Objective: A growing number of patients require revisional procedure due to inadequate weight loss after primary bariatric surgery. Psychological factors and ...
BARIATRIC SURGICAL PRACTICE AND PATIENT CARE Volume 11, Number 4, 2016 ª Mary Ann Liebert, Inc. DOI: 10.1089/bari.2016.0028
Personality but not Eating Behavior Is Different in Revisional Bariatric Surgery Candidates Sylvain Iceta, MD, Msc,1–3 Emmanuel Disse, MD, PhD,3,4 Christian Gouillat, MD, PhD,3,5 Martine Laville, MD, PhD,3,4 Mohamed Saoud, MD, PhD,2 and Maud Robert, MD, PhD3,5
Objective: A growing number of patients require revisional procedure due to inadequate weight loss after primary bariatric surgery. Psychological factors and eating disorder are frequently blamed to be responsible for poor weight loss results after both primary and revisional surgery. The aim of our study was to determine whether preoperative psychological factors, personality disorders (PDs), and eating behaviors of revisional surgery candidates differ from primary bariatric surgery candidates. Methods: From November 2013 to June 2015, 122 candidates to bariatric surgery had an extensive psychological assessment and were included in the study. Patients were evaluated using different autoquestionnaires to assess psychological factors (13-item Short Beck Depression Inventory, Hospital Anxiety and Depression Scale, Cohen Perceived Stress Scale, Rathus Assertiveness Schedule, Rosenberg Self-Esteem Scale), eating behaviors (Bulimic Investigatory Test, Edinburgh, Yale Food Addiction Scale), and PD (SCID-II). Data were compared between both groups (primary vs. revisional procedures). Results: Eighty-nine (73%) subjects were candidates for primary bariatric surgery and 33 (27%) subjects for revisional procedure due to insufficient weight loss. Preoperative psychological factors and also eating behaviors did not differ significantly between primary and revisional surgery candidates. The borderline personality disorder (BDL PD) appeared to be twice as frequent in revisional surgery candidates (37% vs. 19%, respectively, p = 0.02). Discussion: Unexpectedly, we found that eating habits did not make the difference. Looking for BDL disorders and especially impulsivity personality traits seems relevant, as it appears to be a special trait of candidates for revisional procedure and could compromise further weight loss. Keywords: revisional bariatric surgery, eating behavior, obesity, psychological profile, impulsivity, borderline personality Indeed, in the last decades, we observed a growing number of patients who required a revisional procedure due to longterm complications, inadequate weight loss, or weight regain. The overall need for revisional bariatric procedures varies widely in the literature from 5% to 56% of the whole bariatric population.5 Insufficient weight loss or weight regain after a primary bariatric procedure has commonly been attributed to dietary noncompliance, eating disorders, or technical reasons such as a short length of the Roux limb or a large gastric pouch.6
besity is one of the main public health issues for developed countries. Several meta-analysis and randomized trials showed that bariatric surgery is more effective than nonsurgical therapy to achieve weight loss and remission of metabolic comorbidities.1–3 Nevertheless, long-term followup (>10 years) shows an important failure rate, which can reach 20.4% after Roux-en-Y gastric bypass (RYGB) in morbidly obese patients and 34.9% in superobese patients.4
1 Centre Re´fe´rent pour l’Anorexie et les Troubles du Comportement Alimentaire (CREATYON), Hospices Civils de Lyon, Bron Cedex, France. 2 INSERM U1028, CNRS UMR5292, University Lyon 1, Lyon Neuroscience Research Center, Psychiatric Disorders: from Resistance to Response Team, Centre Hospitalier Le Vinatier, France. 3 Centre Inte´gre´ de l’Obe´site´ Rhoˆne-Alpes; Fe´de´ration Hospitalo-Universitaire DO-iT, Department of Endocrinology and Nutrition, Groupement Hospitalier Sud, Hospices Civils de Lyon, Lyon, France. 4 Department of Endocrinology, Diabetology and Nutrition, Groupement Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre Be´nite, France. 5 Department of Digestive Surgery, Center of Bariatric Surgery, University Hospital Edouard Herriot, Hospices Civils de Lyon, Lyon cedex, France.
