The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program bariatric surgical risk/benefit calculator: 30-day risk

BackgroundThere is increasing demand for data-driven tools that provide accurate and clearly communicated patient-specific information. These can aid discussions between practitioners and patients, promote shared decision-making, and enhance informed consent. The American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) sought to create a risk calculator for adult patients considering primary metabolic and bariatric surgery, with multiple prediction features: (1) 30-day risk; (2) 1-year body mass index projections; and (3) 1-year co-morbidity remission.ObjectivesTo evaluate the 30-day risk estimation feature of this tool.SettingNot-for-profit organization, international bariatric surgery clinical data registry.MethodsMBSAQIP data across 5.5 years, 925 hospitals, and 775,291 cases were used to develop the 30-day risk feature. Logistic regression models were employed to estimate postoperative risks for 9 outcomes across 4 procedures: laparoscopic Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, laparoscopic adjustable gastric band, and biliopancreatic diversion with duodenal switch.ResultsThe tool showed good discrimination for mortality and surgical site infection models (c-statistics, .80 and .70, respectively), and was slightly less accurate for the 7 other complications (.62–.69). Graphical representations showed excellent calibration for all 9 outcomes.ConclusionsOverall, the 30-day risk models were accurate and well calibrated, with acceptable discrimination. The MBSAQIP bariatric surgical risk/benefit calculator is publicly available, with the intent to be integrated into healthcare practice to guide bariatric surgical decision-making and care planning, and to enhance communication between patients and their surgical care team.     

Gastric Bypass But Not Sleeve Gastrectomy Increases Risk of Major Osteoporotic Fracture: French Population-Based Cohort Study

The objective of this work was to investigate the risk of major osteoporotic fracture (MOF; hip, proximal humerus, wrist and distal forearm, and clinical spine) in bariatric surgery patients versus matched controls. Bariatric surgery is associated with an increase in fracture risk. However, it remains unclear whether the same degree of fracture risk is associated with sleeve gastrectomy, which has recently surpassed gastric bypass. Records from the French National Inpatient database were used from 2008 to 2018. Bariatric surgery patients, aged 40 to 65 years, with BMI ≥40 kg/m², hospitalized between January 1, 2010 and December 31, 2014, were matched to one control (1:1) by age, sex, Charlson comorbidity index, year of inclusion, and class of obesity (40 to 49.9 kg/m² versus ≥50 kg/m²). We performed a Cox regression analysis to assess the association between the risk of any MOF and, respectively, (i) bariatric surgery (yes/no) and (ii) type of surgical procedure (gastric bypass, gastric banding, vertical banded gastroplasty, and sleeve gastrectomy) versus no surgery. A total of 81,984 patients were included in the study (40,992 in the bariatric surgery group, and 40,992 matched controls). There were 585 MOFs in the surgical group (2.30 cases per 1000 patient-year [PY]) and 416 MOFs in the matched controls (1.93 cases per 1000 PY). The risk of MOF was significantly higher in the surgical group (hazard ratio [HR] 1.22; 95% CI, 1.08–1.39). We observed an increase in risk of MOF for gastric bypass only (HR 1.70; 95% CI, 1.46–1.98) compared with the matched controls. In patients aged 40 to 65 years, gastric bypass but not sleeve gastrectomy or the other procedures increased risk of major osteoporotic fractures. © 2020 American Society for Bone and Mineral Research.     

Relationship between surgeon volume and adverse outcomes after RYGB in Longitudinal Assessment of Bariatric Surgery (LABS) study

BackgroundBariatric surgery is technically demanding surgery performed on high-risk patients. Previous studies using administrative databases have shown a relationship between surgeon volume and patient outcome after Roux-en-Y gastric bypass (RYGB). We examined the relationship between surgeons' annual RYGB volumes and 30-day patient outcomes at 10 centers within the United States.MethodsThe Longitudinal Assessment of Bariatric Surgery (LABS)-1 is a prospective study examining the 30-day adverse outcomes after bariatric surgery. The outcomes after RYGB were adjusted by procedure type (open versus laparoscopic), functional status, body mass index, history of deep vein thrombosis, pulmonary embolism, and obstructive sleep apnea. The data were examined to determine the nature and strength of the association between surgeon volume and patients' short-term (30-day) adverse outcomes after RYGB.ResultsThe analysis included 3410 initial RYGB operations performed by 31 surgeons, 15 of whom averaged <50 cases annually. The crude composite adverse outcome (i.e., death, deep vein thrombosis, pulmonary embolism, reintervention or nondischarge at day 30) incidence was 5.2%. After risk adjustment, a greater surgeon RYGB volume was associated with lower composite event rates, with a continuous relationship (i.e., varying cutpoints differentiated the composite event rates), such that for each 10-case/yr increase in volume, the risk of a composite event decreased by 10%.ConclusionIn the LABS, the patient's risk of an adverse outcome after RYGB decreased significantly with the increase in surgeon RYGB volume (cases performed annually).     

