Concurrent bariatric surgery and paraesophageal hernia repair: an analysis of the Metabolic and Bariatric Surgery Association Quality Improvement Program (MBSAQIP) database

BackgroundParaesophageal hernias (PEH) are common among patients with obesity. Most patients with severe obesity and a PEH will have the PEH repaired at the time of bariatric surgery. However, it is unclear whether there is increased risk when repairing a PEH during bariatric surgery.ObjectivesTo examine short-term outcomes of patients undergoing bariatric surgery with concurrent PEH repair versus bariatric surgery alone.SettingAccredited bariatric centers across the United States and Canada.MethodsPatients who underwent bariatric surgery with concurrent PEH repair were identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry. Using a propensity-score matching algorithm, these patients were matched with a cohort who underwent bariatric surgery only, controlling for age, sex, and other co-morbidities. Overall, 30-day incidence of major complications was the primary outcome. Secondary outcomes included mortality, length of operation, reoperations, and readmissions.ResultsThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database identified 222,320 bariatric procedures without PEH and 42,732 procedures with concurrent PEH repair. With one-to-one propensity score matching, 42,379 pairs were selected. Background characteristics, including age, sex, preoperative body mass index, and preoperative co-morbidities, did not differ statistically between matched cohorts. There was no statistically significant difference in 30-day major complications (3.5% versus 3.4%, P = .317).ConclusionsOur analysis indicates that the incidence of major complications for bariatric surgery with concurrent PEH repair is similar to bariatric surgery alone. Overall, this study demonstrates the safety of concurrent bariatric surgery and PEH repair.     

Evaluating the safety of bariatric surgery for weight loss in class I obesity: A propensity-matched analysis of North American data

BackgroundBariatric surgery is an effective treatment for severe obesity. However, there has been an evolving role for bariatric surgery as a primary treatment in the management of class I obesity.ObjectivesWe aimed to assess the safety of surgery by directly comparing surgical outcomes of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in class I obesity (body mass index [BMI] 30–35 kg/m²) with those with class II obesity (BMI 35–40 kg/m²) and higher (BMI >40 kg/m²) using an analysis of a large-scale matched-patient cohort analysis.SettingMetabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, United States and Canada.MethodsWe performed a retrospective analysis using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, which collects patient information from >790 bariatric surgery centers in North America. Patients included in our analysis underwent surgery in the years 2015 and 2016 and had either LRYGB or LSG for weight loss.ResultsInitial analysis included 274,091 patients. Propensity-matching resulted in 9104 patients for analysis in each of the class I and class II and higher groups. The overall major complication rate between the 2 matched groups was 3.9% for class I and 3.5% for class II and higher (P = .11). We did not find that class I obesity was associated with an increased risk of 30-day complication or death.ConclusionsIn our analysis of propensity-matched patients undergoing LSG and LRYGB for weight loss, class I obesity did not have statistically higher risk of postoperative complication rates compared with class II and higher.     

Perioperative outcomes of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in super-obese and super-super-obese patients: a national database analysis

BackgroundEvidence remains contradictory for perioperative outcomes of super-obese (SO) and super-super-obese (SSO) patients undergoing bariatric surgery.ObjectiveTo identify national 30-day morbidity and mortality of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in SO and SSO patients.SettingThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.MethodsAll LSG and LRYGB patients from 2015 through 2017 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database were grouped based on body mass index (BMI) as follows: morbidly obese (MO; BMI 35.0–49.9 kg/m²), SO (BMI 50.0–59.9 kg/m²), and SSO (BMI ≥60.0 kg/m²). Complications and mortality within 30 days were compared between BMI groups using Pearson X² or Fischer’s exact tests. Multivariate logistic regression was used to adjust for demographic characteristics and co-morbidities, and adjusted odds ratio (AOR) was reported for each outcome.ResultsOf 356,621 patients, 71.6% had LSG and 28.4% LRYGB. A total of 272,195 patients were in the MO group, 65,565 in the SO group, and 18,861 in the SSO group. Higher BMI was associated with increased overall morbidity and mortality. The overall complication rate was significantly higher for SO (AOR = 1.20, 95% confidence interval [CI] 1.13–1.28 for LSG; AOR = 1.08, 95% CI 1.01–1.15 for LRYGB) and SSO (AOR = 1.44, 95% CI 1.31–1.58 for LSG; AOR = 1.31, 95% CI 1.19–1.45 for LRYGB) compared with the MO group. Mortality was also significantly higher for SO (AOR = 1.65, 95% CI 1.10–2.48 for LSG; AOR = 1.85, 95% CI 1.23–2.80 for LRYGB) and SSO (AOR = 3.30, 95% CI 1.98–5.48 for LSG; AOR = 3.32, 95% CI 1.93–5.73 for LRYGB) compared with the MO group.ConclusionsSO and SSO patients are at increased risk of 30-day morbidity and mortality compared with MO patients. Despite this elevated perioperative risk, the overall risk of these procedures remains low and acceptable especially as bariatric surgery is the durable treatment option for obesity.     

