Study population
Data about non-responders was collected in our center from January 2016 till December 2018 and was retrospectively analyzed. Patients were included if they regained > 5% weight with respect to the lowest postoperative weight after RYGB or sleeve gastrectomy (SG) (nadir weight). At the moment of inclusion, > 5% regain was a commonly used cut-off point [6]. Patients with a previous history of BS such as laparoscopic adjustable gastric banding or Mason gastroplasty were included as well. Patients were excluded in case of a banded gastric bypass, one anastomosis gastric bypass (OAGB) or BPD. The primary BS could have taken place in our center or elsewhere. In our center, all patients were screened for primary BS by an MDT. On top of the regular treatment, a preoperative individual treatment was given if indicated by the MDT. Patients were categorized as primary non-response (1NR) if the patients’ excess weight loss (EWL) was less than 50% 12–24 months after primary surgery; patients were categorized as secondary non-response (2NR) if the EWL exceeded the 50% EWL threshold and a regain of > 5% was reported (nadir weight). All patients were discussed in an MDT meeting. The below section describes in more detail the process and approach taken before and during the MDT assessment.
Assessment before MDT meeting
Initial assessment of the patient was done by the bariatric surgeon. Hereafter, the patient was referred to the dietician and physical therapist for assessment of nutritional habits and physical activity. The dietician focused on food intake, food choices, satiety, hunger and signs of emotional eating; the physical therapist focused on an activity habits. If indicated, consultation of a medical psychologist was offered. Gastrointestinal contrast studies and laboratory tests were only performed on indication.
MDT meeting
Once the patient had a consultation with all members of the team individually, the treatment strategy was discussed in a joint MDT meeting (weekly occurrence). These meetings included at least one member of the following fields of expertise: bariatric surgeon, nurse practitioner, dietician, physical therapist and medical psychologist; the meeting was chaired by an experienced bariatric surgeon. Notably, under certain circumstances the patient was discussed in the MDT despite that he/she was not seen by all members of the team. For example, in case of persistent lack of attendance at one of the appointments.
MDT treatment strategy
After evaluation of the patient by the team, a decision was taken whether the patient needed further lifestyle and/or behavioral intervention, or whether the patient was qualified for revisional surgery. On behalf of this study, treatment options were divided into conservative and operative treatment (Fig. 1). A conservative treatment consisted of a nutritional and/or physical intervention, summarized as “lifestyle”. A nutritional intervention was indicated, for example, in case of unhealthy food choices and detrimental eating patterns. A physical intervention was indicated in case of a sedentary lifestyle with the goal to increase activity habits. A behavioral intervention was indicated when there were signs of emotional eating and problems in impulse control. If there were signs indicating an eating disorder, patients were referred to a psychiatric clinic specialized in treatment of such disorders. The indication for operative treatment was not based on the degree of non-response. The type of procedure depended on the index procedure, perioperative findings and expert opinion.
Study outcomes
Patient demographics evaluated in this study include gender, age, BMI, weight loss, previous surgical history and relevant comorbidities. Outcome parameters were MDT-based treatment categorized as conservative or operative, weight loss in a period of 24 months after MDT meeting and complications after revisional surgery. Weight loss was described as %EWL and was calculated as follows: (initial weight − final weight) / (initial weight − ideal body weight) × 100%. Ideal body weight is based on a BMI of 25 kg/m2. Initial body weight was the weight at the moment of screening. Optional, weight loss was also expressed in percent total weight loss (%TWL). %TWL was calculated as follows: ((preoperative weight – final weight) / preoperative weight)) × 100%. The percent of regain was calculated as percent kg gained after reaching lowest postoperative weight.
Statistical Analyses
Descriptive statistics were computed for demographic and medical characteristics. Quantitative data are presented as mean with standard deviation or median with interquartile range; categorical data are expressed in percentages. A paired t-test was performed for comparing pre- and posttreatment weight.