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Which operation?

Study identifies why patients choose banding or bypass

Older patients and those with higher quality of life scores and higher levels of uncontrolled eating were more likely to undergo gastric banding
Patients with type 2 diabetes, those who desired greater weight loss, and those who were willing to assume higher mortality risk to achieve their ideal weight were less likely to proceed with gastric banding

The main factors influencing why obese patients choose one type of weight loss operation over another are whether patients have type 2 diabetes, how much weight they want to lose, and their tolerance for surgical risk to achieve their ideal weight, according to study results published in the December issue of the Journal of the American College of Surgeons. Unlike findings from previous studies the patient's BMI or measure of obesity, does not play a significant role in the decision-making process.

"BMI alone was not an important determinant, suggesting that patients and their surgeons considered the whole patient and what was important to him or her," according to principal investigator, Dr Christine C Wee, associate professor of medicine at Beth Israel Deaconess Medical Center and Harvard Medical School, Boston. "This finding was reassuring."

The researchers at Beth Israel Deaconess, along with colleagues at Boston Medical Center and the Center for Survey Research at the University of Massachusetts, Boston, conducted the Assessment of Bariatric Surgery (ABS) study, to investigate the factors that might lead patients to proceed with one procedure over the other.

They recruited and interviewed patients seeking bariatric surgery from two academic centres in Boston (response rate 70%), and conducted multivariable analyses to identify patient perceptions and clinical and behavioural characteristics that correlated with undergoing gastric banding (n=239) vs. gastric bypass (n=297).

Study subjects answered interview questions about perceptions such as their ideal weight as well as about factors that motivated them to decide to have a bariatric surgical procedure. They also reported how willing they were to accept the risks to lose weight.

In addition, participants rated their quality of life and their level of emotional eating and uncontrolled eating. Information about patients' demographic characteristics, BMI, and obesity-related diseases came from their medical records. The researchers analysed the data by accounting for patients' demographics, such as age and BMI, as well as for patient preferences and eating behaviours.

Results

After adjustment for socio-demographic and clinical factors, they reported that older patients and those with higher quality of life scores and higher levels of uncontrolled eating were more likely to undergo gastric banding as opposed to gastric bypass. In contrast, patients with type 2 diabetes, those who desired greater weight loss, and those who were willing to assume higher mortality risk to achieve their ideal weight were less likely to proceed with gastric banding.

After initial adjustment, male sex and lower body mass index were associated with a likelihood of undergoing gastric banding; however, these factors were no longer significant after adjustment for other significant correlates such as patients' perceived ideal weight, predilection to assume risk to lose weight, and eating behaviour.

"It is important that patients talk to their surgeons about their values, weight loss goals and concerns, such as aversion to risk, the level that obesity has adversely affected their quality of life, and their potential challenges to losing weight, including their eating behaviours," added Wee. "This information will help the surgeon better guide the patient in choosing a weight loss operation."

"One unexpected and concerning finding was that patients who reported having more uncontrolled eating were actually more likely to undergo the less effective laparoscopic banding procedure than gastric bypass,” said Dr Caroline Apovian, professor of medicine and pediatrics at Boston University School of Medicine and director of Nutrition and Weight Management Center at Boston Medical Center,

She speculated that patients who have poorer control over their eating patterns choose the banding procedure because it is reversible, and gastric bypass typically is not.

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