Racial disparity in causes for readmission following bariatric surgery

BackgroundReadmission after bariatric surgery is not cost-effective and is a preventable quality metric within standardized practices. However, reasons for readmission among racial/ethnic bariatric cohorts are less explored and understood.ObjectiveOur study objective was designed to compare reasons for readmission among racial/ethnic cohorts of bariatric patients.SettingAcademic hospital.MethodsWe performed a retrospective analysis of the 2015–2018 MBSAQIP databases to identify Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) cases. Regression analyses determined predictors of all-cause and bariatric-related readmissions. Reasons for readmission were compared between racial/ethnic cohorts using propensity score matching.ResultsMore than 550 000 RYGB and SG cases were analyzed. The readmission rate was 3%–4%. Black race, RYGB, robot-assisted approach, and numerous co-morbidities were independently associated with readmission (P <.05). In RYGB cases, black (versus white) patients were at decreased odds of leak-related (P < .001) and cardiovascular-related (P < .001) readmissions but at increased odds of readmissions related to renal complications (P < .001). Hispanic (versus white) patients had a higher likelihood of venous thromboembolism–related readmissions (P < .001). In SG cases, black (versus white) patients had a similar lower likelihood of readmission related to leaks or cardiovascular complications but higher odds of readmission related to renal complications (P < .001). Hispanic (versus black) patients had a higher likelihood of leak-related readmissions (P < .001).ConclusionReadmission reasons after bariatric surgery vary by race/ethnicity. Perioperative pathways to mitigate complications, including readmissions, should consider these disparate findings.     

Racial disparities in bariatric perioperative outcomes among the elderly

BackgroundBariatric surgery outcomes in elderly patients have been shown to be safe, but with a higher rate of adverse outcomes compared with nonelderly patients. The impact of race on bariatric surgery outcomes continues to be explored, with recent studies showing higher rates of adverse outcomes in black patients. Perioperative outcomes in racial cohorts of elderly bariatric patients are largely unexplored.ObjectiveThe goal of this study was to compare outcomes between elderly non-Hispanic black (NHB) and non-Hispanic white (NHW) bariatric surgery patients to determine whether outcomes are mediated by race.SettingAcademic hospital.MethodsPatients who had a primary Roux-en-Y (RYGB) and sleeve gastrectomy (SG) in the period 2015–2018 and were at least 65 years of age were identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Data File (MBSAQIP PUF). Selected cases were stratified by race. Outcomes were compared between matched racial cohorts. Multivariate regression analyses were performed to determine whether race independently predicted morbidity.ResultsFrom 2015 to 2018, 29,394 elderly NHW (90.8%) and NHB (9.2%) patients underwent an RYGB or SG. At baseline, NHB elderly patients had a higher burden of co-morbid conditions, resulting in higher rates of overall (7.7% versus 6.4%, P = .009) and bariatric-related (5.4% versus 4.1%, P = .001) morbidity. All outcome measures were similar between propensity-score-matched racial elderly bariatric patient cohorts. On regression analysis, NHB race remained independently correlated with morbidity (odds ratio [OR] 1.3, 95% CI 1.08–1.47, P = .003).ConclusionRYGB and SG are safe in elderly patient cohorts, with no differences in adverse outcomes between NHB and NHW patients, accounting for confounding factors. While race does not appear to impact outcomes in the elderly cohorts, NHB race may play a role in access.     

Obstetric outcomes after restrictive bariatric surgery: What happens after 2 consecutive pregnancies?

