is performed. It’s a wonderful thing, the ability to completely cure a patient. 

Unfortunately, as we all know, obesity is a chronic disease that cannot be cured in the OR. Rather, surgeons use their skills to artfully create a tool for patients to implement as they treat their disease. This tool can be incredibly powerful when used appropriately and offers the best results to date of all other treatments available. 

The challenge is that many bariatric surgical practices are not designed to manage this chronic illness. If you think about it, right about the time when patients’ weight loss begins to slow, around 9 to 12 months out, is when typical programs decrease the frequency of patient visits. 

This is very reasonable from the surgeon perspective since complications are uncommon this far out, but, in my opinion, this is not in the best interest of the patient.  

One of the reasons for this deceleration in weight loss is likely due to rising ghrelin levels, which occurs around this same time frame postoperatively. Without good follow-up, patients can get discouraged, not realizing there are other helpful tools available to help them stay on track. 

It is mathematically impossible for surgeons to see everyone they have operated on year over year and continue to serve new patients in the clinic and OR. Many practices employ nurse practitioners/physician assistants (NPs/PAs) to help manage this load, but the fact remains that the percentage of patients following up after two years is poor. 

In the 2019 American Association of Clinical Endocrinology/American College of Endocrinology/The Obesity Society/American Society for Metabolic and Bariatric Surgery/Obesity Medical Association/American Society of Anesthesiology (AACE/ACE/TOS/ASMBS/OMA/ASA) clinical guidelines for bariatric procedures, there was a dismally low number of studies that included long-term data. Of the very few which did, there was an attrition rate of up to 89 percent.1 Wow! The data reviewed also showed that patients who follow up have better resolution of their weight-related comorbidities and typically achieve better overall weight loss. We are starting to see some major efforts to improve this in some centers, so kudos to those programs that are going the extra mile to keep patients connected and track their data.  

For all you surgeons out there: When was the last time you looked at your one-, two-, or five-year data? And I don’t just mean the percent of weight loss in patients you are seeing or the complications, but what percent of patients are you still seeing? In the utopian world, we would say we want ALL patients to adhere to long-term follow-up, but we also know that is unreasonable. What practices are in place to communicate the importance of long-term follow-up? If a patient fails to come back, what are you doing to recapture these patients?  

Nowadays, it’s easier than ever to communicate with patients. It’s important to not only send out regular reminders to patients who are due for their milestone visits, but also to let them know that it is 100 percent normal to have plateaus, and even some weight regain. Let them know your office is there to support them in getting past plateaus and minimize any weight regain. Let them know you’ve got their backs and are in it for the long haul. The messaging is critical and needs to be ongoing. 

Consider recording a short video message that can be sent to patients at various milestones. Offer opportunities to reconnect, reset, or get back on track. Consider telehealth visits. Destigmatize weight regain, which can keep patients away as they feel like they have let their surgeons down.

All patients deserve to have the best chance at long term successful treatment of their disease. After 12 years of work in a combined medical and surgical weight loss program, I can honestly say that patients are best served with a combined, comprehensive approach. With this, everyone wins…the surgeon, the nonsurgeon, and most importantly, the patient. 

In health,

Jenny Seger, MD, FOMA

References

  1. Mechanick JI, Apovian C, Brethauer S, et al. Clincal practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures–2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Surg Obes Relat Dis. 2020;16(2):175–247.  

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