Factors Affecting Patient Adherence to Multivitamin Intake After Bariatric Surgery: Thematic Analysis of Qualitative Data From a Multicenter Study.

Introduction Adherence to daily intake of multivitamin supplementation (MVS) is a major challenge after bariatric surgery (BS). The aim of this study was to identify insights into patients' beliefs and experiences on adherence to MVS intake. Methods A thematic analysis of qualitative data from four high-volume bariatric centers in the Netherlands was conducted. A series of texts from the open-ended question of 1,246 patients were thematically analyzed for common or overarching themes, ideas, and patterns. Results Five key themes emerged regarding participants' suggestions on adherence to daily MVS intake: "gastrointestinal side effects to MVS intake" (n = 850, 68.2%), "negative features of MVS" (n = 296, 23.8%), "satisfaction with advice on MVS" (n = 272, 21.8%), "dissatisfaction with service provision" (n = 160, 12.8%), and "costs" (n = 93, 7.5%). Most problems were experienced when using specialized weight loss surgery (WLS) MVS. These supplements may cause gastrointestinal side effects, and costs are too high. After bariatric surgery, numerous patients strongly felt that information provision was poor in several aspects, and the aftercare pathway process did not provide sufficient support. Conclusion This study found five major themes involved in patient adherence to multivitamin intake after BS: gastrointestinal side effects to MVS intake, negative features of MVS, satisfaction with advice on MVS, dissatisfaction with service provision, and costs of specialized MVS. Challenges lie in stronger education for both patients and healthcare professionals. More personalized care could probably increase patient satisfaction, and MVS companies should look at further optimizing supplements for better tolerability and reducing costs.

Factors Affecting Patient Adherence to Multivitamin Intake After Bariatric Surgery: a Multicentre Survey Study from the Patient's Perspective.

PURPOSE: Lifelong multivitamin supplementation is recommended to prevent nutritional deficiencies. Despite this advice, deficiencies are common which may be due to poor adherence to MVS intake. The aim of this study was to identify which factors affect patient adherence to Multivitamin Supplement (MVS) intake after bariatric surgery. MATERIALS AND METHODS: A 42-item questionnaire was sent to 15,424 patients from four Dutch bariatric center. In total, 4975 patients wanted to participate of which 361 patients were excluded. A total of 4614 patients were included, and MVS users (n=4274, 92.6%) were compared to non-users (n=340, 7.4%). Most patients underwent Roux-en-Y gastric bypass (64.3%) or sleeve gastrectomy (32.3%). RESULTS: Seven hundred and ten patients (15.4%) reported inconsistent MVS use and 340 patients (7.4%) did not use any MVS at all. For inconsistent MVS users, most reported reasons included forgetting daily intake (68.3%), gastro-intestinal side effects (25.6%) and unpleasant taste or smell (22.7%), whereas for non-users gastro-intestinal side effects (58.5%), high costs (13.5%) and the absence of vitamin deficiencies (20.9%) were most frequently reported. Overall, 28.5% were dissatisfied about instructions on MVS use, attention paid to MVS use during medical consultation and the extent to which personal preferences were taken into account. CONCLUSION: The attitude of bariatric patients towards MVS use is predominantly negative. It is important to provide accurate information on different options for MVS intake and collect information about patient's personal preferences when prescribing supplements. Improving adherence to MVS intake is challenging and requires implementation of a shared decision-making process, further optimization of MVS formulas and exploring options for reimbursement.

Nutrient deficiencies before and after sleeve gastrectomy.

BACKGROUND: Obesity is associated with nutritional deficiencies. Bariatric surgery could worsen these deficiencies. Fewer nutritional deficiencies would be seen after sleeve gastrectomy compared to the Roux-en-Y gastric bypass, but sleeve gastrectomy would also cause further deterioration of the deficiencies. The aim of this study was to determine the amount of pre-operative nutrient deficiencies in sleeve gastrectomy patients and assess the evolution of the nutritional status during the first post-operative year. METHODS: Four hundred seven sleeve gastrectomy patients were assigned to a standardized follow-up program. Data of interest were weight loss, pre-operative nutrient status and evolution of nutrient deficiencies during the first post-operative year. Deficiencies were supplemented when found. RESULTS: Two hundred patients completed blood withdrawal pre-operatively and in the first post-operative year. pre-operatively, 5 % of the patients were anemic, 7 % had low serum ferritin and 24 % had low folic acid. Hypovitaminosis D was present in 81 %. Vitamin A had excessive levels in 72 %. One year post-operatively, mean excess weight loss was 70 %. Anemia was found in 6 %. Low-ferritin levels were found in 8 % of the patients. Folate deficiency decreased significantly and hypovitaminosis D was still found in 36 %. CONCLUSIONS: In this study, a considerable amount of patients suffered from a deficient micronutrient status pre-operatively. One year after surgery, micronutrient deficiencies persisted or were found de novo in a considerable amount of patients, despite significant weight loss and supplementation. Significant reductions were seen only for folate and vitamin D.

Outcome of sleeve gastrectomy as a primary bariatric procedure.