Rates of reoperation and nonoperative intervention within 30 days of bariatric surgery

BackgroundComplications arising from laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are not insignificant and can necessitate additional invasive interventions or reoperations.ObjectivesIn this study, we identify early complications that result in nonoperative and operative interventions after LSG and LRYGB, the timeframe within which to expect them, and factors that influence the likelihood of their occurrence.SettingMulti-institutional database from across North America.MethodsData for this study were obtained from Metabolic and Bariatric Accreditation and Quality Improvement Program participant use files for 2015 and 2016. Statistical analysis was performed using STATA 15. Univariate analysis using Χ² for categoric data and independent t test for continuous data was performed to determine between group differences. Multivariable logistic regression analysis was used to identify predictors of operative and nonoperative reinterventions.ResultsIn 2015 and 2016, 243,747 underwent LRYGB or LSG, of which 3013 (1.24%) required a second operative procedure and 1536 (0.63%) required an invasive but nonoperative intervention. Complications occurred in 5.48% of LRYGB patients and 2.28% of LSG patients, the most common of which was bleeding. LSG was associated with far fewer nonoperative and operative interventions (.85% versus 2.2%, respectively) than LRYGB (.67% versus 2.5%). Renal insufficiency, including dialysis dependency, was an important predictor of reoperations among bariatric surgery patients. This was also true of nonoperative interventions; however, history of pulmonary embolism, and use of therapeutic anticoagulation were marginally stronger predictors.ConclusionsIn a representative, multinational sample, operative and nonoperative interventions were half as likely among LSG patients compared with LRYGB; however, overall rates still remained low. These findings, in conjunction with new efficacy data demonstrating comparable long-term weight loss between LRYGB and LSG, provide further support for the safety, effectiveness, and cost efficiency of LSG.     

Predicting serious complications following bariatric surgery in geriatric patients: development of the GeriBari scoring tool using the MBSAQIP database

BackgroundGeriatric patients have a greater risk of complications after bariatric surgery. The objective of this study was to develop a tool to predict serious complications in geriatric patients after minimally invasive bariatric surgery.ObjectivesTo develop a predictive model, GeriBari, for serious complications in geriatric patients after bariatric surgery.SettingMultiple accredited bariatric surgery centers in the United States and Canada.MethodsThis was a retrospective cohort study of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, which collects 30-day bariatric surgery outcomes from 868 accredited centers. Geriatric patients defined as those ≥65 years old who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) were included. Characteristics associated with serious complications were identified using univariate and multivariable analyses. A predictive model, GeriBari, was derived using a forward selection algorithm from operative years 2015, 2017, and 2019. GeriBari’s robustness was tested against a validation cohort of subjects from operative years 2016 and 2018.ResultsA total of 40,199 geriatric patients underwent LRYGB (27.7%) or LSG (72.3%). Overall, 1866 (4.6%) experienced a complication, which included bleeding (1.6%), reoperation (1.6%), reintervention (1.3%), unplanned intubation (.4%), and pneumonia (.4%). Mortality was higher in the geriatric patients than that in younger patients (.27% versus .08%). GeriBari consists of 12 factors that predicted serious complications and stratified individuals into high- (>6%) and low-risk (<6%) groups. This tool accurately predicted events in the validation cohort with sensitivity of 46.0% and specificity of 100%.ConclusionsGeriBari enables preoperative risk stratification for 30-day serious complications in geriatric patients undergoing bariatric surgery. Stratifying low- and high-risk geriatric patients for adverse events allows for informed clinical decision-making prior to bariatric surgery.     

Is laparoscopic sleeve gastrectomy safer than laparoscopic gastric bypass? a comparison of 30-day complications using the MBSAQIP data registry

Background

Laparoscopic sleeve gastrectomy (LSG) has become popular due to its technical ease and excellent short-term results. Understanding the risk profile of LSG compared with the gold standard laparoscopic Roux-en-Y gastric bypass (LRYGB) is critical for patient selection.

