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.     

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.     

The effect of bougie size and distance from the pylorus on dehydration after laparoscopic sleeve gastrectomy: an analysis of the ACS-MBSAQIP database

BackgroundDehydration is the most common cause of readmission after laparoscopic sleeve gastrectomy (SG). Bougie size and distance from the pylorus, both of which have been associated with rates of dehydration postoperatively, varies by surgeon and across institutions.ObjectivesTo determine if there is an association between bougie size or distance from the pylorus on the rate of dehydration after laparoscopic SG.SettingAmerican College of Surgeons Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database.MethodsAll patients undergoing first-time, elective laparoscopic SG from 2015–2016 were identified. The association of bougie size and distance from the pylorus on the rate of dehydration within the first 30 days postoperatively was investigated.ResultsThe inclusion criteria were met by 170,751 patients. The most commonly used bougie size was 36 Fr and the most common distance from the pylorus at which the gastric sleeve was started was 5 cm. Patients were divided into 4 groups based on bougie size and distance from the pylorus (Group 1: bougie size <36 Fr, pylorus distance <4 cm; Group 2: bougie size ≥36 Fr, pylorus distance <4 cm; Group 3: bougie size ≥36 Fr, pylorus distance ≥4 cm; and Group 4: bougie size <36 Fr, pylorus distance ≥4 cm). Patients in Group 4 were significantly less likely than any other group to experience dehydration-related complications.ConclusionBoth distance from the pylorus and bougie size are significantly associated with dehydration-related complications after SG. Consideration should be made for standardizing these technical aspects of SG to help reduce the rate of postoperative dehydration and hospital readmission.     

Trends in revisional bariatric surgery using the MBSAQIP database 2015-2017

BackgroundThe third most common bariatric surgery is revisional bariatric surgery. The American College of Surgeons tracks outcomes using the Metabolic and Bariatric Surgery Accreditation Quality Initiative Program database. We used this database to examine trends in revisional bariatric surgery.ObjectiveTo evaluate how trends in bariatric revisional surgery have changed in recent years.SettingUniversity Hospital, United States.MethodsThe Metabolic and Bariatric Surgery Accreditation Quality Initiative Program database for 2015 to 2017 was examined for revisions of bariatric surgery. Patients who underwent revisional bariatric surgery were identified by the primary Current Procedural Terminology code, the REVCONV and PREVIOUS_SURGERY field as well as secondary Current Procedural Terminology codes. There is no exact code for sleeve gastrectomy (SG) to laparoscopic Roux-en-Y gastric bypass (LRYGB), so we used 43644 (GB)+REVCONV+PREVIOUS_SURGERY for this.ResultsFor the years 2015 to 2017 there were 57,683 revisions/conversions of 528,081 patients. The number of revisions increased over the study period by 5213 cases. The most common revision was laparoscopic adjustable gastric band (LAGB) to SG with 15,433 cases and the second was LAGB to LRYGB with 10,485 cases. There were 14,715 LAGB removals. It is more difficult to track SG to LRYGB but there were 8491 unlisted cases, which may have been sleeve to bypass.ConclusionLAGBs are being taken out or converted, and this group makes up the largest portion of revisions and conversions. It is difficult to track SG to LRYGB, but the number of unlisted cases continues to climb. This will likely surpass LAGB conversions with time. The Metabolic and Bariatric Surgery Accreditation Quality Initiative Program should be modified to capture revisions/conversions of SG.     

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.     

Safety of concomitant cholecystectomy with laparoscopic sleeve gastrectomy and gastric bypass: a MBSAQIP analysis