Comparison of perioperative bariatric complications using 2 large databases: does the data add up?

BackgroundThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database is a prospective clinical database that looks at short-term (30-day) outcomes of bariatric surgery. The Texas Inpatient Public Use Data File (PUDF) is an administrative database that uses hospital discharge information to compile data on admission and discharge diagnoses.ObjectiveTo determine interdatabase reliability for common bariatric complications.SettingUniversity hospital, United StatesMethodsThe Texas Inpatient PUDF and MBSAQIP were queried for patients undergoing sleeve gastrectomy and gastric bypass in the year 2015. Admission diagnoses of morbid obesity with a discharge diagnosis of bariatric surgery status and also the International Classification of Diseases 9 Clinical Modification and Current Procedural Terminology procedure codes for bariatric surgeries were queried. The same postoperative complications were examined in both databases.ResultsThere were 137,291 patients in MBSAQIP and 9474 patients in the PUDF undergoing bariatric surgery. Patients in the PUDF had greater adjusted and unadjusted odds ratio for acute renal failure, cardiac arrest and postoperative myocardial infarction, pneumonia, progressive renal failure and postoperative sepsis.ConclusionThere is a significant difference in the rates of perioperative complications of bariatric surgery when different databases are used. If surgeons are to be graded or potentially financially affected by these outcome metrics, the proper use of and interpretation of data is paramount and quality monitoring organizations should not use only administrative databases as the primary method to measure quality.     

The effect of smoking on bariatric surgical outcomes

Background

Bariatric surgery is an effective long-term treatment for morbid obesity. Although smoking is known to increase postoperative complications, the independent effect of smoking on bariatric surgical outcomes is unclear. The purpose of this study was to investigate the effect of smoking on bariatric surgical outcomes using the National Surgical Quality Improvement Program (NSQIP).

Study design

Bariatric patients from 2005 to 2010 were identified in NSQIP for all types of bariatric procedures except adjustable gastric banding. Pre-treatment variables’ univariate associations with smoking were examined with chi-square and t tests. Association of smoking with outcomes, corrected for relevant covariates, was tested with logistic regression within laparoscopic and open treatment groups.

Results

A total of 41,445 patients underwent bariatric surgery (35,696 laparoscopic; 5,749 open). After controlling for covariates, smoking significantly increased the risk of organ space infection, prolonged intubation, reintubation, pneumonia, sepsis, shock, and longer length of stay in all patients undergoing bariatric surgery. In the open bariatric surgery subgroup, smoking was associated with a significantly higher incidence of organ space infection, prolonged intubation, pneumonia, and length of stay. In the laparoscopic surgery subgroup, smokers had a significantly increased incidence of prolonged intubation, reintubation, sepsis, shock, and length of stay. Smoking did not significantly increase the risk of mortality for patients undergoing bariatric surgery.

Conclusions

These data suggest that smoking is a modifiable preoperative risk factor that significantly increases the incidence of postoperative morbidity but not mortality in both laparoscopic and open bariatric surgery. Smoking cessation may minimize the risk of adverse outcomes. Future investigation is needed to identify the optimal length of preoperative smoking cessation.     

Medication Use Following Bariatric Surgery: Factors Associated with Early Discontinuation

Background

Medication discontinuation is a common result of bariatric surgery. The influence of individual patient characteristics and surgical outcomes on overall and specific medication discontinuation is not well understood. The purpose of the current study was to assess changes in medication use and identify individual characteristics and surgical outcomes associated with medication discontinuation among bariatric patients.