BackgroundThe objective of this study was to compare the outcomes of 2 consecutive pregnancies of the same women who conceived after restrictive bariatric surgeries.MethodsA retrospective study comparing consecutive pregnancy outcomes of the same women, who conceived before and twice after a restrictive bariatric surgery, was conducted.ResultsThis study included 109 women, and therefore, 327 paired pregnancies: 109 pregnancies preceded and 218 followed restrictive bariatric surgery (87% had laparoscopic banding, and 13% had silastic ring vertical gastroplasty). Both prepregnancy and predelivery body mass index were significantly lower after bariatric surgery (36.7±4.4 versus 31. 5±5.5, P<.001; 40.6±5.5 versus 35.3±6.1, P<.001; respectively). This effect was preserved at the subsequent pregnancy (31.5±5.5 versus 31.3±6.3, P = .609, and 35.3±6.1 versus 35.1±5.9, P = .706, respectively). The rates of hypertensive disorders and gestational diabetes mellitus were significantly lower after the bariatric operation, for the first and the second pregnancy (21% versus 7.4% and 4.7%, P = .009, and 19% versus 5.6% and. 6.6%, P = .007, respectively). The rate of macrosomic newborn was significant lower in the second postbariatric pregnancy (11.1% before versus 1.1% after second pregnancy, P = .02). Using multiple logistic regression models controlling for maternal age, prepregnancy body mass index, and the type of surgery, the reduction in hypertensive disorders (adjusted odds ratio (OR) .3, 95% confidence interval (CI) .12–.82; P = .018 for the first postoperative pregnancy and adjusted OR .2, 95% CI .06–.64; P = .007 for the second postoperative pregnancy), and gestational diabetes mellitus (adjusted OR .2, 95% CI .06–.48; P = .001 for the first postoperative pregnancy and adjusted OR .3, 95% CI .05–.51; P = .002 for the second postoperative pregnancy) remained significant.ConclusionsA significant decrease in pregnancy complications, such as hypertensive disorders and gestational diabetes mellitus, is achieved after a restrictive bariatric surgery. This improvement is maintained at the second subsequent pregnancy.     

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.     

Impact of insurance plan design on bariatric surgery utilization

BackgroundBariatric surgery is underused in the United States.ObjectivesThis study examined whether utilization of bariatric surgery is associated with payor and insurance plan type, after removing potential sociodemographic confounders.SettingThe study used Pennsylvania Health Care Cost Containment Council’s data in 5 counties of Pennsylvania from 2014 to 2016.MethodsBariatric surgery patients and eligible patients who did not undergo surgery were identified and 1:1 matched by age, sex, race, and zip code (n = 5114). A logistic regression was performed to investigate the association of payor type and insurance plan within payor type with odds of undergoing bariatric surgery.ResultsThe odds of undergoing bariatric surgery were not statistically different based on payor type. Medicare preferred provider organization plan was associated with greater odds of undergoing surgery (odds ratio [OR] = 2.49, 95% confidence interval [CI] 1.23–5.04, P = .01) compared with Medicare health maintenance organization (HMO). Medicaid fee for service plan was associated with smaller odds of undergoing surgery (OR = .04, 95% CI .005–.27, P = .001) compared with Medicaid HMO. Individuals with Blue Cross preferred provider organization (OR = 2.43, 95% CI 1.83–3.24, P < .001), Blue Cross fee for service (OR = 1.79, 95% CI 1.32–2.43, P < .001), and Blue Cross HMO (OR = 1.85, 95% CI 1.39–2.46, P < .001) had greater odds of undergoing surgery compared with those with other commercial HMO plans.ConclusionsSpecific aspects of insurance plan design, rather than more general payor type, is more strongly associated with the utilization of bariatric surgery. Further investigations could identify which components of insurance plan design have the greatest influence on the utilization of bariatric surgery.     

Racial Disparities in Mortality in Patients Undergoing Bariatric Surgery in the USA

Background

Non-Hispanic blacks bear a disproportionate burden of the growing obesity epidemic. Bariatric surgery is an effective treatment for morbid obesity. We sought to assess for racial disparities in short-term outcomes following bariatric surgery.

Methods

Patients undergoing bariatric surgery were extracted from the Nationwide Inpatient Sample between 1999 and 2007. In-hospital mortality and length of stay were compared between different racial groups undergoing bariatric surgery after stratification by gender, and multivariate analysis was conducted to adjust for demographic, surgery year, and clinical and hospital characteristics.