BackgroundGallstone disease occurs more commonly in the obese population and is often diagnosed during the preoperative evaluation for bariatric surgery.ObjectivesThis study analyzed outcomes of laparoscopic gastric bypass (LGB) and laparoscopic sleeve gastrectomy (SG), with and without cholecystectomy (LC), using data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.SettingPatients reported to Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participating centers in the United States and Canada in 2015.MethodsAll cases of LGB and SG, with and without LC, were analyzed. A 1:1 propensity-matched cohort was created for both SG and LGB, with and without concomitant LC. Multivariate logistic regression stratified by procedure was used to identify predictors of major complications after SG and LGB, using concomitant LC as a predictor. We also constructed a model for surgical site infections (SSIs) for SG group.ResultsOf 98,292 sleeve operations, 2046 (2%) had concomitant LC. Of 44,427 bypass operations, 1426 (3%) had concomitant LC. For the sleeve group, concomitant LC increased operative time by an average of 27 minutes but did not affect length of stay, mortality, or major complications. Concomitant LC was associated with increased SSI (1% versus .4%) and need for reoperation (1.6% versus .7%) in univariate models. After adjusting for other predictors, concomitant LC was associated with increased risk for SSI (odds ratio 2.5, confidence interval 1.0–5.9, P = .04). For the bypass group, concomitant LC increased operative time by an average of 28 minutes to the operation, and postoperative length of stay averaged ～5 hours longer (2.4 versus 2.2 d, P = .03). Thirty-day complications were similar between the groups. On multivariate analysis, concomitant LC was not a significant risk factor for major complications. Only operative time was an independent factor for major complications.ConclusionsConcomitant LC with laparoscopic sleeve gastrectomy or gastric bypass did not affect mortality or risk of major complication. For sleeve patients, concomitant LC was associated with a .6% increased risk (.4% to 1.0%) of SSI. Concomitant LC with laparoscopic sleeve gastrectomy or gastric bypass is safe when indicated for gallstone disease.     

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.     

Bariatric surgery outcomes in oxygen-dependent patients: analysis of the MBSAQIP database

BackgroundThe number of bariatric procedures performed on complex, oxygen-dependent patients has increased. These patients often have other medical co-morbidities that can be improved after bariatric surgery; however, questions remain regarding their perioperative risk.ObjectiveTo assess the safety of bariatric surgery among oxygen-dependent patients, and to compare outcomes in this patient group after laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy.SettingUniversity and private hospitals enrolled in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry.MethodsThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data from 2015 to 2017 was analyzed. A multivariable regression analysis was performed looking at 30-day serious complications for oxygen-dependent patients, with a secondary propensity-matched analysis performed comparing patients undergoing laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass.ResultsIn total, 430,396 patients were analyzed, 3034 (0.7%) of whom were oxygen dependent. The absolute 30-day complication rate among oxygen-dependent patients was more than twice as high (8.24% versus 3.46%, P < .001). The postoperative leak (.69% versus .41%, P = .017), bleed (2.08% versus .91%, P < .001), cardiac event (.16% versus .07%, P = .034), and pneumonia rate (.89% versus .19%, P < .001) were all significantly higher. Mortality was significantly higher among oxygen-dependent patients (.49% versus .09%, P < .001). On multivariable analysis, oxygen dependency was an independent predictor of adverse outcomes (odds ratio 1.30 [1.22–1.50], P < .001). Laparoscopic Roux-en-Y gastric bypass was associated with a statistically significant higher complication rate compared with laparoscopic sleeve gastrectomy (13.23% versus 5.16%, P < .001).ConclusionOxygen-dependent patients undergoing bariatric surgery are at a higher risk of both morbidity and mortality postoperatively.     

Laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass in the pediatric population: a MBSAQIP analysis

BackgroundThe growing prevalence of childhood obesity has resulted in an increased number of children and adolescents who undergo bariatric surgery. The safety of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) remains controversial in the pediatric population.ObjectiveTo assess the safety of LSG compared with LRYGB in patients aged ≤21 years.SettingA retrospective analysis of the 2016 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.MethodsPatients aged ≤21 years who underwent LSG or LRYGB were identified in the 2016 to 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. A logistic regression model was used to create a 1:1 propensity-score matched cohort adjusting for age, sex, body mass index, and obesity-related co-morbidities. Unmatched and propensity-score matched analyses were performed to compare baseline characteristics and outcome data between LSG and LRYGB procedure groups. Primary outcomes of interest included 30-day major complications, such as death, reoperation, and anastomotic leak.ResultsOf 3571 patients included in our study, 2911 (81.52%) underwent LSG and 660 (18.48%) underwent LRYGB. Patients who underwent LRYGB had an increased body mass index and a higher rate of obesity-related co-morbidities. The LRYGB group had a significantly increased rate of major complications within the first 30 days in both the unmatched cohort (4.55% versus 1.34%, P < .001) and the propensity-score matched cohort (4.57% versus .91%, P < .001).ConclusionsLSG and LRYGB are both relatively safe to perform in the pediatric population with acceptable complication rates and low mortality. However, LSG demonstrated a significantly decreased rate of major complications in the first 30 days compared with LRYGB.     

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.     

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.     

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.     