Methods

The patients included in the current study received bariatric surgery from the Northern Colorado Surgical Associates of Fort Collins, Colorado, USA, between October 2007 and September 2010. Demographic, weight, health, and medication data from 400 patients with at least one 6- or 12-month post-operative appointment were extracted from the Bariatric Outcome Longitudinal Database. Multivariate regression analyses were used to investigate how patient factors affect total medication use over time, use of medications grouped by co-morbidity post-operatively, and use of specific medication classes post-operatively.

Results

Baseline co-morbidities, particularly type 2 diabetes, male sex, and Roux-en-Y gastric bypass surgery were significantly associated with decreased total medication use following surgery. Weight loss, systemic disease, sex, baseline co-morbidities, surgical complications, and race were significantly associated with continued use of specific medications following surgery.

Conclusions

Bariatric surgery can help patients with certain characteristics discontinue medications but is not effective for all patients. Baseline health, sex, race, bariatric procedure, surgical complications, and post-operative weight loss may affect how bariatric patients' medication use changes pre-operatively to post-operatively.     

Risk stratification of serious adverse events after gastric bypass in the Bariatric Outcomes Longitudinal Database

BackgroundThere is now sufficient demand for bariatric surgery to compare bariatric surgeons and bariatric centers according to their postsurgical outcomes, but few validated risk stratification measures are available to enable valid comparisons. The purpose of this study was to develop and validate a risk stratification model of composite adverse events related to Roux-en-Y gastric bypass (RYGB) surgery.MethodsThe study population included 36,254 patients from the Bariatric Outcomes Longitudinal Database (BOLD) registry who were 18–70 years old and had RYGB between June 11, 2007, and December 2, 2009. This population was randomly divided into a 50% testing sample and a 50% validation sample. The testing sample was used to identify significant predictors of 90-day composite adverse events and estimate odds ratios, while the validation sample was used to assess model calibration. After validating the fit of the risk stratification model, the testing and validation samples were combined to estimate the final odds ratios.ResultsThe 90-day composite adverse event rate was 1.48%. The risk stratification model of 90-day composite adverse events included age (40–64, ≥65), indicators for male gender, body mass index (50–59.9, ≥60), obesity hypoventilation syndrome, back pain, diabetes, pulmonary hypertension, ischemic heart disease, functional status, and American Society of Anesthesiology classes 4 or 5. Our final gastric bypass model was predictive (c-statistic = .68) of serious adverse events 90 days after surgery.ConclusionsWith additional validation, this risk model can inform both the patient and surgeon about the risks of bariatric surgery and its different procedures, as well as enable valid outcomes comparisons between surgeons and surgical programs.     

The impact of chronic kidney disease on bariatric perioperative outcome: a MBSAQIP matched analysis

BackgroundMorbid obesity is considered a strong independent risk factor for chronic kidney disease (CKD), and bariatric surgery remains the most effective treatment for obesity-related co-morbidities. Previous large database analyses have suggested that CKD does not independently increase the risk of adverse outcomes after bariatric surgery. The safety of elective bariatric surgery in this patient population remains unclear. To this end, we compared 30-day outcomes in this patient population after laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass.ObjectivesTo compare 30-day outcomes in CKD patients after laparoscopic sleeve gastrectomy or gastric bypass.SettingUniversity Hospital, United States.MethodsUsing the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database, we identified patients with CKD who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass in 2015 or 2016. An unmatched cohort analysis, a propensity-matched analysis, and a case-control, matched-cohort analysis was performed of patients with and without CKD.ResultsOf the 302,092 patients included in this study, 2362 (.7%) had CKD, of whom 837 (35.4%) required dialysis. CKD patients were older with significantly higher rates of co-morbid conditions. Hospital length of stay, intensive care unit admission, reoperation, readmission, bleeding, cardiopulmonary, infectious complications, and total morbidity were significantly higher in CKD patients. In propensity-matched and case-control matched analyses of 4006 patients and 2264 patients, respectively, poorer outcomes in CKD patients highlight it an independent risk factor for morbidity.ConclusionsIn contrast to previously reported large database analysis, CKD and dependence on dialysis independently increases the risk of 30-day adverse outcomes after primary bariatric surgery. The benefits conferred by bariatric surgery should be carefully weighed against the increased risk of complications in this challenging population.     

