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.     

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.     

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.     

Comparative analysis of robotic versus laparoscopic revisional bariatric surgery: perioperative outcomes from the MBSAQIP database

BackgroundThere are limited data evaluating the role of robotics in revisional bariatric surgery (RBS) compared with laparoscopy.ObjectiveThe purpose of this study was to compare perioperative outcomes of laparoscopic and robotic RBS.SettingThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.MethodsThe 2015 to 2017 MBSAQIP database was queried for patients undergoing revisional robotic and laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Multivariate logistic regression was used to compare outcomes between robotic and laparoscopic approaches, adjusting for demographic characteristics, co-morbidities, and operative time.ResultsA total of 17,012 patients underwent revisional SG with 15,935 (93.7%) laparoscopic and 1077 (6.3%) robotic, and 12,442 patients underwent revisional RYGB with 11,212 (90.1%) laparoscopic and 1230 (9.9%) robotic. Overall morbidity was higher in robotic SG compared with laparoscopic SG (6.7% versus 4.5%; adjusted odds ratio 1.51; P < .01) which was not the case after adjustment for operative time. Robotic RYGB was associated with comparable overall morbidity to laparoscopic (9.3% versus 11.6%; adjusted odds ratio .83; P = .07) although respiratory complications, pneumonia, superficial surgical site infections, and postoperative bleeding were lower with robotic RYGB. The robotic approach with both procedures was associated with longer operative time (P < .01). Length of stay was longer in the robotic group for SG (P < .01) but was not different for RYGB (P = .91).ConclusionsRobotic RBS has an increased complication profile compared with the laparoscopic approach for SG and decreased for RYGB. Further analysis is needed regarding variability in surgeon technique and operative experience to determine what factors contribute to these differences.     

Outcomes in racial minorities after robotic Roux-en-Y gastric bypass and sleeve gastrectomy: a retrospective review of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database

BackgroundThe rate of robotic-assisted metabolic and bariatric surgery (MBS) is increasing. While discord remains about racial disparity in primary MBS, there are no data on robotic MBS outcomes in racial cohorts.ObjectivesTo determine whether outcomes following robotic-assisted Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are mediated by race or ethnicity.SettingUniversity Hospital, United States.MethodsRobotic RYGB and SG cases were identified from the 2015–2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) databases using Current Procedure Terminology codes 43644, 43645, and 43775. Selected cases were stratified by race and ethnicity. Case-control matched and logistic regression analyses were performed.ResultsMatched analyses compared outcomes in 2666 RYGB cases of Black versus White patients and 1794 RYGB cases of Hispanic versus White patients. Black RYGB patients had longer operative lengths (OLs; P = .0008) and postoperative lengths of stay (P = .001), and a higher rate of pulmonary embolism (P = .05). Hispanic (versus White) RYGB patients had longer lengths of stay (P = .007). All other outcomes were similar between RYGB racial and ethnic cohorts. Matched analyses also compared outcomes of 8328 SG cases in Black versus White patients and 4852 SG cases in Hispanic versus White patients. Black patients had longer OLs (P = .004), had longer lengths of stay (P < .0001), had higher overall morbidity (P = .02), had higher bariatric-related morbidity (P = .02), had higher rates of readmission (P = .009), and were more likely to have an operative drain present at 30 days (P = .001). All other outcome measures were similar between racial/ethnic SG cohorts.ConclusionRobotic-assisted SG is associated with higher overall and bariatric-related morbidity, but not mortality. However, robotic-assisted RYGB and SG remain safe, with lower rates of mortality and morbidity.     