Results

There were 115,507 bariatric surgeries. Overall mortality rate was 2.5 deaths per 1,000 and was higher among non-Hispanic blacks compared to non-Hispanic whites (3.7 vs. 2.3 per 1,000; P?=?0.007). Racial mortality disparities were most pronounced among males and at hospitals with lowest surgical volumes. In multivariate analysis, predictors of mortality were non-Hispanic black race (odds ratio [OR], 1.73; 95 % confidence interval [CI], 1.22–2.45), increasing age, increasing Charlson index (OR, 1.26; 95 % CI, 1.16–1.37), Medicare (OR, 2.13; 95 % CI, 1.57–2.91), and Medicaid (OR, 3.35; 95 % CI, 2.29–4.91) insurance. Incremental calendar year had reduced odds of mortality (OR, 0.80; 95 % CI, 0.76–0.83). Above national median neighborhood income (OR, 0.59; 95 % CI, 0.42–0.83) was protective in males, while teaching hospital status conveyed greater mortality (OR, 2.12; 95 % CI, 1.40–3.22).

Conclusions

Non-Hispanic blacks undergoing bariatric surgery demonstrate higher in-hospital mortality than their racial counterparts. It is unclear if this disparity is due to susceptibility to obesity-related mortality or suboptimal delivery of healthcare in the perioperative setting.     

Cholecystectomy increases the risk of dumping syndrome and postbariatric hypoglycemia after bariatric surgery

BackgroundDumping syndrome (DS) and postbariatric hypoglycemia (PBH) are frequent complications of bariatric surgery. Bile acids (BA) have been implicated in their pathogenesis because both bariatric surgery and cholecystectomy (CCx) are known to modulate human BA metabolism.ObjectivesOur investigation aimed to compare the prevalence of self-reported complaints of DS and PBH in postbariatric patients with and without CCx.SettingA large peripheral hospital in the Netherlands.MethodsAll patients who underwent bariatric surgery in 2008–2011 received standardized questionnaires on DS/PBH complaints. The relative risk (RR) of CCx was calculated as the risk of perceived DS and PBH in patients with and without CCx.ResultsOf 590 participants, 146 (25%) had CCx before assessment of DS/PBH complaints. Participants were mostly female (82%) with median age of 46 years (interquartile range, 39–53). The RR for DS after CCx was higher in patients with body mass index <30 kg/m² at the study (RR, 1.59; 95% CI, 1.04–2.42; P = .007) and in primary Roux-and-Y gastric bypass surgery patients (RR, 1.63; 95% CI, 1.10–2.42; P = .018). Detailed analysis of the latter group associated women, age younger than 50 years, without diabetes and (most prominently) with excess weight loss ≥70% (RR, 2.73; 95% CI, 1.57–4.77; P = .0004) with greater risk of DS. The RR for PBH was higher after CCx in sleeve gastrectomy patients (RR, 4.5; 95% CI, 1.00–20.3; P = .036).ConclusionHigh suspicion of DS and PBH after CCx is increased after bariatric surgery in certain subgroups, suggesting involvement of altered BA metabolism in their pathophysiology.     

Outcomes of bariatric surgery in patients with obesity and compensated liver cirrhosis

BackgroundObesity is a major health burden worldwide and is associated with nonalcoholic fatty liver disease, which can lead to cirrhosis. Bariatric surgery is increasingly being used to treat obesity, and the number of patients with obesity and cirrhosis undergoing bariatric surgery is also rising. However, the safety and feasibility of bariatric surgery in patients with obesity and cirrhosis are controversial.ObjectivesIn this meta-analysis, we compared postoperative complications, mortality, and weight loss between patients with and without cirrhosis undergoing bariatric surgery.SettingAn electronic search of Medline, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL).MethodsPatient morbidity and mortality odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were assessed. Intraoperative and overall complications, length of hospital stay, in-hospital mortality, long-term mortality, and total weight loss were recorded.ResultsThe literature search yielded 2977 articles. Eight studies were included in the analysis. Meta-analysis showed that the overall complications (OR: 2.1; 95% CI: 1.47–3.00; P < .0001), postoperative bleeding (OR: 2.22; 95% CI: 1.95–2.54; P < .00001), length of hospital stay (MD: .68; 95% CI: .14–1.19; P = .01), and in-hospital/90-day mortality (OR: 3.59; 95% CI: 2.84–4.54; P < .00001) were significantly higher in patients with compensated cirrhosis than in patients without cirrhosis. Intraoperative complications, operation time, major complications, and long-term mortality were similar between the groups. Total weight loss was also not significantly different between the groups.ConclusionBariatric surgery can be considered only in highly selected patients with obesity and compensated cirrhosis.     