Primary laparoscopic sleeve gastrectomy versus gastric bypass: a propensity-matched comparison of 30-day outcomes

BackgroundBariatric surgery is the most effective treatment for obesity. There is uncertainty regarding rates of adverse outcomes between the most common methods: laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG).ObjectivesTo compare rates of readmission, reoperation, intervention, unplanned intensive care unit (ICU) admission, all-cause and procedure-related mortality, and postoperative complications at 30 days between LRYGB and LSG.SettingRetrospective, observational, multicenter registry.MethodsWe identified 611,619 patients from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry between January 1, 2015, and December 31, 2018 (447,326 [73.1%] LSG; 164,293 [26.9%] LRYGB).ResultsAdverse events were more common after LRYGB (readmission: 3% with LSG versus 5.9% with LRYGB [P < .001; odds ratio {OR}, LSG/LRYGB = .489]; intervention: .9% with LSG versus 2.4% with LRYGB [P < .001; OR, LSG/LRYGB = .357]; reoperation: .8% with LSG versus 2.3% with LRYGB [P < .001; OR, LSG/LRYGB = .363]; unplanned ICU admission: .52% with LSG versus 1.1% with LRYGB [P < .001; OR, LSG/LRYGB = .454]; all-cause mortality: .07% with LSG versus .15% with LRYGB [P < .001; OR, LSG/LRYGB = .489]; procedure-related mortality: .04% with LSG versus .08% with LRYGB [P < .001; OR, LSG/LRYGB = .446]; Clavien-Dindo I: .20% with LSG versus .63% with LRYGB [P < .001; OR, LSG/LRYGB = .317]; Clavien-Dindo II: .70% with LSG versus 1.3% with LRYGB [P < .001; OR, LSG/LRYGB = .527]; Clavien-Dindo III: 3.3% with LSG versus 6.6% with LRYGB [P < .001; OR, LSG/LRYGB = .481]; Clavien-Dindo IV: .36% with LSG versus .76% with LRYGB [P < .001; OR, LSG/LRYGB = .466]; and Clavien-Dindo V: .07% with LSG versus .15% with LRYGB [P < .001; OR, LSG/LRYGB = .488]). Surgery type was among the strongest independent predictors of adverse events, and LRYGB conferred higher adjusted odds of all adverse outcomes (all-cause mortality: OR, LRYGB/LSG = 1.791 [P < .001]; procedure-related mortality: OR, LRYGB/LSG = 1.979 [P < .001]; readmission: OR, LRYGB/LSG = 1.921 [P < .001]; unplanned ICU admission: OR, LRYGB/LSG = 1.870 [P < .001]; intervention: OR, LRYGB/LSG = 2.662 [P < .001]; reoperation: OR, LRYGB/LSG = 2.646 [P < .001]; and Clavien-Dindo grade: OR, LRYGB/LSG = 2.007 [P < .001]).ConclusionThe rates of 30-day adverse outcomes are lower after LSG compared with after LRYGB. LRYGB independently conferred increased odds of adverse outcomes compared with LSG, and surgery type was among the strongest predictors of adverse outcomes.     

Outcomes of robotic bariatric surgery in super-obese patients: first report based on MBSAQIP database

BackgroundBariatric surgery in the super-obese (SO) patient population represents a challenge. Although the robotic platform is increasingly used for these patients, there are limited data on outcomes compared with conventional laparoscopy.ObjectiveOur study compared the safety and short-term outcomes of robotic and laparoscopic platforms for SO patients compared with morbidly obese patients based on the 2015 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.SettingUniversity Hospital, United States.MethodsWe evaluated all primary robotic and laparoscopic cases and extracted 30-day outcomes in patients with body mass index <50 and ≤50 kg/m². For our primary analysis, we used the Cochran-Mantel-Haenszel method with surgery type Roux-en-Y gastric bypass (RYGB) versus sleeve gastrectomy (SG) as the stratification variable to determine the association between body mass index categories and outcomes.ResultsA total of 355,278 patients were included in our analysis. For the robotic RYGB (R-RYGB) group (n = 6645) and R-SG (n = 15,984) there were 1674 SO patients (25.2%) and 3688 SO patients (23.1%), respectively.For the laparoscopic RYGB (LRYGB) group (n = 95,374) and LSG group (n = 237,275), there were 24,991 (26.2%) and 51,524 SO patients (21.7%), respectively. The incidence of serious adverse events in SO patients for R-RYGB and LRYGB groups was 7.6% versus 7.2% (P > .05) and 4% versus 3.5% (P > .05) for R-SG and L-SG, respectively. The incidence of organ space infection in SO patients for R-RYGB and LRYGB groups was .5% versus .4% (P > .05) and .4% versus .2% (P < .05) for R-SG and LSG, respectively.ConclusionsBased on 2015 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data, we found no difference in outcomes between robotic and laparoscopic approaches in SO patients. There was a higher incidence of serious adverse events in SO patients compared with morbidly obese patients for both approaches.     