The impact of co-morbid disease on cancer control and survival following radical cystectomy

PURPOSE: We clarified the impact of concurrent medical disease on tumor control and survival following radical cystectomy. MATERIALS AND METHODS: A total of 106 consecutive patients with clinically localized (cT2 or less) disease underwent radical cystectomy at the University of Michigan between 1997 and 1998. The Charlson Index, a validated risk adjustment index, was used to assess preoperative co-morbidity. The 3 primary end points were pathological stage, disease specific survival and overall survival. Logistic regression models were used to determine the relationship between Charlson Index and pathological stage, while Cox regression models were used for the 2 survival end points. RESULTS: Of our study population 24% had a Charlson Index score of 2 or greater. Myocardial infarction, nonurothelial solid malignancies and cerebrovascular disease were the most common co-morbid conditions at 14%, 12% and 10%, respectively. On bivariate analysis the Charlson Index was significantly associated with decreased disease specific (p = 0.049) and overall (p = 0.016) survival. In a multivariate model the index was independently associated with decreased cancer specific survival (p = 0.049) and increased risk of extravesical disease (p = 0.033). CONCLUSIONS: We demonstrated an association between co-morbid illness and adverse pathological and survival outcome following radical cystectomy. This finding underscores the value of assessing overall health before recommending and proceeding with surgery. Moreover, our results emphasize the need to adjust for co-morbidity when comparing outcomes following radical cystectomy.     

The SAGES Bariatric Surgery Outcome Initiative

Background The recent initiative for identifying centers of excellence in bariatric surgery calls for documentation of surgical outcomes. The SAGES Outcomes Initiative is a national database introduced in 1999 as a method for surgeons to accumulate and compare their data with summary national data. A bariatric-specific dataset was established later in 2001. The aim of this study was to compare the outcomes of bariatric surgery from the Society of American Gastrointestinal Endoscopic Surgeons’ (SAGES) bariatric database with data derived from a national administrative database of academic centers. Methods Between 2001 and 2004, 24 surgeons with 1,954 patients participated in the SAGES Bariatric Outcome Initiative, and 97 institutions with 42,847 patients participated in the University HealthSystem Consortium (UHC) database. Only 7 of the 24 surgeons participating in the SAGES Bariatric Outcome Initiative submitted more than 50 cases. The main outcome measures included demographics, comorbidities, type of bariatric procedure, operative time, length of hospital stay, short- and long-term complications, mortality, and weight loss. Results Both datasets were comparable for gender. Roux-en-Y gastric bypass had been performed for 88% of the patients in the SAGES database and 96% of the patients in the UHC database. Associated comorbidities were similar between the two groups except for a higher rate of hyperlipidemia for the patients in the SAGES database. The SAGES database contains more bariatric-specific information such as body mass index, operative time, blood loss, bariatric-specific complications, long-term complications, and weight loss data than the UHC database. According to the available data, no statistically significant differences exist between the two datasets in terms of perioperative complications and mortality. Conclusions The SAGES Bariatric Outcome Initiative provides valuable bariatric-specific data not currently available in an administrative database that may be useful for benchmarking purposes. However, this database is currently underutilized. Presented at the Annual 2005 Meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Hollywood, FL, USA, 14 April 2005     

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.     

Impacts of bariatric surgery on adverse liver outcomes: a systematic review and meta-analysis

BackgroundBariatric surgery has been reported to improve degeneration, inflammation, and fibrosis in nonalcoholic fatty liver disease, but the effects of bariatric surgery on the associated clinical outcomes is not known.ObjectivesThis work aimed to assess the impacts of bariatric surgery on adverse liver outcomes in people with obesity.SettingAn electronic search was performed on EMBASE, PubMed, and Cochrane Central Register of Controlled Trials (CENTRAL).MethodsThe primary outcome was the incidence of adverse liver outcomes following bariatric surgery. Liver cancer, cirrhosis, liver transplantation, liver failure, and liver-related mortality were defined as adverse hepatic outcomes.ResultsWe analyzed data from 18 studies comprising 16,800,287 post bariatric surgical patients and 10,595,752 control patients. We found that bariatric surgery reduced the risk of adverse liver outcomes in people with obesity (hazard ratio [HR] = .33, 95% confidence interval [CI] = .31–.34; I² = 98.1%). The subgroup analysis showed that bariatric surgery reduced the risk of nonalcoholic cirrhosis (HR = .07, 95% CI = .06–.08; I² = 99.3%) and liver cancer (HR = .37, 95% CI = .35–.39; I² = 97.8%), although bariatric surgery may also increase the risk of postoperative alcoholic cirrhosis (HR = 1.32, 95% CI = 1.35–1.59).ConclusionsThis systematic review and meta-analysis revealed that bariatric surgery lowered the incidence of adverse hepatic outcomes. However, bariatric surgery may also increase the risk of alcoholic cirrhosis after surgery. Future randomized controlled trials are required to further investigate the effects of bariatric surgery on liver of people with obesity.     

