In our study, almost 40% of the patients had a regular follow-up by the bariatric center multidisciplinary team. Our guideline-compliant follow-up rate therefore seems better than the national average. The provision of very detailed preoperative information and the strict organization of follow-up reminders may partly explain these results. If we add the GP follow-up rate, the monitoring of our patients appeared to be quite good.
Our results show that the patients who complied with long-term multidisciplinary follow-up experienced a weight loss that was consistent with that expected from SG (70% excess weight loss) (12–16). This was similar in patients followed in the bariatric center and those followed by their GP only. This could in part be explained by the fact that we organized several training sessions for the GPs in our area (although those sessions were not mandatory, there were subsidized and followed by most of them).
We nevertheless observed that almost one-third (29%) of the patients who underwent SG were non-compliant with follow-up appointments and did not even visit their GP. This proportion of patients lost to follow-up is still very worrying.
How could we limit attrition? (30).
During the preoperative assessment, several characteristics have been shown to predict poor long-term follow-up: young age (34, 35), male sex [33,34], smoking (34), spinsterhood (34), ethnicity (36), living a long way from the bariatric center (37, 38, 39), work and/or family problems (40), high BMI (37), high blood pressure (36), but not diabetes (32), obstructive sleep apnea (40), phobic anxiety or/and major depression (34, 35, 36, 41), impaired cognitive function (42), abnormal hunger, and binge eating (41) (but binge eating was not found to predict poor follow-up in the large prospective SOS study of Konttinen et al.) (43). Theese characteristics are very diverse, making any prognosis difficult, and ultimately, the easiest way to anticipate the quality of postoperative follow-up could simply be the regularity of preoperative bariatric clinic attendance (44).
In the early postoperative period, when attendance at clinics is usually good, missed appointments are associated with poorer results (36, 45, 46). Other negative factors include poor initial weight loss and the absence of correction, or the postoperative onset of eating disorders (23, 43).
Identifying these unfavorable factors during the preoperative assessments could help to target the patients with predicted poor postoperative follow-up, to address the risk with more frequent and/or adapted interventions, and to delay or perhaps contraindicate surgery. In the postoperative period, special efforts should be made to encourage these patients to comply with the follow-up program.
Retention is a real challenge and needs a lot of work and commitment from the bariatric team (31, 32, 34, 42, 47). Patients also must remain compliant and, depending on the healthcare organization, may incur significant expenses during follow-up (32). A better understanding of the patients’ expectations and needs could help to lessen attrition (47). Online software (48, 49) or telemedicine (50) could provide a solution to alleviate the burden of follow-up for the patients and the bariatric teams.
Finally, while regular follow-up enables the prevention and treatment of postoperative complications, it is obviously difficult to trace patients lost to follow-up and therefore to prove the usefulness of follow-up in obtaining a satisfactory weight loss and avoid complications. Study results are conflicting on this point (38, 45, 46, 51). A recent review (52) suggests that “long-term follow-up in a bariatric center of excellence may not be necessary in terms of weight loss and emphasizes that follow-up in its current form should be evaluated”. Although this was not an end-point of our study, our results suggest that follow-up by the patient’s GP could be as effective as a multidisciplinary follow-up.