Predictors of postoperative emergency department visits after laparoscopic bariatric surgery

BackgroundPostoperative emergency department (ED) visits are a quality metric for bariatric surgical programs. Predictive factors of ED visits that do not result in readmission are not clear.ObjectivesWe aimed to identify predictors of ED visits in patients without readmission after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB).SettingThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.MethodsThe MBSAQIP database was queried for patients who underwent LSG and LRYGB from 2015 through 2017. Patients were grouped by those who presented to the ED (ED group) and those who did not. ED visits analyzed included only those that did not result in readmission. Multivariable forward selection logistic regression was used to report adjusted odds ratios (AORs) with 95% CIs for ED visits.ResultsOf 276,073 patients, 257,985 (93.4%) were in the group who did not present to the ED, and 18,088 (6.6%) were in the ED group. Most underwent LSG (71.9%) versus LRYGB (28.1%). Multivariable forward logistic regression identified outpatient treatment for dehydration (AOR, 22.26; 95% CI, 21.30–23.27; P < .001) as the most predictive factor of an ED visit, followed by urinary tract infection (AOR, 7.25; 95% CI, 6.22–8.46; P < .001), wound disruption (AOR, 4.63; 95% CI, 3.09–6.96; P < .001), and surgical site infection (AOR, 3.80; 95% CI, 3.38–4.28; P < .001).ConclusionsPostoperative complications were the strongest predictors of ED visits after laparoscopic bariatric surgery. Quality improvement initiatives should target these variables to decrease postoperative ED visits.     

Perioperative outcomes of bariatric surgery in the setting of chronic steroid use: an MBSAQIP database analysis

BackgroundChronic steroids are a treatment option for many chronic diseases but predispose patients to both weight gain and surgical complications. They therefore represent a unique interface between obesity, chronic disease, and surgical risk. As the benefits of bariatric surgery for controlling metabolic disease become more apparent, patients with chronic illnesses on corticosteroids are increasingly being referred for surgery despite an unclear safety profile. The Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database represents the largest bariatric-specific clinical data set for comparing outcomes in this complex patient population.ObjectiveTo compare perioperative outcomes following bariatric surgery in the setting of chronic steroid/immunosuppression.SettingUniversity Hospital, United States.MethodsUsing the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program MBSAQIP database, we identified patients on chronic corticosteroids who underwent laparoscopic sleeve gastrectomy or laparoscopic gastric bypass in 2015 or 2016. Unmatched as well as propensity-score and case-controlled matched cohort analyses were performed of patients on corticosteroid therapy compared with those without.ResultsOf the 302,140 patients who underwent sleeve gastrectomy or laparoscopic gastric bypass in 2015–2016, a total of 4947 (1.63%) were on chronic steroids/immunosuppressive drugs. Patients using steroids were older with significantly higher rates of co-morbid conditions. Hospital length of stay, intensive care unit admission, reoperation, readmission, bleeding, leak, and infectious complications were significantly higher in steroid users; however, in a propensity and case-control matched analysis of 8710 patients and 6598 patients, respectively, steroids were not found to be independent risk factors for poorer outcomes except for an increased rate of leak.ConclusionsGenerally, steroid use does not independently predict poorer outcomes among bariatric surgery patients except for an increased leak rate. With appropriate patient selection based on associated co-morbid factors, primary bariatric surgery is safe in patients using corticosteroids, with an acceptable 30-day postoperative risk profile.     