Perioperative morbidity associated with bariatric surgery: an academic center experience

HYPOTHESIS: As the demand for bariatric surgery increases, it becomes increasingly important to define predictors of morbidity and mortality. We hypothesize that specific clinical variables predict postoperative morbidity after bariatric surgery.Design, Setting, and PATIENTS: This is a retrospective review of 452 patients undergoing inpatient bariatric surgery at an academic tertiary care institution. INTERVENTIONS: Patients underwent open or laparoscopic gastric bypass or biliopancreatic diversion with duodenal switch at Oregon Health & Science University, Portland, from 2000 to 2003. Patient data were prospectively entered into a database. MAIN OUTCOME MEASURES: Postoperative morbidity and mortality were analyzed among all patients, and logistic regression was used to identify clinical predictors of morbidity. RESULTS: Major and minor morbidity rates were 10% and 13%, respectively; mortality was 0.9%. Age was associated with postoperative complications (odds ratio = 1.056 for each additional year). Duodenal switch was also associated with higher morbidity than gastric bypass (odds ratio = 2.149). Body mass index, sex, diabetes, surgical approach, and surgeon experience did not predict complications. CONCLUSIONS: Increased age is a predictor of complications after bariatric surgery. Duodenal switch is also associated with a higher morbidity rate than gastric bypass. Surgeons should caution older patients (>/=60 years) of a higher risk of postoperative complications, and a higher risk associated with duodenal switch. Large multicenter studies will be necessary to accurately define other clinical predictors of morbidity and mortality after bariatric surgery.     

Adherence to outpatient program postoperative appointments after bariatric surgery

BACKGROUND: Surgery is the only treatment that has been proved to have beneficial long-term effects for the morbidly obese (body mass index >40 kg/m(2)). One of the requirements for the Centers for Excellence program instituted by American Society for Bariatric Surgery is to have a system in place to provide comprehensive follow-up care. A recent study showed that the complication rate after bariatric surgery is 39.6% during the 180 days after discharge. Inadequate adherence to follow-up care has been recognized as contributory to the development of complications after bariatric surgery. The purpose of this study was to examine the variables that relate to patients' adherence to scheduled appointments after bariatric surgery. METHODS: A block entry logistic regression analysis was done from a database of an outpatient bariatric program that contained cross-sectional data collected for 1 year. Patient adherence to follow-up was defined as having 1 postoperative follow-up appointment within 90 days of undergoing surgery. A total of 375 subjects completed the preoperative program and underwent either laparoscopic Roux-en-Y gastric bypass (84.3%) or gastric banding (15.7%). RESULTS: Of the 14 variables used in the analysis, 5 were statistically significant (P <.05) predictors of adherence: age, body mass index, marital status, employment status, and insurance coverage. CONCLUSION: Incorporation of the identified predictors into preoperative screening tools to flag patients at risk of nonadherence might improve follow-up care. Additional research is needed on possible interventions to decrease complications after bariatric surgery.     

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.     