BACKGROUND: Sleeve gastrectomy is being performed increasingly in Europe. Data on long-term outcome would be helpful in defining the role of sleeve gastrectomy. The aim of this study was to evaluate the outcome of sleeve gastrectomy as a primary bariatric procedure. METHODS: Medical charts of all patients who underwent a primary sleeve gastrectomy at the authors' institution between August 2006 and December 2012 were reviewed retrospectively using a prospective online data registry. For evolution of weight loss and co-morbidity, only patients with follow-up of at least 1 year were included. A subgroup analysis was done to compare patients with an intended stand-alone procedure and those with an intended two-stage procedure. RESULTS: A total of 1041 primary sleeve gastrectomies were performed in the study period. Median duration of surgery was 47 min, and median hospital stay was 2 days. Intra-abdominal bleeding occurred in 27 patients (2·6 per cent) and staple-line leakage in 24 (2.3 per cent). Some 866 patients had at least 1 year of follow-up. Mean excess weight loss was 68.4 per cent after 1 year (P < 0.001) and 67.4 per cent after 2 years. Smaller groups of patients achieved a mean excess weight loss of 69.3 per cent (163 patients), 70.5 per cent (62) and 58.3 per cent (19) after 3, 4 and 5 years respectively. No difference in postoperative complications was found between the subgroups. Seventy-one (8.2 per cent) of 866 patients had a revision of the sleeve gastrectomy; reflux or dysphagia was the indication in 34 (48 per cent) of these patients. CONCLUSION: Sleeve gastrectomy is a safe and effective bariatric procedure. Maximum weight loss was achieved after 4 years. Long-term results regarding weight loss and co-morbidities were satisfactory.

Sleeve gastrectomy in older obese patients.

BACKGROUND: With global aging, obesity will increasingly affect the older population with higher risks of morbidity and mortality, yet full consensus has been obtained for the role of sleeve gastrectomy (SG) in the older obese. OBJECTIVE: The aim of this study is to report the outcomes of SG in the older obese. SETTING: Bariatric department, large teaching hospital, The Netherlands. METHODS: Between August 2006 and December 2011, 135 patients aged 55 years or older underwent SG. Outcomes in terms of perioperative complications, weight loss, remission of comorbidities, and revision were extracted from our prospectively held database. A subanalysis was done comparing three age groups: 55-59 years, 60-64 years, and 65 years and older. RESULTS: During mean follow-up of 14.6 months, short-term mortality was 0 %. The 30-day complication rate was 11.1 %, without significant differences between age groups. Late complications occurred in 4.4 %. In 14 patients, revisions were performed because of development of reflux disease or dysphagia. Significant reduction of comorbidities was found in all age groups, except for sleep apnea. Among the total cohort, excellent weight loss was achieved during follow-up. CONCLUSIONS: Laparoscopic sleeve gastrectomy (LSG) as a primary treatment modality for the older morbidly obese is an effective and relatively safe procedure in terms of weight loss and remission of comorbidities with an acceptable low complication rate.

To Sleeve or NOT to Sleeve in Bariatric Surgery?

Morbid obesity has become a global epidemic during the 20th century. Until now bariatric surgery is the only effective treatment for this disease leading to sustained weight loss and improvement of comorbidities. The sleeve gastrectomy is becoming a promising alternative for the gold standard the gastric bypass and it is gaining popularity as a stand-alone procedure. The effect of the laparoscopic sleeve gastrectomy is based on a restrictive mechanism, but a hormonal effect also seems to play an important role. Similar results are achieved in terms of excess weight loss and resolution of comorbidities compared to the gastric bypass. Inadequate weight loss or weight regain can be treated by revisional surgery. Complication rates after LSG appear to be lower compared with gastric bypass. General guidelines recommend bariatric surgery between the age of 18 and 65. However bariatric surgery in the elderly seems safe with respect to weight loss and resolution of comorbidities. At the same time weight loss surgery is more often performed in adolescent patients failing weight loss attempts. Even though more studies are needed describing long-term effects, there is already enough evidence that this technique is an effective single procedure for a considerable proportion of obese patients.

Indications and short-term outcomes of revisional surgery after failed or complicated sleeve gastrectomy.

BACKGROUND: Sleeve gastrectomy (SG) is an upcoming primary treatment modality for morbid obesity. The aim of this study was to report the indications for and the outcomes of revisional surgery after SG. METHODS: Four hundred sixteen individuals underwent a SG between August 2006 and July 2010 with a minimum follow-up of 12 months. The patients that needed revision were identified from our prospective registry. Patients were subdivided in a first group undergoing revision as part of a two-step procedure, a second group with failure of a secondary SG, and a third group with failure of a primary SG. RESULTS: Twenty-three patients (5.5%) had an unplanned revision. Fourteen (3.4%) had a two-step procedure because of super obesity. A significant additional weight loss was achieved after revision; no complications occurred in this group. Five patients with failure of a secondary SG had no significant additional weight loss after revision. Reflux disease was cured. Eighteen patients in the third group showed significant additional weight loss and remission of diabetes and hypertension. Both reflux disease and dysphagia did not heal in all affected patients after revision. The early complication rate in the whole cohort was 23.4%; staple line leakage was 5.4%, and bleeding was 8.1%. Revision-related mortality was 0%. CONCLUSION: In a large series of sleeve gastrectomies, the unplanned revision rate was 5.5%. Revision of a sleeve gastrectomy is feasible in patients that do not achieve sufficient weight loss and in those patients developing complications after the initial sleeve gastrectomy.

In treatment of popliteal artery cystic adventitial disease, primary bypass graft not always first choice: two case reports and a review of the literature.

Cystic adventitial disease (CAD) is a rare cause of unilateral intermittent claudication of unknown aetiology, which is characterized by the formation of multiple mucin-filled cysts in the adventitial layer of the arterial wall resulting in obstruction to blood flow. The disease predominantly presents in young otherwise healthy males and most commonly affects the popliteal artery. CAD can be diagnosed by magnetic resonance imaging, computed tomographic angiography, or duplex ultrasound. Surgery is the primary mode of treatment, including exarterectomy, or replacement of the affected vascular segment by venous or synthetic interposition graft. Alternatively, the cysts can be drained by percutaneous ultrasound-guided needle aspiration. We provide a literature update on the aetiology and treatment of this uncommon condition and present two cases supporting patient tailored treatment without primary bypass grafting.