Dehydration risk factors and impact after bariatric surgery: an analysis using a national database

BackgroundDehydration is a common complication after bariatric surgery and often quoted as the reason for emergency department (ED) visits and readmission.ObjectiveWe sought to investigate risk factors for dehydration after bariatric surgery and evaluate its impact on ED visits and readmission.SettingThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.MethodsWe used the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database to identify patients who underwent laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2016 through 2017. The primary outcome was need for outpatient treatment of dehydration within 30 days postsurgery. Secondary outcomes were association between need for outpatient dehydration therapy and 30-day readmission or ED evaluation not resulting in admission.ResultsOf 256,817 patients, 73% underwent laparoscopic sleeve gastrectomy and 27% LRYGB. Of 9592 patients who required dehydration treatment, they were more often younger than age 40, female, black, had a ≥3-day length of stay during their index admission, and experienced a postoperative complication. More patients receiving LRYGB than laparoscopic sleeve gastrectomy required treatment for dehydration. On multivariable analysis, independent-risk factors for postoperative dehydration treatment included LRYGB, length of stay ≥3 days, gastroesophageal reflux disease, hypertension, previous deep vein thrombosis, chronic steroid/immunosuppression, and a postoperative complication. Patients who developed dehydration requiring treatment compared with those that did not had adjusted odds ratio of 3.7 (95% confidence interval: 3.44–3.96; P < .001) and 22 (95% confidence interval: 21.05–23.06; P < .001) of readmission and ED visit.ConclusionDehydration is a strong risk factor for postoperative ED visits and readmission. Closer surveillance and proactive measures for those at higher risk may prevent the development of postoperative dehydration.     

Trends in early postoperative major adverse cardiovascular and cerebrovascular events associated with bariatric surgery: an analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry

BackgroundThe population undergoing bariatric surgery (BaS) has many cardiovascular risk factors that can lead to significant perioperative cardiovascular morbidity.ObjectivesWe aimed to examine trends in the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) after BaS.SettingAcademic Hospital, United StatesMethodsWe performed a retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry for patients aged ≥18 years undergoing laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2015 to 2019. Data on demographics, co-morbidities, and type of procedure were collected. MACCE was defined as a composite variable including perioperative acute myocardial infarction (AMI), cardiac arrest requiring cardiopulmonary resuscitation, acute stroke, and all-cause mortality. We utilized the Cochrane-Armitage and Jonckheere-Terpstra tests to assess for significant trend changes throughout the years.ResultsA total of 752,722 patients were included in our analysis (LSG = 73.2%, LRYGB = 26.8%). Postoperative MACCE occurred in 1058 patients (.14%), and was more frequent in patients undergoing LRYGB (.20%). The frequency of MACCE declined from .17% to .14% (P = .053), driven by a decline in the frequency of AMI (.04% to .02%, P = .002), cardiac arrest (.05% to .04%, P = .897), and all-cause death (.11% to .08%, P = .040), but with an increase in perioperative stroke (.01% to .02%, P = .057).ConclusionThe overall risk of MACCE after BaS is .14% and has been declining in the last 5 years. This trend is likely multifactorial and further analysis is necessary to provide a detailed explanation.     

Predictors and outcomes of bleed after sleeve gastrectomy: an analysis of the MBSAQIP data registry

BackgroundBleeding after laparoscopic sleeve gastrectomy (LSG) is an important complication associated with significant morbidity and a drastic increase in healthcare resources. Multiple strategies have been developed to minimize bleeding, including varying bougie size, line reinforcement, and intra-operative tranexamic acid. These techniques, however, have been implemented without a clear understanding of the pre-, intra-, and postoperative predictors of bleeding in patients undergoing SG.ObjectivesThe purpose of this study was to examine predictors and outcomes associated with postoperative bleeding in patients undergoing LSG.SettingThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement data registry.MethodsWe identified Metabolic and Bariatric Surgery Accreditation and Quality Improvement patients who underwent LSG in 2015 and 2016. Primary outcomes of interest include identifying the prevalence, impact, and predictors of bleeding in LSG patients. Our secondary outcomes of interest include characterizing overall complication rates in LSG patients. Univariate analysis of pre-, intra-, and postoperative variables was performed using Χ² tests for categorical data and independent sample t test for continuous data. A nonparsimonious multivariable logistic regression model was then developed to determine predictive factors for development of postoperative bleed.ResultsA total of 175,353 patients underwent LSG from 2015 to 2016. The majority of patients were female (79.0%), with a mean age of 44.4 ± 12.0 years and a mean body mass index of 45.2 kg/m² ± standard deviation of 7.9 kg/m². A total of 1116 (.6%) patients had a postoperative bleed. Bleeding was associated with a mortality of 1.0% versus .1% among patients without bleeding. The mean operative time was 74.0 ± 36.6 minutes with a mean bougie size of 36.9 ± 2.9 Fr, and a mean pylorus distance of 4.80 ± 1.1 cm. Staple-line reinforcement was used in 67.8% of patients while 22.4% were oversewn. Bleeds were associated with a statistically significant increase in all complications, readmission, reoperation, and mortality rates at 30 days. The following statistically significant independent predictors of bleed after LSG were identified using multivariable logistic regression analysis: bougie size, age, prior cardiac procedure, hypertension, renal insufficiency, therapeutic anticoagulation, diabetes, obstructive sleep apnea, and operative length. Staple-line reinforcement, staple-line oversewing, and higher body mass index were found to be protective for bleed after adjusting for confounders and interactions. An increase in pylorus distance did show a signal toward a protective effect; however, this was not statistically significant.ConclusionBleeding after LSG is associated with increased complications, readmission and reoperation rates, and mortality at 30 days. Staple-line reinforcement techniques independently predict a lower risk of postoperative bleeding after LSG. Adoption of these techniques may therefore have an important role in reducing morbidity and mortality for patients who undergo LSG.     