Impact of preoperative opioid use on health outcomes after bariatric surgery

BackgroundOpioid consumption in North America has risen to alarming levels and represents a potentially modifiable risk factor in perioperative management. Chronic pain and obesity are commonly associated and bariatric surgery remains the most effective intervention for weight loss in morbidly obese patients.ObjectivesTo understand how preoperative opioid use impacts surgical outcomes in patients undergoing bariatric surgery.SettingThe Ontario Bariatric Registry.MethodsData collected in the Ontario Bariatric Registry between 2010 and 2018 were used for this retrospective study. Preoperative opioid use was retrospectively retrieved from the medication review during preoperative assessment. Primary outcomes were complications and readmissions at 30 and 90 days of surgery. Secondary outcomes included hospital length of stay and complication types at 30 and 90 days. Analyses were risk-adjusted for procedure type and patient-specific risk factors, such as age, sex, race, body mass index, and co-morbid conditions.ResultsOverall, 5357 patients were included in the study. Among those, 12% (n = 643) used opioids preoperatively. Risk-adjusted analyses demonstrated that opioid users, compared with opioid-naïve patients, had a longer length of stay (odds ratio: 2.50, 95% confidence interval: 1.05–6.00, P < .05) and higher rates of complications at 30 days (odds ratio: 1.40, 95% confidence interval: 1.02–2.18, P < .05). Subgroup analyses revealed that within preoperative opioid users, patients who underwent Roux-en-Y gastric bypass had poorer outcomes than those who underwent sleeve gastrectomy.ConclusionOpioid use is common before bariatric surgery and is independently associated with prolonged length of stay and complication rates at 30 days. Preoperative opioid use represents a potentially modifiable risk factor and a unique target to improving the quality of surgical care.     

Bariatric surgery improves the circulating numbers and biological activity of late outgrowth endothelial progenitor cells

BackgroundAlthough the salutary effects of bariatric surgery as a treatment for excess weight and type 2 diabetes are established, there is scant evidence for effects on other contributors to cardiovascular diseases such as repair of endothelial dysfunction. This study evaluates outcomes of bariatric surgery on late outgrowth endothelial progenitor cells (LOEPCs), a cell phenotype essential for endothelial repair.MethodsPatients with a body mass index >35 kg/m² and type 2 diabetes were enrolled into either medical or bariatric surgical arms. Primary outcomes included analysis of isolated LOEPCs from peripheral blood for growth, function, and mitochondrial respiration. Plasma was used for metabolic profiling.ResultsMedical arm patients showed no improvement in any of the parameters tested. Bariatric surgical arm patients showed a 24% reduction in body mass index as early as 3 months postintervention and resolution of type 2 diabetes at 24 months postintervention (HbA1c 31% reduction; fasting glucose 29% reduction). Bariatric surgery increased the numbers of LOEPCs 8-fold and increased LOEPC network formation 3-fold at 24 months postintervention. The increased numbers and activity of LOEPCs in the bariatric surgical arm correlated with improvements in body mass index, insulin, and triglyceride levels only at 24 month postintervention. LOEPC mitochondrial respiration displayed a trend toward improvement compared with baseline as evidenced by an increase (36%) at 24 months in the bariatric arm.ConclusionBariatric surgery increases LOEPC levels and activity, which correlates with weight loss and improved metabolic profile at 24 months postintervention.     

Racial disparities in bariatric surgery postoperative weight loss and co-morbidity resolution: a systematic review

While bariatric surgery is an accepted treatment for morbid obesity, the impact of race on surgical outcomes remains unclear. This systematic review aims to compare differences in weight loss and co-morbidity outcomes among various races after bariatric surgery. PubMed, Medline, and SCOPUS databases were queried to identify publications that included more than 1 racial group and reported weight loss outcomes after bariatric surgery. A total of 52 studies were included. Non-Hispanic black (NHB) patients comprised between 5.5% and 69.7% and Hispanic patients comprised between 4.7% and 65.3% of the studies’ populations. Definitions of weight loss success differed widely across studies, with percent excess weight loss being the most commonly reported outcome, followed by percent total weight loss and change in body mass index (BMI). Statistical analyses also varied, with most studies adjusting for age, sex, preoperative weight, or BMI. Some studies also adjusted for preoperative co-morbidities, including diabetes mellitus, hypertension, and hyperlipidemia, or socioeconomic status, including income, education, and neighborhood poverty. The majority of studies found less favorable weight loss in NHB compared to Hispanic and non-Hispanic white (NHW), patients while generally no difference was found between Hispanic and NHW patients. The trend also indicates no association between race and resolution of obesity-related co-morbidities. Racial minorities lose less weight than NHW patients after bariatric surgery, although the factors associated with this discrepancy are unclear. The heterogeneity in reporting weight loss success and statistical analyses amongst the literature makes an estimation of effect size difficult. Generally, racial disparity was not seen when examining co-morbidity resolution after surgery. More prospective, robust, long-term studies are needed to understand the impacts of race on bariatric surgery outcomes and ensure successful outcomes for all patients, regardless of race.