Safety of bariatric surgery in patients older than 65 years

BackgroundThe increase in life expectancy along with the obesity epidemic has led to an increase in the number of older patients undergoing bariatric surgery. There is conflicting evidence regarding the safety of performing bariatric procedures on older patients.ObjectiveThe purpose of this study was to compare the safety of laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) for older patients (>65 yr).SettingNationwide analysis of accredited centers.MethodsThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 to 2017 database was used to identify nonrevisional laparoscopic RYGB and SG procedures. Comparisons were made based on patient age. Clinical outcomes included postoperative events and mortality.ResultsThere was a total 13,422 and 5395 matched pairs for SG and RYGB in comparing patients aged 18 years to those aged 65 and >65 years, respectively, and 5395 matched RYGB and SG procedures performed in patients >65 years. The complication rate was higher in older patients undergoing RYGB compared with SG (risk difference = 2.39%, 95% confidence interval: 1.57%–3.21%, P < .0001). When comparing older to younger patients, the older group had a higher complication rate for SG but not for RYGB (SG: risk difference = 1.01%, 95% confidence interval: .59%–1.43%, P < .0001, RYGB: risk difference = .59%, 95% confidence interval: ?.29% to 1.47%, P = .2003).ConclusionsOverall complication rates of bariatric surgery are low in patients >65 years. SG appears to have a favorable safety profile in this patient population compared with RYGB. The overall complication rate for RYGB is not significantly different between the older and younger groups.     

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.     

Racial disparities in perioperative outcomes after bariatric surgery

BackgroundNonHispanic black patients bear a disproportionate burden of the obesity epidemic and its related medical co-morbidities. While bariatric surgery is the most effective treatment for morbid obesity, black patients access bariatric surgery at lower rates than nonHispanic white patients.ObjectivesTo examine racial differences before bariatric surgery and in short-term perioperative outcomes and complications, and the extent to which race is independently associated with perioperative morbidity and mortality.SettingMetabolic and Bariatric Surgery Accreditation and Quality Improvement Program national database.MethodsData were extracted from the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use File. Multivariate analysis was used to identify differences in mortality, length of stay, readmission, and reintervention by race in patients undergoing laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy (SG).ResultsA total of 108,198 patients were included in the analysis. There were significant differences in perioperative disease burden. Black patients had a higher body mass index at the time they underwent surgery (laparoscopic Roux-en-Y gastric bypass: 48.0 versus 45.7 kg/m²; SG: 46.8 versus 44.9 kg/m²; P < .001). Black patients had significantly longer length of stay and higher rates of readmission in both the laparoscopic Roux-en-Y gastric bypass and SG groups. In the SG group, black patients had significantly higher 30-day mortality (.2% versus .1%, odds ratio = 3.613, 95% confidence interval 1.990–6.558, P < .001) and higher rates of reoperation or reintervention.ConclusionsWe found significant racial disparities in bariatric surgery outcomes, including higher mortality in black patients undergoing SG. The specific causes of these disparities remain unclear and must be the subject of future research.     

Operative time as a marker of quality in bariatric surgery

BackgroundFew studies have examined the effect of prolonged operative time (OT) on outcomes in laparoscopic bariatric surgery. Existing studies mostly focus on 30-day complications, whereas serious complications may not occur until well after 30 days from the index operation.ObjectiveTo determine the effect of prolonged OT on 1-year morbidity and mortality after laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG).SettingThe Bariatric Outcomes Longitudinal Database (BOLD).MethodsData on primary LRYGB and LSG cases performed between 2008 and 2012 in the BOLD were analyzed. Converted cases and cases concurrent with other procedures were excluded. Multivariate logistic regression was used to assess the association between OT and 1-year morbidity and mortality, with adjustment for preoperative demographic and clinical characteristics.ResultsA total of 93,051 cases were examined, including 74,745 (80.3%) LRYGB and 18,306 (19.7%) LSG cases. For LRYGB, mean OT was 104 minutes (standard deviation [SD] 46.6). Every additional 10 minutes of OT was associated with increased odds of 1-year mortality (adjusted odds ratio [AOR] 1.04; P = .02), leak (AOR 1.07; P < .0001), and any adverse event (AOR 1.03; P < .001). For LSG, mean OT was 78 minutes (SD 37.4). Every additional 10 minutes of OT was associated with increased odds of 1-year leak (AOR 1.07; P = .0002). Data on patients lost to follow-up was unavailable.ConclusionProlonged operative time is associated with a significant increase in the odds of mortality and serious complications after laparoscopic bariatric surgery. Operative time may be a useful marker of quality in primary laparoscopic bariatric surgery.     

Bariatric surgery in the elderly: a randomized prospective study comparing safety of sleeve gastrectomy and Roux-en-Y gastric bypass (BASE Trial)

BackgroundThe aging population along with the obesity epidemic has increased the number of older patients undergoing bariatric surgery. Nevertheless, there is still conflicting data regarding surgical safety in this population.ObjectivesThe aim of this study was to compare the surgical morbidity of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) for older patients.SettingUniversity hospital, São Paulo, Brazil.MethodsWe performed a prospective randomized clinical trial from September 2017 to May 2019. Obese patients aged ≥65 years were randomized to LSG or LRYGB. Data collection included demographic information, body mass index (BMI), and co-morbidities. We assessed readmission, postoperative complications, and mortality. Complications were scored according to Clavien-Dindo classification.ResultsA total of 36 patients, with a BMI between 35.5 and 52.8 kg/m² were randomized to either LSG (18 patients) or LRYGB (18 patients). The overall complication rate was similar between LSG and LRYGB (3 versus 7, P = .13). Severe complication was more prevalent in LRYGB patients but had no statistically significant difference (0 versus 3, P = .07). Each group had 1 readmission and there was no mortality in 90-day follow-up.ConclusionsMorbidity and mortality rates of bariatric surgery are low in elderly obese patients. Despite not statistically significant, LSG had a lower rate of severe complications compared with LRYGB in this population setting.     

First assistant impact on early morbidity and mortality in bariatric surgery

BackgroundThe future of bariatric surgery depends largely on how effectively residents and fellows are trained. The challenge is to assure patient safety during training. Our study compares the impact of first assistants on patient outcomes after Roux-en-Y gastric bypass and sleeve gastrectomy.MethodsA retrospective review of primary, elective Roux-en-Y gastric bypass and sleeve gastrectomy procedures performed in 2015 and 2016 from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participant user files was performed. Patient cohorts were categorized by the level of training of the surgical first assistant (FA). Multivariate regression models were developed to determine the impact of the FA level on patient outcomes, adjusting for patient demographic characteristics and co-morbid conditions.ResultsCompared with an attending weight loss surgeon as FA, minimally invasive surgery fellows and general surgery residents were more likely to have an unplanned admission to the intensive care unit (ICU) within 30 days (odds ratio [OR] 1.422, 95% confidence interval [CI] 1.196–1.691; OR 1.206, 95% CI 1.034–1.406, respectively, P < .0001) and were more likely to have a 30-day hospital readmission (OR 1.143, 95% CI 1.056–1.236; OR 1.127, 95% CI 1.055–1.204, respectively, P < .0001). Compared with having a weight loss surgeon as FA, operative duration was significantly longer for all other assistant levels, or no assistant (P < .0001).ConclusionThe training level of the FA does not impact early patient mortality or reoperation rates after Roux-en-Y gastric bypass or sleeve gastrectomy. However, unplanned intensive care unit admissions and readmissions within 30 days were significantly associated with surgical resident or minimally invasive surgery fellow FAs. Further analysis is needed to understand this cause and effect; however, these data provide direction to redesign residency and fellowship training.     

Racial disparities in perioperative outcomes after metabolic and bariatric surgery: a case-control matched study

BackgroundMetabolic and bariatric surgery remains a safe and effective treatment for severe obesity. Ethnic minorities are disproportionately affected by obesity but are less likely to undergo metabolic and bariatric surgery. There remains controversy about outcomes among black patients compared with other ethnic groups after bariatric surgery.ObjectiveThe purpose of this case-control matched study using the largest clinically available bariatric data was to determine if there is racial disparity in perioperative outcomes after primary bariatric surgery.SettingsUniversity Hospital, United States.MethodsPatients who had a primary Roux-en-Y gastric bypass or sleeve gastrectomy in 2015 to 2016 were identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Case controlled–matched analyses were performed.ResultsWe compared 80,238 equally matched nonHispanic black and white patients. Operative length and hospital stay were longer in black patients. All-cause mortality was 2-fold higher in black patients (P = .003). Black patients had significantly higher rates of 30-day readmission and reintervention (P < .0001), pulmonary embolism (P =.0004), and aggregate renal (P = .01) and venous thromboembolic (P = .001) complications. Postoperative myocardial infarction, cardiac arrest, pulmonary embolism, and all-cause mortality were significant higher in black patients after sleeve gastrectomy, but not Roux-en-Y gastric bypass.ConclusionIn this study, pulmonary embolism and mortality were significantly higher in black patients after sleeve gastrectomy. Further studies are needed to determine causality.     

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.