Method of venous thromboembolism prophylaxis is not a predictor of pulmonary embolus following elective bariatric surgery: a retrospective cohort study of 135,409 patients

BackgroundPatients with obesity are at increased risk of pulmonary embolus (PE), a risk that increases perioperatively and is challenging to manage.ObjectiveAn analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was performed to determine predictors of PE in patients undergoing elective bariatric surgery.SettingNorth American accredited bariatric surgery institutions included in the MBSAQIP database from 2020–2021.MethodsWe extracted data from the MBSAQIP database (2020–2021) on patients who underwent elective Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Data were extracted on patient co-morbidities, race, prior history of deep vein thrombosis (DVT), and type of DVT prophylaxis. A multivariate logistic regression model was developed to determine predictors of PE and impact of PE on 30-day serious complications and mortality.ResultsIn the MBSAQIP database, a total of 135,409 patients underwent SG or RYGB from 2020 to 2021. PE was reported in 194 patients (.14%). Prior history of DVT (odds ratio [OR] = 3.28; 95% confidence interval [CI]: 1.85–5.83; P < .0001), Black race (OR = 3.03; 95% CI: 2.22–4.13; P < .0001), gastroesophageal reflux disease (OR = 1.51; 95% CI: 1.11–2.04; P = .008), higher body mass index (OR = 1.11; 95% CI: 1.01–1.20; P = .023), male sex (OR = 1.76; 95% CI: 1.26–2.45; P = .001), and older age (OR = 1.27; 95% CI: 1.10–1.46; P = .001) were associated with increased odds of PE. Chronic obstructive pulmonary disease, sleep apnea, and hypertension were not significant predictors of PE (P > .05). Neither combined mechanical and pharmacologic DVT prophylaxis nor pharmacologic prophylaxis alone was a significant predictor of PE (P > .05).ConclusionPrior history of DVT is the strongest predictor of PE after bariatric surgery. African American race, male sex, and gastroesophageal reflux disease are additional risk factors. Method of venous thromboembolism prophylaxis was not identified as significant predictor of PE. Further, studies on the evaluation and optimization of venous thromboembolism prophylaxis are required.     

Outcomes in racial and ethnic minorities after revisional robotic-assisted metabolic and bariatric surgery: an analysis of the MBSAQIP database

BackgroundRobotic-assisted metabolic and bariatric surgery (MBS) is being performed with increased frequency in the United States, including for revisional MBS. However, little is known about perioperative outcomes between racial and ethnic cohorts after revisional robotic-assisted MBS.ObjectiveThe goal of our study was to determine if there are racial differences in outcomes after robotic-assisted revisional MBS.SettingUniversity Hospital, United States.MethodsUsing the 2015–2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, we identified patients undergoing revisional MBS by a robotic-assisted approach. Univariate analyses were performed of unmatched and matched racial and ethnic cohorts, comparing black versus white patients and Hispanic versus white patients.ResultsOf 2027 robotic-assisted revisional MBS cases in the database, 1922 were included in our analysis, including 67%, 22.6%, and 10.4% white, black, and Hispanic patients, respectively. At baseline, there were some differences in patient characteristics between racial and ethnic cohorts. After propensity matching, outcomes between black and white patients were similar, except for higher rates of superficial surgical site infection among white patients (P = .05) and higher rates of organ space surgical site infection in black patients (P = .05). Outcomes were also similar between matched white and Hispanic patients, except for a higher bleeding in white patients (2% versus 0%, P = .04). There were no mortality or morbidity differences between racial and ethnic cohorts.ConclusionMorbidity and mortality after robotic-assisted revisional MBS do not seem to be mediated by race or ethnicity.     

Hypoalbuminemia as a risk factor for complications in revisional/conversional bariatric surgery: an MBSAQIP analysis

BackgroundHypoalbuminemia (HA) is a risk factor for serious complications after elective bariatric surgery. Patients undergoing revisional/conversional bariatric surgery may represent a higher-risk group who often have underlying co-morbid medical illnesses and more complex surgery.ObjectivesThis study investigated the postoperative complications in patients with HA undergoing revisional/conversional bariatric surgery.SettingMetabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), years 2015–2019.MethodsThe MBSAQIP database was used to evaluate patients undergoing non-banding revisional/conversional bariatric surgery between 2015 and 2019. Patients were categorized by serum albumin (≤3.5 g/dL). Variables were assessed via bivariate analysis and multivariable regression. Propensity score matching was conducted to compare gastric bypass (RYGB) to sleeve gastrectomy (VSG).ResultsOne hundred forty-seven thousand four hundred thirty patients underwent revisional/conversional procedures. After applied exclusions, 58,777 patients were available for analysis. The HA group had a significantly (P < .05) higher prevalence of being black (22.95% versus 17.76%), renal insufficiency (1.08% versus .36%), smoking history (9.47% versus 6.91%), chronic obstructive pulmonary disease (COPD) (2.54% versus 1.33%), and history of deep vein thrombosis (DVT) (4.03% versus 2.3%). Postoperative complications associated with HA included perioperative blood transfusion (3.1% versus 1.27%; P < .001), 30day readmission (10.87 versus 6.77%; P < .001), 30day reoperation (4.9% versus 3.18%; P < .001), and 30day mortality (.40% versus .14%; P < .0001). HA was a significant predictor of 30day readmission in the RYGB versus VSG matched cohort (odds ratio [OR], 1.30; 95% confidence interval [CI], [1.14, 1.48]; P < .001).ConclusionsHA is a risk factor requiring attention for patients undergoing revisional/conversional bariatric surgery and optimization of nutritional status or medical comorbidities associated with HA prior to bariatric surgery may help avoid postoperative complications.     

Conception rates and contraceptive use after bariatric surgery among women with infertility: Evidence from a prospective multicenter cohort study

BackgroundLack of prospective trials have resulted in a dearth of information regarding postbariatric surgery conception rates in women with a preoperative history of infertility.ObjectiveTo examine associations between preoperative history of infertility and postbariatric surgery conception.SettingA multicenter cohort study at 10 United States hospitals (2006–2009).MethodsParticipants completed a preoperative reproductive health questionnaire, with annual postoperative assessments for up to 7 years until January 2015. This report was restricted to women 18- to 44-years old with no history of menopause, hysterectomy, or hormone replacement therapy. The primary outcomes were postoperative (0 to <90 mo) conception rate, early conception rate (0 < 18 mo), and postoperative unprotected intercourse with a male partner while not trying to conceive.ResultsOf 740 eligible women, 650 (87.8%) provided required responses. Median interquartile range (IQR) preoperative age was 34 (30–39) years and follow-up was 6.5 (5.9–7.0) years. Nulliparous women with a preoperative history of infertility represented 8.0% (52/650) of the total cohort, 63.5% (33/52) of whom had never conceived. Compared with women without this history, these women had a higher postoperative conception rate (121.2 [95% confidence interval (CI), 102.3–143.5]/1000 versus 47.0 [95%CI, 34.2–62.9]/1000 woman-yr; P < .001), early conception rate (115.4 [95%CI, 96.1–138.5]/1000 versus 33.9 [95%CI, 23.6–47.1]/1,000 woman-yr; P < .01), and a higher risk of unprotected intercourse (ARR 1.48 [95% CI, 1.14-1.90], P = 0.003).ConclusionAfter bariatric surgery, preoperative history of infertility and nulliparity was associated higher conception rates and unprotected intercourse.     

Impact of bariatric surgery on heart failure mortality

BackgroundThe impact of bariatric surgery on discrete cardiovascular events has not been well characterized.ObjectivesTo assess the impact of prior bariatric surgery on mortality associated with heart failure (HF) admission.SettingA retrospective analysis of 2007–2014 Healthcare Cost and Utilization Project—Nationwide Inpatient Sample.MethodsParticipants including 2810 patients with a principal discharge diagnosis of HF who also had a history of prior bariatric surgery were identified. These patients were matched 1:5 with patients who had similar principal diagnoses but no history of bariatric surgery (controls). Propensity scores, balanced on baseline characteristics, were used to assemble 2 control groups. Control group-1 included patients with obesity (body mass index [BMI] ≥35 kg/m²) only. In control group-2, the BMI was considered as one of the matching criteria in propensity matching. Multivariate regression models were utilized to calculate the odds ratio (OR) and 95% confidence interval (CI) of mortality and length of stay (LOS).ResultsWith well-balanced matching, 33,720 (weighted) patients were included in the analysis. In-hospital mortality rates after HF admission were significantly lower in patients with a history of bariatric surgery compared with control group-1 (0.96% versus 1.86%, OR .52, 95% CI .35–0.77, P = .0013) and control group-2 (0.96% versus 1.86%, OR .52, 95% CI .35–0.77, P = .0011). Furthermore, LOS was shorter in the bariatric surgery group compared with control group-1 (4.8 ± 4.4 versus 5.7 ± 5.7 d, P < .001) and control group-2 (4.8 ± 4.4 versus 5.4 ± 6.3 d, P < .001).ConclusionsOur data suggest that prior bariatric surgery is associated with almost 50% reduction in in-hospital mortality and shorter LOS in patients with HF admission.     

Independent predictors and timing of portomesenteric vein thrombosis after bariatric surgery

BackgroundPortomesenteric vein thrombosis (PVT) is a rare complication following bariatric surgery but can result in severe morbidity as well as death.ObjectiveIdentification of risk factors for PVT to facilitate targeted management strategies to reduce incidence.SettingProspective, statewide bariatric-specific clinical registry.MethodsWe identified all patients who underwent primary bariatric surgery between June 2006 and November 2021 (n = 102,869). Patient characteristics, procedure type, operative details, and 30-day postoperative complications were analyzed with multivariable logistic regression to evaluate for independent predictors of PVT.ResultsA total of 117 patients (.11%) developed a postoperative PVT, with 6 (5.1%) associated deaths. The majority of PVTs occurred in patients who underwent sleeve gastrectomy (109 patients; 93.2%), and the PVT occurred most commonly during the second (37%), third (31%), and fourth weeks (23%) after surgery. Independent risk factors for PVT included a prior history of venous thromboembolism (odds ratio [OR] = 3.1; 95% confidence interval [CI]: 1.64–5.98; P = .0005), liver disorder (OR = 2.3; 95% CI: 1.36–4.00; P = .0021), undergoing sleeve gastrectomy (OR = 12.4; 95% CI: 4.98–30.69; P < .0001), and postoperative complications including obstruction (OR = 12.5; 95% CI: 4.65–33.77; P < .0001), leak (OR = 7.9; 95% CI: 2.76–22.64; P = .0001), and hemorrhage (OR = 7.6; 95% CI: 3.57–16.06; P < .0001).ConclusionsIndependent predictors of PVT include a prior history of venous thromboembolism, liver disease, undergoing sleeve gastrectomy, and experiencing a serious postoperative complication. Given that the incidence of PVT is most common within the first month after surgery, extending postdischarge chemoprophylaxis during this time frame is advised for patients with increased risk.     

Investigating racial disparities in bariatric surgery referrals

BackgroundPrior studies investigating racial, socioeconomic, and/or insurance disparities with regard to access to care and outcomes in bariatric surgery have been performed with varying results.ObjectivesOur aim was to determine if racial or ethnic disparities exist in referral patterns for bariatric surgery at a single center.MethodsAn institutional, retrospective chart review from January 2012 through June 2017 was performed for patients meeting referral criteria to bariatric surgery. Data collection was limited to patients referred to the bariatric surgery clinic from on-site primary care clinics.ResultsIn total, 4736 patients were eligible for bariatric surgery during the study period. Patients were 63.8% female (n = 3022), and 36.2% male (n = 1714); 53.9% white (n = 2553), 37.8% black (n = 1790), and 8.3% Hispanic (n = 393). Female patients were more likely to be referred than male patients (5.5% versus 4.1%, χ² 4.59, P = .032). On univariate comparison, Hispanic patients were less likely to be referred compared with black or white patients (2.0% versus 5.3% and 5.2%, χ² 7.88, P = .019).ConclusionHispanic patients were less likely to be referred at our institution for bariatric surgery compared with white or black patients. A barrier to referral may be explained by the disproportionate number of Hispanic patients that were designated as “self-pay” rather than private insurance or Medicaid/Medicare coverage that is required for bariatric surgery referral. This finding underscores the need for further research surrounding barriers to access to care for Hispanic patients.     

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.     

Bariatric surgery in patients with obesity and end-stage renal disease

BackgroundBariatric surgery has been suggested as a treatment for obesity and end-stage renal disease (ESRD). Although the number of bariatric surgeries in patients with ESRD is increasing, its safety and effectiveness in these patients are still controversial and the surgical method of choice in these patients is under debate.ObjectivesTo compare the outcomes of bariatric surgery between patients with and without ESRD and to assess different methods of bariatric surgery in patients with ESRD.SettingMeta-analysis.MethodsA comprehensive search was conducted in Web of Science and Medline (via Pubmed) until May 2022. Tow meta-analyses were performed: A) to compare bariatric surgery outcomes among patients with and without ESRD, and B) to compare outcomes of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) in patients with ESRD. Using a random-effect model, odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were computed for surgical and weight loss outcomes.ResultsOf 5895 articles, 6 studies were included in meta-analysis A and 8 studies in meta-analysis B. The risk of bias was moderate to serious among studies. Major postoperative complications (OR = 2.82; 95% CI = 1.66–4.77; P = .0001), reoperation (OR = 2.66; 95% CI = 1.99–3.56; P < .00001), readmission (OR = 2.37; 95% CI = 1.55–3.64; P < .0001), and in-hospital/90-d mortality (OR = 4.03; 95% CI = 1.80–9.03; P = .0007) were higher in patients with ESRD. Patients with ESRD also had a longer hospital stay (MD = 1.23; 95% CI = .32–2.14; P = .008). Bleeding, leakage, and total weight loss were comparable among groups. SG showed a 10% lower rate of overall complications and significantly shorter hospital stay than RYGB did. The quality of evidence was very low for the outcomesConclusionsBariatric surgery in patients with ESRD seems to have higher rates of major complications and perioperative mortality than in patients without ESRD, but a comparable rate of overall complications. SG has fewer postoperative complications and could be the method of choice in these patients. These findings should be interpreted cautiously in light of the moderate to high risk of bias in most included studies.     

Are racial differences in hospital mortality after coronary artery bypass graft surgery real? A risk-adjusted meta-analysis

BackgroundDespite several reports, there are still conflicting data on the influence of ethnicity on mortality rates associated with coronary artery bypass grafting (CABG). We aimed to get further insights into the effect of race on mortality following CABG by performing a risk adjusted meta-analysis.MethodsRelevant studies were searched on PubMed, Embase, BioMed Central, and the Cochrane Central register. Pairwise meta-analysis was used to estimate the relative risk of hospital death of black, Hispanic, and Asian patients using white patients as reference. Risk adjusted meta-analytic estimates were obtained using generic inverse variance methods with random effect model.ResultsA total of 28 studies were selected for analysis. A total of 21 studies reported on hospital mortality in black (n = 222,892) versus white (n = 3,884,043) patients, 7 studies reported on Hispanic (n = 91,256) versus white (n = 1,458,524) and 9 studies reported on Asian (n = 27,820) versus white (n = 1,081,642). When compared with white patients, adjusted risk of hospital death was significantly greater for black patients (adjusted odds ratio [OR], 1.25; 95% confidence interval [CI], 1.13-1.39; P < .001), and not statistically different for Asian (OR, 1.33; 95% CI, 0.99-1.77; P = .05) and Hispanic patients (adjusted OR, 1.08; 95% CI, 0.94-1.23; P = .26). Meta-regression showed a significant trend toward lower mortality rates in most recent series in both black (P = .02) and white (P = .0007) and Asian (P = .01) but not for Hispanic (P = .41). However, as mortality rates were lower across the different races, the relative disadvantage between the study groups persisted, which may explain the lack of interaction between study period and race effect on mortality for black (adjusted P = .09), Asian (adjusted P = .63), and Hispanic (adjusted P = .97) patients.ConclusionsThe present meta-analysis showed that despite progress is being made in lowering in-hospital mortality rates among the major racial/ethnic groups, ethnical disparities in hospital mortality after CABG remain.     

Postoperative care fragmentation in bariatric surgery and risk of mortality: a nationwide study

BackgroundReadmission after bariatric surgery may to lead to fragmentation of care if readmission occurs at a facility other than the index hospital. The effect of readmission to a nonindex hospital on postoperative mortality remains unclear for bariatric surgery.ObjectivesTo determine postoperative mortality rates according to readmission destinations.SettingNationwide analysis of all surgical facilities in France.MethodsMulticenter, nationwide study of adult patients undergoing bariatric surgery from January 1, 2013, through December 31, 2018. Data from all surgical facilities in France were extracted from a national hospital discharge database.ResultsIn a cohort of 278,600 patients who received bariatric surgery, 12,760 (4.6%) were readmitted within 30 days. In cases of readmission, 23% of patients were admitted to a nonindex hospital. Patients readmitted to a nonindex facility had different characteristics regarding sex (men, 23.6% versus 18.2%, respectively; P < .001), co-morbidities (Charlson Co-morbidity Index, .74 versus .53, respectively; P < .001), and travel distance (38.3 km versus 26.9 km, respectively; P < .001) than patients readmitted to the index facility. The main reasons for readmission were leak/peritonitis and abdominal pain. The overall mortality rate after readmission was .56%. The adjusted odds ratio (OR) of mortality for the nonindex group was 4.96 (95% confidence interval [CI], 3.1–8.1; P < .001). In the subgroups of patients with a gastric leak, the mortality rate was 1.5% and the OR was 8.26 (95% CI, 3.7–19.6; P < .001).ConclusionReadmissions to a nonindex hospital are associated with a 5-fold greater mortality rate. The management of readmission for complications after bariatric surgery should be considered as a major issue to reduce potentially preventable deaths.     

Impact of accreditation in bariatric surgery

BackgroundSeveral studies have shown improved outcomes associated with accredited bariatric centers. The aim of our study was to examine the outcomes of bariatric surgery performed at accredited versus nonaccredited centers using a nationally representative database. Additionally, we aimed to determine if the presence of bariatric surgery accreditation could lead to improved outcomes for morbidly obese patients undergoing other general laparoscopic operations.MethodsUsing the Nationwide Inpatient Sample database, for data between 2008 and 2010, clinical data of morbidly obese patients who underwent bariatric surgery, laparoscopic antireflux surgery, cholecystectomy, and colectomy were analyzed according to the hospital’s bariatric accreditation status.ResultsA total of 277,068 bariatric operations were performed during the 3-year period, with 88.4% of cases performed at accredited centers. In-hospital mortality was significantly lower at accredited compared to nonaccredited centers (.08% versus .19%, respectively). Multivariate analysis showed that nonaccredited centers had higher risk-adjusted mortality for bariatric procedures compared to accredited centers (odds ratio [OR] 3.1, P<.01). Post hoc analysis showed improved mortality for patients who underwent gastric bypass and sleeve gastrectomy at accredited centers compared to nonaccredited centers (.09% versus .27%, respectively, P<.01). Patients with a high severity of illness who underwent bariatric surgery also had lower mortality rates when the surgery was performed at accredited versus nonaccredited centers (.17% versus .45%, respectively, P<.01). Multivariate analysis showed that morbidly obese patients who underwent laparoscopic cholecystectomy (OR 2.4, P<.05) and antireflux surgery (OR 2.03, P<.01) at nonaccredited centers had higher rates of serious complications.ConclusionAccreditation in bariatric surgery was associated with more than a 3-fold reduction in risk-adjusted in-hospital mortality. Resources established for bariatric surgery accreditation may have the secondary benefit of improving outcomes for morbidly obese patients undergoing general laparoscopic operations.