Reduction in obesity-related comorbidities: is gastric bypass better than sleeve gastrectomy?

Background

Bariatric surgery is currently the most effective treatment for morbid obesity. It provides not only substantial weight loss, but also resolution of obesity-related comorbidities. Laparoscopic sleeve gastrectomy (LSG) has rapidly been gaining in popularity. However, there are limited data on the reduction of obesity-related comorbidities for LSG compared to laparoscopic Roux-en-Y gastric bypass (LRYGB). The aim of this study was to assess the effectiveness of laparoscopic LSG versus LRYGB for the treatment of obesity-related comorbidities.

Methods

A total of 558 patients who underwent either LSG or LRYGB for morbid obesity at the Westchester Medical Center between April 2008 and September 2010 were included. Data were collected prospectively into a computerized database and reviewed for this study. Fisher’s exact test analyses compared 30-day, 6-month, and 1-year outcomes of obesity-related comorbidities.

Results

A total of 558 patients were included in the analysis of obesity-related comorbidity resolution; 200 underwent LSG and 358 underwent LRYGB. After 1 year, 86.2 % of the LSG patients had one or more comorbidities in remission compared to 83.1 % LRYGB patients (P = 0.688). With the exception of GERD (?0.09 vs. 50 %; P < 0.001), similar comorbidity remission rates were observed between LSG and LRYGB for sleep apnea (91.2 vs. 82.8 %; P = 0.338), hyperlipidemia (63 vs. 55.8 %; P = 0.633), hypertension (38.8 vs. 52.9 %; P = 0.062), diabetes (58.6 vs. 65.5 %; P = 0.638), and musculoskeletal disease (66.7 vs. 79.4 %; P = 0.472).

Conclusions

Laparoscopic sleeve gastrectomy markedly improves most obesity-related comorbidities. Compared to LRYGB, LSG may have equal in reducing sleep apnea, hyperlipidemia, hypertension, diabetes, and musculoskeletal disease. LRYGB appears to be more effective at GERD resolution than LSG.     

Trends in risk factors for readmission after bariatric surgery 2015–2018

BackgroundReadmission after bariatric surgery is multifactorial. Understanding the trends in risk factors for readmission provides opportunity to optimize patients prior to surgery identify disparities in care, and improve outcomes.ObjectivesThis study compares trends in bariatric surgery as they relate to risk factors for all-cause readmission.SettingMetabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) participating facilities.MethodsThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was used to analyze 760,076 bariatric cases from 854 centers. Demographics and 30-day unadjusted outcomes were compared between laparoscopic adjustable gastric banding (LAGB), sleeve gastrectomy (LSG), and Roux-en-Y gastric bypass (RYGB) performed between 2015 and 2018. A multiple logistic regression model determined predictors of readmission.ResultsA total of 574,453 bariatric cases met criteria, and all-cause readmission rates decreased from 4.2% in 2015 to 3.5% in 2018 (P < .0001). The percentage of non-Hispanic Black adults who underwent bariatric surgery increased from 16.7% of the total cohort in 2015 to 18.7% in 2018 (P < .0001). The percentage of Hispanic adults increased from 12.1% in 2015 to 13.8% in 2018 (P < .0001). The most common procedure performed was the LSG (71.5%), followed by RYGB (26.9%) and 1.6% LAGB (1.6%) (P < .0001). Men were protected from readmission compared with women (odds ratio [OR]: .87; 95% confidence interval [CI]: .84–.90). Non-Hispanic Black (OR: 1.52; 95% CI: 1.47–1.58)] and Hispanic adults (OR: 1.14; 95% CI: 1.09–1.19) were more likely to be readmitted compared with non-Hispanic White adults. LSG (OR: 1.27; 95% CI: 1.10–1.48) and RYGB (OR: 2.24; 95% CI: 1.93–2.60) were predictive of readmission compared with LAGB.ConclusionReadmission rates decreased over 4 years. Women, along with non-Hispanic Black and Hispanic adults, were more likely to be readmitted. Future research should focus on gender and racial disparities that impact readmission.     