Case-matched analysis studies have also shown that revisional bariatric procedures are less effective than primary procedures to achieve substantial weight loss.7,8 Indeed, patients who require revisional bariatric surgery have failed to achieve adequate results in the past, and multifactorial issues contributing to their morbid obesity may persist. Eating habits are one of the most often blamed factors. It is the reason why revisional bariatric surgery requires careful and extensive patient selection if satisfactory results are to be achieved. In this way, a recent publication suggests that psychological factors should be first evaluated in the event of weight loss failure or weight regain after bariatric surgery before considering anatomic evaluation.9 However, to our knowledge, the comparison of psychological and behavioral profiles of candidates for revisional versus primary bariatric procedures has never been reported. The aim of the current study was to provide a descriptive analysis of presurgical psychological traits of revisional bariatric surgery candidates for insufficient weight loss, in comparison with primary bariatric surgery candidates.
ICETA ET AL.
IV, and two individuals proposed for research (depressive personality and passive-aggressive personality). Psychological factors.
Materials and Methods Population
From November 2013 to June 2015, 133 patients were evaluated before bariatric surgery by our dedicated university psychiatric team. Patients were evaluated for psychiatric, psychological, and behavioral traits with a structured interview and self-reported questionnaires, during two 1-hour sessions. The retrospective study was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and our organization policy on retrospective studies. Ethics committee approval was not required since patients’ identity is not disclosed and data were collected during and according to routine examination of the patients. Patients did not undergo any treatment or examination specifically devised to collect data used in this study, and for which their informed consent would have been required. Moreover, this study provides data that are part of a cohort study called Bariasurg, conducted in our tertiary care center, and registered in national clinical trial.gov under the number: NCT02857179. This study is also registered by the French supervisory authority for the protection of personal data under the number 15-107. Nine patients refused to complete the entire usual standardized evaluation and three were unable to because of illiteracy. Finally, 122 patients were included in the present study. Following the Multidisciplinary Case Conference (MCC), patients could be accepted or refused for bariatric surgery. For statistical analysis, the study population was divided into two groups: candidates for primary versus revisional bariatric procedures. Psychological factors, personality traits, and eating behaviors were assessed as follows: Psychological and behavioral assessment Personality disorders and traits. Structured Clinical Interview for DSM-IV, Axis II—SCID-II self-administered questionnaire10 was used. SCID-II is used for evaluating different personality disorders (PDs) described in the DSMIV. The SCID-II allows an assessment of the 10 PDs in DSM-
Several tools were used to assess
13-item Short Beck Depression Inventory—BDI11: The BDI is a self-report questionnaire to measure depression symptoms and their severity. Similar degrees of reliability have been found between the 13-item short and the complete form. The total score can go from 0 to 39 points. The BDI suggests four different cutoffs corresponding to different degrees of depression: 0–4 none or minimal; 5–7 mild; 8–15 moderate; and 16–39 severe depression. Hospital Anxiety and Depression Scale—HADS12: The HADS was designed to measure psychological distress in nonpsychiatric inpatient populations. It consists of 14 multiple-choice items divided into anxiety and depression subscales. The items are rated on a 4-point Likert scale scored from 0 to 3, resulting in a final score ranging from 0 to 21. A cutoff score of 8+ on each subscale is in favor of a possible depression or anxiety disorder. Cohen Perceived Stress Scale—PSS13: This scale measures the degree to which participants feel they are unable to control important aspects of their life, their confidence to handle personal problems, how often they are unable to cope with all the things they needed to do, and how often their difficulties were overwhelming over the month before the administration of the survey. The PSS is scored using a 5-point scale (0 = never, 1 = almost never, 2 = sometimes, 3 = fairly often, 4 = very often). Final scores are ranging from 0 to 56, and higher scores representing higher stress levels. Rathus Assertiveness Schedule—RAS14: The RAS consists of 30 items, including 16 inverted items, and is scored with a Likert scale. Each item is scored from -3 (very much true) to +3 (completely untrue). Respondents are requested to select the most applicable reaction in each situation. The scale ranges from -90 (least assertive) to +90 (most assertive). Rosenberg Self-Esteem Scale—RSES15: The scale consists of 10 items and is used to measure overall selfesteem. Participants are asked to indicate the extent to which each item describes them on a 4-point Likert scale ranging from 1 (not true of me) to 4 (very true of me). Scores range from 10 to 40, with higher composite scores indicating greater positive self-evaluation.