Health disparity in access to bariatric surgery

BackgroundSociodemographic disparities in terms of access to bariatric surgery are ongoing.ObjectivesThis study aimed to examine the trends for bariatric interventions based on patient characteristics from 2011 to 2018 in the state of New York.SettingAdministrative statewide database.MethodsThis study used the New York Statewide Planning and Research Cooperative System database to identify all patients with obesity who underwent Roux-en-Y gastric bypass (RYGB), laparoscopic sleeve gastrectomy (SG), and laparoscopic adjustable gastric banding (LAGB) between 2011 and 2018. The trends were studied for the types of bariatric procedures performed across different patient characteristics, including median household income as determined based on ZIP code. A multivariable logistic regression analysis was performed to compare the yearly trends.ResultsWe identified 111,793 patients who underwent bariatric surgery. The number of bariatric procedures increased from 9304 in 2011 to 16,946 in 2018. RYGB was the most performed bariatric operation in 2011, but was replaced by SG from 2013 to 2018. Patients living in the highest decile median household income ZIP code areas had the highest increase in SG (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.46–1.55; P < .0001) and the largest decrease in LAGB (OR, .53; 95% CI, .51–.56; P = .0007).ConclusionsThe use of bariatric surgery increased significantly from 2011 to 2018. However, the disproportionately and substantially increased use of SG and the decreased use of LAGB in patients living in wealthier areas suggest that disparity in the use of bariatric interventions still exists. Public health efforts should be made to equalize access to bariatric surgery.     

Perioperative and 1-year outcomes of bariatric surgery in septuagenarians: implications for patient selection

BackgroundAlthough bariatric surgery is an effective treatment for obesity, utilization of bariatric procedures in older adults remains low. Previous work reported higher morbidity in older patients undergoing bariatric surgery. However, the generalizability of these data to contemporary septuagenarians is unclear.ObjectivesWe sought to evaluate differences in 30-day outcomes, 1-year weight loss, and co-morbidity remission after bariatric surgery among 3 age groups as follows: <45 years, 45–69 years, and ≥70 years.SettingStatewide quality improvement collaborative.MethodsUsing a large quality improvement collaborative, we identified patients undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) between 2006 and 2018. We used multivariable logistic regression models to evaluate the association between age cohorts and 30-day outcomes, 1-year weight loss, and co-morbidity remission.ResultsWe identified 641 septuagenarians who underwent SG (68.5%) or RYGB (31.5%). Compared with 45–69 year olds, septuagenarians had higher rates of hemorrhage (5.1% versus 3.1%; P = .045) after RYGB and higher rates of leak/perforation (.9% versus .3%; P = .044) after SG. Compared with younger patients, septuagenarians lost less of their excess weight, losing 64.8% after RYGB and 53.8% after SG. Remission rates for diabetes and obstructive sleep were similar for patients aged ≥70 years and 45–69 years.ConclusionsBariatric surgery in septuagenarians results in substantial weight loss and co-morbidity remission with an acceptable safety profile. Surgeons with self-imposed age limits should consider broadening their selection criteria to include patients ≥70 years old.     

Metabolic effects of bariatric surgery on patients with type 2 diabetes: a population-based study

BackgroundBariatric surgery among patients with obesity and type 2 diabetes (T2D) can induce complete remission. However, it remains unclear whether sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) has better T2D remission within a population-based daily practice.ObjectivesTo compare patients undergoing RYGB and SG on the extent of T2D remission at the 1-year follow-up.SettingNationwide, population-based study including all 18 hospitals in the Netherlands providing metabolic and bariatric surgery.MethodsPatients undergoing RYGB and SG between October 2015 and October 2018 with 1 year of complete follow-up data were selected from the mandatory nationwide Dutch Audit for Treatment of Obesity (DATO). The primary outcome is T2D remission within 1 year. Secondary outcomes include ≥20% total weight loss (TWL), obesity-related co-morbidity reduction, and postoperative complications with a Clavien-Dindo (CD) grade ≥III within 30 days. We compared T2D remission between RYGB and SG groups using propensity score matching to adjust for confounding by indication.ResultsA total of 5015 patients were identified from the DATO, and 4132 (82.4%) had completed a 1-year follow-up visit. There were 3350 (66.8%) patients with a valid T2D status who were included in the analysis (RYGB = 2623; SG = 727). RYGB patients had a lower body mass index than SG patients, but were more often female, with higher gastroesophageal reflux disease and dyslipidemia rates. After adjusting for these confounders, RYGB patients had increased odds of achieving T2D remission (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.14–2.1; P < .01). Groups were balanced after matching 695 patients in each group. After matching, RYGB patients still had better odds of T2D remission (OR, 1.91; 95% CI, 1.27–2.88; P < .01). Also, significantly more RYGB patients had ≥20%TWL (OR, 2.71; 95% CI, 1.96–3.75; P < .01) and RYGB patients had higher dyslipidemia remission rates (OR, 1.96; 95% CI, 1.39–2.76; P < .01). There were no significant differences in CD ≥III complications.ConclusionUsing population-based data from the Netherlands, this study shows that RYGB leads to better T2D remission rates at the 1-year follow-up and better metabolic outcomes for patients with obesity and T2D undergoing bariatric surgery in daily practice.     