Beyond 5 years: a matched cohort of sleeve gastrectomy versus gastric bypass

BackgroundLaparoscopic sleeve gastrectomy (LSG) has demonstrated excellent short-term outcomes. However, existing studies suffer from loss to follow-up, and most long-term data focus on laparoscopic Roux-en-Y gastric bypass (LRYGB). This study compares weight loss in patients ≥5 years from LSG with that in matched patients who underwent LRYGB.ObjectivesThe purpose of this study was to compare long-term weight loss in patients undergoing LRYGB and LSG.SettingUniversity hospital, United States.MethodsWe retrospectively evaluated patients who underwent LSG before August 2012 with follow-up data ≥5 years. LSG patients were matched 1:1 with LRYGB patients by sex, age at surgery, and preoperative body mass index. Univariate and multivariate analyses were performed with weight loss at the longest duration the primary outcome.ResultsOne-hundred and sixty-five patients underwent LSG during the study period. Long-term follow-up data (≥5 years) were available for 85 patients (52%). There were no preoperative differences between those with and without follow-up data. Six LSG patients (7%) were excluded because they underwent reoperation that altered intestinal anatomy. Of the 79 patients remaining, 75 were matched with post-LRYGB patients. The average follow-up period was 6.4 years for LSG patients and 6.5 years for LRYGB patients (P = .08, not significant). Change in body mass index was 6.81 kg/m² for LSG patients and 13.11 kg/m² for LRYGB patients. Percentage of total body weight loss was 15.25% for LSG patients and 28.73% for LRYGB patients. Percentage of excess body weight loss was 37% for LSG patients and 67% for LRYGB patients (P < .0001). Weight loss for LSG patient follow-up in clinic versus outside the clinic was 46% versus 34% (P = .18, not significant).ConclusionsLSG is now the most common bariatric surgery in the United States. Long-term data are needed to confirm that observed short-term favorable outcomes are maintained. Recent studies have produced divergent results. We observed significantly less weight loss at ≥5 years in LSG patients compared with matched LRYGB patients.     

Robotic gastric bypass is getting better: first results from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program

Background

The use of robotic platforms in performing laparoscopic Roux-en-Y gastric bypass (LRYGB) is increasing, though their safety compared with the conventional laparoscopic approach remains unclear.

Predictors and outcomes of leak after Roux-en-Y gastric bypass: an analysis of the MBSAQIP data registry

BackgroundGastrointestinal leak is one of the most severe postoperative complications after Roux-en-Y gastric bypass (RYGB), occurring in up to 2% of all patients. This has led to adoption of simpler procedures, such as sleeve gastrectomy, which have improved safety profiles but potentially less effective long-term metabolic outcomes. Yet, in contrast to sleeve gastrectomy, a paucity of modern literature exists regarding predictors of leak for RYGB.ObjectivesThe purpose of this study was to examine gastrointestinal leak in patients undergoing RYGB using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement data registry.MethodsWe identified all Metabolic and Bariatric Surgery Accreditation and Quality Improvement patients who underwent RYGB in 2015 and 2016. Primary outcomes of interest include identifying the prevalence, impact, and predictors of leak in RYGB patients. Our secondary outcomes of interest include characterizing overall complication rates in RYGB patients. Univariate analysis of pre-, intra-, and postoperative variables was performed using Χ² tests for categoric data and independent sample t test for continuous data. A nonparsimonious multivariable logistic regression model was then developed to determine predictive factors for development of leak.SettingAll centers belonging to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement data registry.ResultsA total of 77,596 patients underwent RYGB from 2015 to 2016. The majority of patients were female (79.8%), white (75.9%), and underwent laparoscopic RYGB (89.7%). The mean age of patients was 45.2 years (standard deviation 11.9) with a mean body mass index of 46.3 kg/m² (standard deviation 8.17). Complication rates for RYGB were low with a mortality of .16% and a total complication rate of 7.5%. A total of 476 leaks were identified with an overall leak rate of .6% and a mortality of 1.5%. Leak was associated with a statistically significant increase in all complications as well as readmission, reoperation, and mortality rates at 30 days. Multivariable logistic regression analysis revealed the following statistically significant independent predictors of leak: body mass index, age, operative length, American Society of Anesthesiologists score >3, prior pulmonary embolus, and partially dependent functional status. Albumin was the only independent protective variable after adjusting for confounders and interactions.ConclusionUsing the robust Metabolic and Bariatric Surgery Accreditation and Quality Improvement database, we found RYGB to be a safe procedure with low morbidity and mortality. The overall leak rate was .6% with leak significantly increasing all other complications, readmission, reoperation, and mortality rates at 30 days. Logistic regression identified prior pulmonary embolus and partially dependent functional status as the 2 largest predictors of leak while increased albumin was the only protective factor. Optimizing preoperative nutrition and strength in these patients through structured multidisciplinary programs may therefore have a role in the ongoing improvement of outcomes after RYGB.     