Two tests were used to assess eating
behaviors: Bulimic Investigatory Test, Edinburgh—BITE16: The BITE is a 33-item, self-report measure developed by Henderson and Freeman to assess the severity and frequency of binge eating symptoms. The severity of people’s binge eating behavior is assessed according to the symptom score from this scale, which ranges from 0 to 30. Higher scores mean higher binge eating symptoms. Yale Food Addiction Scale—YFAS17: The YFAS is a 25-item, self-report scale designed to measure the symptoms of food addiction that have occurred over the
EATING DISORDERS IN REVISIONAL SURGERY CANDIDATES
past 12 months. The authors developed this scale to identify people exhibiting signs of addiction regarding foods by extrapolating the DSM-IV-TR criteria for substance dependence. This scale includes mixed response categories (dichotomous or Likert type). Food addiction is diagnosed when three or more symptoms were present during the past 12 months. Statistical analysis
Statistical analysis was performed using the software R, version 3.1.318 and the Rcmdr package, 2.1-7 version.19 Data are presented as mean – standard deviation for continuous variables and value and frequency percentages for categorical variables. Continuous variables were compared using independent sample Student’s t-test and categorical variables were compared using a chi-square test (or Fisher’s exact test). Generalized linear models adjusted for gender, body mass index, and age compared the psychological scores in both groups of surgery (revisional vs. primary). All tests were two tailed and p < 0.05 was considered as statistically significant. Results
Table 1 shows the baseline characteristics of our study population. Among the 122 patients of the study population, 89 (73%) were candidates for a primary bariatric surgery and 33 (27%) were intended for revisional procedure. No difference was observed between both groups regarding age, gender, and anthropometric characteristics. Most patients (62/122, 51%) were candidates for laparoscopic gastric bypass procedures and the proportion of gastric bypass was significantly higher in the revisional surgery group (76% vs. 42%, p < 0.0001). All revisional procedures were indicated for insufficient weight loss or weight regain, after vertical banded gastroplasty (n = 11), laparoscopic adjustable gastric banding (n = 21), or sleeve gastrectomy (n = 1). The number of patients
who were contraindicated for bariatric surgery after the MCC was similar between the primary and revisional bariatric procedure groups (n = 24 vs. n = 14, p = 0.1529). Analysis of psychological factors and eating behaviors
Table 2 summarizes the results obtained regarding psychological traits and eating behaviors scales. Evaluations of mood and anxiety (BDI, HADS) were similar in primary and revisional bariatric surgery groups. Cohen Perceived Stress Scale (PPS), assertiveness (RAS), and self-esteem (RSES) did not differ between the two groups. In the same way, regarding eating behaviors, scores did not significantly differ. The rate of candidates with eating compulsions (BITE) or food addiction (YFAS) was similar between groups. Analysis of PD and traits
Data regarding PD are summarized in Table 3. In the primary procedure group, Obsessive-Compulsive (OBC) was the most frequent PD (41%). Avoidant (AVD, 28%), Depressive trait (DT, 21%), Borderline (BDL, 19%), Narcissistic (NAR, 14%), and Paranoid (12%) were also current PDs in this group. In the revisional procedure group, the distribution of PDs appeared to be different. BDL was the most prevalent PD (37%) followed by AVD (33%), OBC (26%), DT (15%), Paranoid (11%), and Narcissistic (11%). In the primary procedure group, 25 (27.9%) did not present any PD versus 11 (37.9%) in the revisional procedure group ( p = 0.38). The rate of BDL personality was significantly higher in the revisional group than in the primary bariatric procedure group (37% vs. 19%, respectively, p = 0.02, adjusted comparisons). Discussion
More and more bariatric procedures are done every year worldwide. Thus, the number of revisional procedures is
Table 1. Baseline Characteristics of the Study Population Population Age Height Weight BMI (kg/m2) Gender Female Male MCC (n = 120) Refused Accepted Planned surgery RYGB OLGB SG LAGB BPD/DS Awaiting surgery
Overall, n = 122
Primary surgery, n = 89
Revisional surgery, n = 33
43.7 – 12.19 1.65 – 0.09 122.4 – 25.08 44.5 – 7.10
42.8 – 12.49 1.66 – 0.09 123.6 – 0.09 44.7 – 7.17
46.1 – 11.18 1.64 – 0.08 118.9 – 0.08 44.2 – 7.03
0.17 0.18 0.33 0.77
89 (73) 33 (27)
63 (71) 26 (29)
26 (79) 7 (21)
39 (33) 81 (68)
25 (29) 62 (71)
14 (42) 19 (58)
44 18 39 5 2 14
23 14 37 5 0 10
21 4 2 0 2 4
(36) (15) (32) (4) (2) (11)
(26) (16) (42) (6) (0) (11)
(64) (12) (6) (0) (6) (12)