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.     

Comparative early outcomes of three laparoscopic bariatric procedures: sleeve gastrectomy,Roux-en-Y gastric bypass,and biliopancreatic diversion with duodenal switch

BackgroundSince the introduction of the isolated sleeve gastrectomy in 1997, this procedure has gained immense popularity in the hopes of reducing the operative risks with a less complex operation. We reviewed our recent 2-year experience with bariatric surgery to compare the early outcomes of the 3 complex procedures routinely performed by our private practice at a single institution: sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with duodenal switch (BPD-DS).MethodsThe 30-day morbidity and 90-day mortality rates were retrospectively reviewed among a total of 507 primary bariatric procedures. The early postoperative outcomes of 360 RYGB, 88 SG, and 59 BPD-DS procedures performed during this period were compared.ResultsThe patients weighed more in the BPD-DS and SG groups. The SG patients were significantly older than the RYGB and BPD-DS patients. Co-morbidities were significantly more frequent in the SG and BPD-DS patients. One patient died after RYGB but none did so after BPD-DS or SG. The global complication rate was significantly increased after BPD-DS (P = .0017) compared with RYGB; however, no difference was found between RYGB and SG, although bleeding was likely to appear more frequent, not only after BPD-DS, but also after SG compared with RYGB.ConclusionAlthough no fatal outcomes occurred after SG, this procedure did not demonstrate a reduced risk of postoperative complications compared with RYGB with a significantly greater rate of bleeding. RYGB appears to be a relatively safe bariatric procedure, although the groups were not comparable in terms of the preoperative body mass index or co-morbidities, the exact role of which on postoperative morbidity remains controversial. Although the increased risk of RYGB to BPD-DS was confirmed, SG failed to live up to its “more benign” reputation.     

Variations in bariatric surgical practice patterns between general and bariatric surgeons: a matched analysis of the 2017 MBSAQIP database

BackgroundWhile general surgeons (GSs) perform metabolic and bariatric surgery (MABS), these procedures are increasingly performed by metabolic and bariatric surgeons (MBSs). Because MABS is an evolving practice with changing surgical platforms and approaches, it is important to evaluate outcomes between different specialists performing these procedures.ObjectivesTo compare perioperative practice pattern variations and outcomes of MABS performed by GSs versus MBSs.SettingUniversity Hospital, United States.MethodsUsing the 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, we identified Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) cases and stratified them by specialization (GSs versus MBSs). Patient characteristics, practice patterns and outcomes, complications, and 30-day outcomes were compared between cohorts. Matched procedure-specific analyses were performed.ResultsOf 172,430 MABS procedures, 4394 (2.5%) were performed by GSs and 168,036 (97.4%) by MBSs. At baseline, patients of GSs had fewer co-morbidities. GSs more commonly used the robotic platform for SG cases and performed interventions such as staple line reinforcement and staple line check with provocative testing. MBSs more commonly performed robotic (versus laparoscopic) RYGB. Overall complications were low in both study cohorts. After propensity matching, transfusion and venous thromboembolism were higher in SG performed by GSs, while surgical site infection was higher in SG and RYGB performed by MBSs. These findings were not reproduced after case-control matching. In matched analyses, there were no mortality or morbidity differences between study cohorts.ConclusionMABS is performed safely by both GSs and MBSs, with no difference in morbidity and mortality.     

Effects of intraoperative leak testing on postoperative leak-related outcomes after primary bariatric surgery: an analysis of the MBSAQIP database

BackgroundIntraoperative leak test (IOLT) is commonly performed to evaluate the integrity of an anastomosis or staple line during bariatric surgery. However, the utility of IOLT is controversial.ObjectiveTo evaluate the effect of IOLT on postoperative leak-related outcomes after primary bariatric surgery.SettingMetabolic and Bariatric Surgery Accreditation and Quality Improvement Program–accredited centers.MethodsThe 2015 and 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement databases were analyzed for sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with duodenal switch (BPDDS) to determine the postoperative anastomotic/staple line leak (A/SL) and leak-related outcomes.ResultsData for a total of 265,309 patients who underwent SG (69.6%), RYGB (29.7%), or BPDDS (.8%) were analyzed. IOLT was performed in 81.9% of all patients. Overall A/SL, mortality rate in patients with leakage, and 30-day leak-related mortality were .28%, .1%, and .003%, respectively. There were no significant differences between the IOLT and non-IOLT groups in terms of A/SL, 30-day mortality in patients with leakage, 30-day leak-related mortality, readmission, reoperation, intervention, or organ/space surgical site infection. However, the rate of 30-day leak-related intervention in BPDDS was significantly lower in the IOLT group compared to the non-IOLT group (.18% versus 1.15%, P = .01). Whether IOLT was performed endoscopically or nonendoscopically had no effect on the rate of postoperative leaks. Overall mean operative time increased by 19.1 minutes (9.5, 11.9, and 21.2 min for SG, RYGB, and BPDDS, respectively) when IOLT was performed.ConclusionThe overall rate of postoperative A/SL and leak-related morbidity was low. This study provided no evidence of either benefit or harm from IOLT in patients who underwent SG, RYGB, or BPDDS.     

Comparison of Short-term Safety of One Anastomosis Gastric Bypass to Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in the United States: 341 cases from MBSAQIP-accredited Centers

BackgroundOne anastomosis gastric bypass (OAGB) is the third most common (4%) primary bariatric procedure worldwide but is seldom performed in the United States and is currently under consideration for endorsement by the American Society for Metabolic and Bariatric Surgery. Evidence from the United States on safety of OAGB compared to Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) is limited.ObjectiveTo compare the short-term safety outcomes of the three primary bariatric procedures.SettingMetabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)-accredited hospitals in the United States and Canada.MethodsUsing the 2015–2019 MBSAQIP database, we compared the safety outcomes of adult patients who underwent primary laparoscopic OAGB, RYGB, and SG. Exclusion criteria included age over 80 years, emergency operation, conversion, and incomplete follow-up. The primary outcome was 30-day overall complication. Secondary outcomes were 30-day surgical and medical complications and hospitalization length.ResultsA total of 341 patients underwent primary OAGB. Using propensity scores, we matched the OAGB cohort 1:1 with two cohorts of similar baseline characteristics who underwent RYGB and SG, respectively. The OAGB cohort had a lower overall complication rate than the RYGB cohort (6.7% versus12.3%, P = .02) and a similar rate to the SG cohort (5.0%, P = .43). The OAGB cohort had a similar rate of surgical complication to the RYGB cohort (5.0% versus 8.5%, P = .1) and a higher rate than the SG group (1.2%, P = .009). The OAGB cohort had a shorter median hospitalization than the RYGB cohort (1 d [interquartile range (IQR) 1–2 d] versus 2 d [IQR 1–2 d], P < .001) and a similar hospitalization length to the SG cohort ([1–2 d], P = .46).ConclusionUsing the largest and the most current U.S. data, this study demonstrated that the short-term safety profile of primary OAGB is acceptable, but future studies should determine the long-term safety.     

Robot-assisted sleeve gastrectomy and Roux-en-y gastric bypass: results from the metabolic and bariatric surgery accreditation and quality improvement program data registry

BackgroundA stronger evidence base is needed to more fully understand the precise role that robot-assisted (RA) approaches may play in bariatrics.ObjectiveTo investigate the utilization and safety of RA–sleeve gastrectomy (RA-SG) and RA–Roux-en-Y gastric bypass (RA-RYGB) using data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry.SettingNational Database.MethodsWe queried the MBSAQIP 2015 through 2016 registry for patients who underwent primary conventional laparoscopic or RA-SG and RA-RYGB. We compared pre- and perioperative characteristics and 30-day outcomes using logistic regression where number of events met statistical guidelines.ResultsWe included 126,987 cases: conventional laparoscopic SG (n = 83,940), RA-SG (n = 6,780), conventional laparoscopic RYGB (n = 33,525), and RA-RYGB (n = 2,742). The RA significantly lengthened operation time by 24 and 23 minutes for SG and RYGB, respectively. Mortality and serious adverse events were similar for the 2 techniques. RA-SG was associated with higher rates of 30-day intervention (1.3% versus .8%, OR: 1.38, P < .05) and hospital stay >2 days (12.1% versus 9.3%, OR: 1.30, P < .001). RA-RYGB was associated with higher 30-day rates of reoperation (2.6% versus 2.0%, OR: 1.37, P < .05) and readmission (7.0% versus 5.8%, OR:1.21, P < .05) and lower rates of transfusion (0.62% versus 1.12%, OR: .54, P < .05) and hospital stay >2 days (15.7% versus 17%, OR: .89, P < .05).ConclusionRA is as safe as the conventional laparoscopic approach in terms of mortality and serious adverse events.     

Conversion of gastric sleeve to Roux-en-Y gastric bypass and biliopancreatic diversion/duodenal switch: safe and viable options

BackgroundSleeve gastrectomy (SG) remains the most performed bariatric surgery. As numbers of SG increase, so do the numbers of patients requiring conversion for insufficient weight loss or weight regain. However, the literature has cited complication rates as high as 30%for reoperative bariatric surgery.ObjectiveWith the recent inclusion of conversion surgery variables in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, we compared the safety and efficacy of SG conversion to Roux-en-Y gastric bypass (RYGB) versus biliopancreatic diversion and duodenal switch (BPD/DS).SettingMBSAQIP database.MethodsAnalysis of the 2020 MBSAQIP Participant Use Files revealed 6020 patientswho underwent SG conversion to RYGB (5348) and BPD/DS (672). We examined 30-day outcomes including death, anastomotic leak, readmission, any complication, dehydration, and weight loss.ResultsThere was no statistically significant difference in mortality (.12% versus 0%) or; complication rate (6.5% versus 5.1%) with SG conversion to RYGB or BPD/DS. There was a statistically significant difference in anastomotic leak (.5% versus 1.2%, P = .024).Interestingly, BPD/DS was less likely to require dehydration treatments (4.2% versus 2.2%, P = .009) and had fewer readmissions within 30 days (7.3% versus 5.4%, P = .043).ConclusionsComplication rates after conversion of SG to RYGB or BPD/DS may be significantly lower than previously reported and only slightly higher than after primary weight loss surgery. SG conversion to either RYGB or BPD/DS remain safe, viable options forpatients who had insufficient weight loss or regain, and BPD/DS may be the better option in the appropriate patient.     

Metabolic bone disease and fracture risk after gastric bypass and sleeve gastrectomy: comparative analysis of a multi-institutional research network

BackgroundRoux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the two most performed bariatric procedures. Multiple studies have investigated the metabolic bone complications after bariatric surgery, but there is a paucity of data comparing bone health after RYGB and SG.ObjectivesTo compare the rates of major fractures and osteoporosis after Roux-en-Y gastric bypass and sleeve gastrectomy.SettingData from TriNetX multi-institutional research network that includes data from multiple health care organizations in the USA was analyzed at West Virginia University.MethodsWe conducted a retrospective cohort study using TriNetX, a federated multi-institutional research network. We identified patients who underwent RYGB or SG. Primary outcome was the rate of major fractures at 3 years after the procedure. Other outcomes included the rate of spine fracture, femur fracture, osteoporosis, and vitamin D deficiency at follow-up.ResultsIn unmatched analysis, patients with SG were less likely to have major fractures or an osteoporosis diagnosis than RYGB patients at 3 years after the procedure (P < .05). After propensity-score matching, similar results were noted; patients with SG were less likely to have major fractures than RYGB patients at 3 years after procedure (2.85% versus 3.66%, risk ratio [RR]: .78, 95% confidence interval [CI]: .71–.85), and a lower rate of osteoporosis diagnosis was noted in the SG group. High rates of vitamin D deficiency were noted in both cohorts. The incidence of spine fractures was significantly lower in the SG group than in the RYGB group (.76% versus 1.18%, RR: .65, 95% CI: .54–.77). Similarly, the incidence of femur fracture was significantly lower after SG (RR: .62, 95% CI: .44–.88). Female sex, higher age, smoking history, and diabetes were independently associated with osteoporosis diagnosis during follow-up (all P values <.05).ConclusionOur analyses showed that RYGB is associated with a higher risk of osteoporosis, vitamin D deficiency, and osteoporotic fractures. Thus, in patients with a higher baseline osteoporotic risk, SG may be preferred option; however, further studies are needed.     

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.     

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.     

Band removal and conversion to sleeve or bypass: are they equally safe?

Introduction

Patients who require laparoscopic adjustable gastric band (LAGB) removal are often converted to sleeve gastrectomy (SG) or roux-en-Y gastric bypass (RYGB). The relative safety of these salvage bariatric procedures is unclear. We hypothesized that LAGB removal with conversion to SG (BSG) or RYGB (BRYGB) would be associated with higher morbidity and mortality compared to primary SG or RYGB.

Methods

National Surgical Quality Improvement Project data (2005–2011) were analyzed. Patients undergoing SG, RYGB, BRYGB, and BSG were identified. The incidence of major complications, as well as mortality was compared between groups. Multivariate analysis was performed to identify patient factors and operation types associated with major complications or mortality. Odds ratios (OR) were calculated with 95 % confidence intervals (CI) with p value <0.05 considered statistically significant.

Results

A total of 51,609 patients were analyzed, consisting of primary RYGB (n = 46,153), BRYGB (495), primary SG (n = 4,831), and BSG (n = 130) patients. All groups had similar mean age (45 ± 11-years old). Salvage patients were more commonly female (89 vs. 79 %) and with lower body-mass index than primary bariatric patients (BMI 42 ± 8 vs. 46 ± 8 kg/m2). Major complication rates were 5.23 % (RYGB), 4.65 % (BRYGB), 3.95 % (SG) and 6.92 % (BSG), with 30-day mortality of 0.16 % (RYGB), 0.20 % (BRYGB), 0.08 % (SG) and 0.77 % (BSG). Multivariate analysis showed that compared to SG, RYGB, and BSG were independent predictors of major complications. Multivariate analysis of mortality showed BSG was an independent predictor of mortality compared to SG (OR 8.02, 95 % CI 1.08–59.34, p = 0.04).

Conclusions

Band removal with conversion to RYGB is not associated with higher morbidity or mortality compared to primary RYGB. However, band removal with conversion to sleeve gastrectomy appears to be independently associated with a higher rate of major complications and mortality, and thus may not be the salvage procedure of choice.     

Hospital utilization 4 years after bariatric surgery: sleeve gastrectomy versus Roux-en-Y gastric bypass

BackgroundWhile sleeve gastrectomy (SG) has lower perioperative risk compared with Roux-en-Y gastric bypass (RYGB), long-term data about their differential impact on overall health are unclear. Hospital use after bariatric surgery is an important parameter for improving peri- and postoperative care.ObjectiveThis present study was aimed to compare SG and RYGB in terms of their effect on long-term hospital-based healthcare utilization.SettingMulticenter, statewide database.MethodsA retrospective cohort study of adult patients who underwent SG and RYGB between 2009 and 2011, with follow-up until 2015 and 2-year presurgery information. Propensity score–matched SG and RYGB groups were created using preoperative demographic characteristics, co-morbidities, and presurgery hospital use, measured by cumulative length of stay (LOS) and frequency of emergency department visits. Postsurgery yearly LOS, incidence of hospital visits, and the reason for the visit were compared. Primary outcomes included postoperative hospital visits during years 1 to 4 after bariatric surgery and cumulative LOS. Secondary outcomes included specific reasons for hospital use.ResultsThere were 3540 SG and 13,587 RYGB patients, whose mean (95% confidence interval [CI]) LOS was 1.3 (1.3–1.4), .9 (.8–1), 1 (.9–1.1), and 1.2 (1–1.3) days at years 1 through 4, respectively. Postoperative yearly LOS was similar between the 2 propensity-matched groups. The risk of hospitalizations (odd ratio .73, 95% CI .64–.84, P < .0001) and emergency department visits (odds ratio .84, 95% CI .75–.95, P = .005) was significantly lower for SG, during the first postoperative year. The reverse was seen at the fourth postoperative year, with higher risk of emergency department use after SG (odds ratio 1.16, 95% CI 1.01–1.33, P = .035).ConclusionPostoperative 4-year hospital utilization remains low for both SG and RYGB. The previously established lower early perioperative risk of SG was not appreciated for longer-term hospital use compared with RYGB.