Comparison of robotic revisional weight loss surgery and laparoscopic revisional weight loss surgery using the MBSAQIP database

BackgroundThe most common bariatric operation in the United States is sleeve gastrectomy. The second and third most common bariatric operations are gastric bypass and revisional bariatric surgery, respectively.ObjectiveThe objective of the study was to assess the differences between laparoscopic revisional weight loss surgery (LRWLS) and robotic revisional weight loss surgery (RRWLS).SettingUniversity hospital, United States.MethodsData were extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database spanning 2015 to 2016 to look at demographic characteristics, operative time, co-morbidities, and length of stay. Using the specified Current Procedural Terminology codes, patients who underwent bariatric procedures and required a revisional procedure were identified.ResultsA total of 354,865 patients were included in this study; 37,917 (11.9%) patients required revision after undergoing a bariatric procedure. Of these revisions, 94.9% (n = 35,988) were LRWLS, and 5.1% (n = 1929) were RRWLS. There were no differences in patient characteristics between the LRWLS and RRWLS groups. There was a significant difference between the RRWLS and the LRWLS groups in operative time, with the RRWLS group taking 167 minutes and the LRWLS group taking 103 minutes (P < .001). There was a statistically significant increase in length of stay for RRWLS, 2.3 days versus 1.7 for LRWLS (P < .005). In terms of postoperative complications, there were no significant differences between the 2 groups.ConclusionsRRWLS is as safe as LRWLS in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. There is an increase in operative times and length of stay for robotic cases.     

Comparison of cholecystectomy cases after Roux-en-Y gastric bypass,sleeve gastrectomy,and gastric banding

BackgroundRapid weight loss after bariatric surgery has been a factor of inducing gallstones postoperatively. Many studies have reported increased gallstone formation after laparoscopic Roux-en-Y gastric bypass (LRYGB). However, not many studies have compared symptomatic gallstone frequencies between LRYGB, laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB). The aim of our study is to evaluate symptomatic cholelithiasis cases requiring cholecystectomy after each bariatric procedure.MethodsBetween January 2009 and August 2011, a total of 937 patients underwent bariatric surgery at our institution. Of these patients, 598 had primary LRYGB, 197 had LSG, and 142 had LAGB. We excluded patients with previous cholecystectomy or concomitant cholecystectomy at the time of bariatric procedure. A retrospective review of a prospectively collected database was performed for all patients.ResultsOf 367 LRYGB patients, 5.7% (n = 21) had symptomatic gallstones. Of 115 LSG patients, 6.1% (n = 7) required cholecystectomy, and of 104 LAGB patients, .0% (n = 0) developed symptomatic gallstones. The differences in the occurrences of symptomatic gallstones between LRYGB and LSG were not statistically significant (P>.88). However, statistical significance was present between LRYGB and LAGB (P<.02), as well as between LSG and LAGB (P<.02). Mean percentage of excess weight loss (%EWL) at 24 months was 85.7%, 58.8%, and 38.3% in LRYGB, LSG, and LAGB patients, respectively. There was no complication related to the cholecystectomy procedure.ConclusionsFrequency of symptomatic gallstones after LRYGB and LSG was not significantly different and after LAGB was significantly lower. Slow and less amount of weight loss would have contributed to the low rate of symptomatic gallstone formation in the LAGB patients. (Surg Obes Relat Dis 2013;0:000–00.) © 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved.