Safety of laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass in elderly patients – analysis of the MBSAQIP

Background

An increase in the prevalence of obesity and longer life expectancy has resulted in an increased number of candidates over the age of 60 who are pursuing a bariatric procedure.

Is laparoscopic sleeve gastrectomy a lower risk bariatric procedure compared with laparoscopic Roux-en-Y gastric bypass? A meta-analysis

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the current “gold standard” bariatric procedure in the United States. Laparoscopic sleeve gastrectomy (LSG) has recently become a commonly performed procedure for many reasons, including patients' perception that LSG has less complexity and invasiveness, and lower risk. Our objective was to review the literature and compare the leak rates, morbidity, and mortality for LRYGB versus LSG.

Methods

Publications from 2002 to 2012 with n greater than or equal to 25 and postoperative leak rate reported were included. Statistical analysis included chi-square according to patient number.

Results

Twenty-eight (10,906 patients) LRYGB and 33 (4,816 patients) LSG articles were evaluated. Leak rates after LRYGB versus LSG were 1.9% (n = 206) versus 2.3% (n = 110), respectively (P = .077). Mortality rates were .4% (27/7,117) for LRYGB and .2% (7/3,594) for LSG (P = .110). Timing from surgery to leak ranged from 1 to 12 days for LRYGB versus 1 to 35 days for LSG.

Conclusions

Leak and mortality rates after LRYGB and LSG were comparable. The appropriate procedure should be tailored based on patient factors, comorbidities, patient and surgeon comfort level, surgeon experience, and institutional outcomes.     

Is preoperative gastroscopy necessary before sleeve gastrectomy and Roux-en-Y gastric bypass?

Background

Consensus on the necessity of esophagogastroduodenoscopy (EGD) before bariatric surgery is lacking. Recommendations and practices vary by country and unit. Several reports have expressed concerns on gastroesophageal reflux disease (GERD) and its consequences after sleeve gastrectomy (SG) and the risk of leaving a premalignant lesion in the excluded stomach after Roux-en-Y gastric bypass (RYGB).

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

Background

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

Methods

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

Results

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

Conclusions

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

Current role of staple line reinforcement in 30-day outcomes of primary laparoscopic sleeve gastrectomy: an analysis of MBSAQIP data, 2015–2016 PUF

Background

Laparoscopic sleeve gastrectomy (LSG) has become a dominant bariatric procedure. In the past, significant leak rates prompted the search for staple line reinforcement (SLR) techniques. Previous analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for all LSG suggested a detrimental influence of SLR on leak rates and overall morbidity.

Is high BMI associated with specific complications after laparoscopic Roux-en-Y gastric bypass?

Controversy remains whether patients with body mass index (BMI) > or =50 kg/m2 experience more complications after laparoscopic Roux-en-y gastric bypass (LRYGB) than those with a lower BMI. Whether BMI > or =50 kg/m2 is associated with specific complications remains unknown. Charts of 152 patients who underwent LRYGB were reviewed. Logistic regression was used to determine whether high BMI is associated with minor or major complications. Overall, there was a trend that major complications occurred more frequently in patients with BMI > or =50 compared with BMI < 50, (30.4% vs. 19.8%, P = 0.138). Major bleeding complications occurred in 16.1 per cent of high BMI patients as compared with 5.2 per cent with lower BMI (P = 0.025). Multivariate regression found that BMI > or =50 was associated with higher odds of a major technical complication (OR = 2.73, P = 0.04), particularly for bleeding complications (odds ratio [OR] = 5.59, P = 0.01). Male gender was also associated with higher odds of a major technical complication (OR = 3.43, P = 0.04). These results suggest that high BMI patients may be better candidates for other types of weight loss surgery, such as staged procedures, and that surgeons early in their career should operate on patients with lower BMI.     

Conversion of failed laparoscopic adjustable gastric banding: Sleeve gastrectomy or Roux-en-Y gastric bypass?

BackgroundIn the literature, late complications and treatment failures in laparoscopic adjustable gastric banding (LAGB) have been reported. When the patient presents with failure of LAGB, surgeons have the option to convert it to a different procedure. The aim of our study is to evaluate and compare the safety and efficacy of converting LAGB to laparoscopic sleeve gastrectomy (LSG) versus laparoscopic Roux-en-Y gastric bypass (LRYGB).MethodsBetween March 2008 and October 2012, a total of 54 patients underwent conversion of LAGB at our institution. Of these patients, 41 (75.9%) were converted to LRYGB, and 13 (24.1%) patients were converted to LSG. A retrospective review of a prospectively collected database was performed, noting the outcomes and complications of the procedure.ResultsMean body mass index at the time of conversion was 41.8±6.5 kg/m² in LRYGB and 39.0±6.6 kg/m² in LSG. Mean percentage of excess weight loss was 57.4%±17.0% and 62.4%±19.6% in LRYGB, and it was 47.7%±4.2% and 65.6%±34.5% in LSG at 12 months (P>.34) and 24 months (P>.79) after conversion. Of LRYGB patients, 7 (17.5%) were readmitted as a result of abdominal pain, dehydration, and nausea/vomiting, and 4 (10.0%) patients required reoperation. One LSG patient (8.3%) was readmitted for new-onset severe reflux and underwent hiatal hernia repair. She was converted to LRYGB 32 months after the LSG procedure. Readmission rate (P>.61) and reoperation rate (P>.63) did not show statistical difference between the 2 procedures.ConclusionConverting LAGB to LSG and LRYGB both seem feasible and resulted in substantial further weight loss.     

Validation and improvement of a highly predictive bariatric surgery mortality risk calculator to include sleeve gastrectomy using MBSAQIP 2015–2017 data

BackgroundInitial development of a prominent bariatric surgery mortality risk calculator comprising cases that now account for <10% of commonly performed operations. Whether the previously highly predictive model is valid with more recent data is unknown.ObjectivesTo validate and improve a bariatric-surgery-specific mortality calculator with updated case mix and outcomes data.SettingMetabolic and Bariatric Surgery Accreditation and Quality Improvement Program–accredited bariatric surgery programs.MethodsThe Metabolic and Bariatric Accreditation and Quality Improvement Program Participant Use File from years 2015 to 2017 was used for the analysis. C-statistics were calculated with observed death as the outcome and estimated 30-day mortality risk as the only predictor and receiver operating characteristic curve was plotted. Similar analyses were repeated for each body mass index (BMI) subgroup. Backward selection logistic regression was used to investigate the potential of improving the robustness of the model.ResultsPatients were predominantly female (n = 446,149, 80.4%) and white (n = 409,350, 73.7%) with a mean (standard deviation) age of 45.4 (12.0) years and BMI of 44.5 (8.4) kg/m², and the most commonly performed operation was sleeve gastrectomy (n = 338,061, 60.9%). Assessing previous model using present data, area under the curve was .7412. By BMI subgroup, area under the curve for BMI <45 kg/m² was .7645, for BMI 45 to 60 kg/m² was .7586, and for BMI >60 kg/m² was .6576.DiscussionThe present study found that the model previously developed maintains discrimination with changing surgical procedures. Though variables in the initial calculator are helpful, additional factors should be considered when weighing risk, such as sex, previous surgery, and renal function. Future studies are needed to determine whether changes in modifiable risk factors will impact mortality rates.     

Safety of concurrent sleeve gastrectomy and hiatal hernia repair: a propensity score–matched analysis of the MBSAQIP registry

BackgroundHiatal hernia repair is an essential step to reduce the incidence of gastroesophageal acid reflux disease in patients undergoing sleeve gastrectomy. The safety of addition, a hiatal hernia repair to sleeve gastrectomy, is a critical question.ObjectivesOur study aimed to assess the safety of concurrent hiatal hernia repair and sleeve gastrectomy based on Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data.SettingUniversity health network, United States.MethodsThis study was a registry-based analysis. Preoperative characteristics and 30-day outcomes from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Files 2015 to 2017 were selected for all patients who underwent sleeve gastrectomy with hiatal hernia repair. Propensity score matching (1:1) was used to control for potential confounding.ResultsA total of 101,902 patients (50,951 patients matched pairs) were included in the study. The groups were closely matched as intended. Sleeve gastrectomy with hiatal hernia repair, compared with sleeve gastrectomy alone, was associated with similar risks of death (.02% versus .02%; relative risk [RR], 1.50; 95% confidence interval [CI], .61–3.67, P = .503), and higher risk of 30-day readmission (4.01% versus 2.96%; RR, 1.35; 95%CI, 1.27–1.45, P < .001), 30-day reoperation (1.10% versus .77%; RR, 1.42; 95% CI, 1.25–1.61, P < .001), 30-day intervention (1.24% versus .95%; RR, 1.31; 95%CI, 1.16–1.47, P < .001), and 30-day morbidity (1.85% versus 1.47%; RR, 1.25; 95%CI, 1.14–1.38, P < .001).ConclusionsSleeve gastrectomy with hiatal hernia repair is relatively safe in the short term with no increase in the risk of mortality. However, this additional procedure slightly increases the risk of readmission, reoperation, and postoperative intervention, as well as morbidity.     

Is BMI greater than 60 kg/m2 a predictor of higher morbidity after laparoscopic Roux-en-Y gastric bypass?

Background  

It has been hypothesized that patients who are super-supermorbidly obese, defined as having a body mass index (BMI) of 60 kg/m² or higher, have an increased rate of postoperative complications. As surgical techniques and operator experience with Roux-en-Y gastric bypass improved with time, the selection criteria have expanded to include the super-supermorbidly obese. We hypothesize that a higher BMI does not predict a higher postoperative complication rate.     

Laparoscopic sleeve gastrectomy at a new bariatric surgery centre in Canada: 30-day complication rates using the Clavien–Dindo classification

Background

Newfoundland and Labrador (NL) has the highest rate of obesity in Canada, prompting the establishment of a bariatric surgery program at the Health Sciences Centre in NL. This retrospective study examined 30-day complication rates in more than 200 consecutive patients who underwent laparoscopic sleeve gastrectomy (LSG) between May 2011 and February 2014.

Methods

We performed a chart review and collected data on 30-day postoperative complications. Complications were graded and reported using the Clavien–Dindo classification. Grades I and II were defined as minor and grades III and higher were defined as major complications.

Results

We reviewed the charts of the first 209 patients to undergo LSG. The mean body mass index was 49.2, 81% were women and the average age was 43 years. Comorbidities included hypertension (55.0%), obstructive sleep apnea (46.4%), dyslipidemia (42.1%), diabetes (37.3%), osteoarthritis (36.4%) and cardiovascular disease with previous cardiac stents (5.3%). Furthermore, 38.3% of patients reported psychiatric diagnoses, such as depression and anxiety. The overall 30-day complication rate was 15.3%. The complication rate for minor complications was 13.4% and for major complications was 1.9% (2 leaks, 1 stricture and 1 fistula).

Conclusion

Our results support the feasibility of safely performing LSG surgery at bariatric centres completing fewer than 125 procedures annually.     

Does the future of laparoscopic sleeve gastrectomy lie in the outpatient surgery center? A retrospective study of the safety of 3162 outpatient sleeve gastrectomies

Background

Laparoscopic sleeve gastrectomy (LSG) is a safe and effective procedure that can be performed as an outpatient procedure.

The effect of laparoscopic sleeve gastrectomy on the antireflux mechanism: can it be minimized?

Background

Laparoscopic sleeve gastrectomy (LSG) is a promising procedure for the treatment of morbid obesity. The stomach is usually transected near the angle of His; hence, the lower esophageal sphincter (LES) may be affected with consequences on postoperative gastroesophageal reflux disease (GERD). The purpose of this study was to examine the effect of LSG on the LES and postoperative GERD.

Methods

Severely obese asymptomatic patients submitted to LSG underwent esophageal manometry and GERD evaluation preoperatively and at least 6 weeks postoperatively. Data reviewed included patient demographics, manometric measurements, GERD symptoms, and pathology. Statistical analysis was performed by SPSS software.

Results

Twelve male and eleven female patients participated in the study. Mean age was 38.5 ± 10.9 years, and initial body mass index was 47.9 ± 5.1 kg/m². At follow-up examination, mean excess body mass index loss was 32.3 ± 12.7 %. The LES total and abdominal length increased significantly postoperatively, whereas the contraction amplitude in the lower esophagus decreased. There was an increase in reflux symptoms postoperatively (p < 0.009). The operating surgeon who mostly approximated the angle of His resulted in an increased abdominal LES length (p < 0.01). The presence of esophageal tissue in the specimen correlated with increased total GERD score (p < 0.05).

Conclusions

LSG weakens the contraction amplitude of the lower esophagus, which may contribute to postoperative reflux deterioration. It also increases the total and the abdominal length of the LES, especially when the angle of His is mostly approximated. However, if this approximation leads to esophageal tissue excision, reflux is again aggravated. Thus, stapling too close to the angle of His should be done cautiously.     

Comparison of complications after laparoscopy-assisted distal gastrectomy and open distal gastrectomy for gastric cancer using the Clavien–Dindo classification

Background  

The complication rate after surgery for gastric cancer varies according to the particular definition of morbidity. Complications after gastrectomy should be reported using a standardized method. The present study retrospectively analyzed patient outcomes after open distal gastrectomy (ODG) and laparoscopy-assisted distal gastrectomy (LADG) for gastric cancer using a standardized classification system of the severity of complications (the Clavien–Dindo system).     

Is there a benefit of pancreaticosplenectomy with gastrectomy for advanced gastric cancer?

BACKGROUND: In Japan, wide resection with extended lymph node dissection has been performed for advanced cancer with good prognosis. Pancreaticosplenectomy with gastrectomy is performed to facilitate dissection of the lymph nodes around the splenic artery. We attempted to evaluate the effects of pancreaticosplenectomy and splenectomy with gastrectomy for advanced gastric cancer. METHODS: Gastric cancer patients underwent splenectomy with gastrectomy (78 cases), pancreaticosplenectomy with gastrectomy (105 cases), or gastrectomy alone (1,755 cases). Survival rates were compared among the three groups for each factor of the depth of invasion, stage, and curability. RESULTS: There were no significant differences among the three groups. Pancreaticosplenectomy or splenectomy with gastrectomy to dissect lymph nodes does not improve survival but is associated with severe complications. CONCLUSIONS: The spleen should be resected when a patient has clearly positive node metastasis around the splenic hilus and artery, and pancreaticosplenectomy be performed when the cancer lesion invades the pancreas.     

Sleeve gastrectomy versus Roux-en-Y gastric bypass in patients Aged ≥65 years: a comparison of short-term outcomes

BackgroundBariatric surgery in the elderly population has been reported as feasible and safe. Sleeve gastrectomy (SG) seems to have fewer complications than Roux-en-Y gastric bypass (RYGB) even in the 65 years of age population. We analyzed the difference in weight loss between SG and RYGB in patients age 65 years.ObjectivesTo analyze and compare outcomes between SG and RYGB in patients 65 years of age and older.SettingAcademic hospital, United States.MethodsAfter internal review board approval, we retrospectively reviewed 2486 patients who underwent either SG or RYGB between 2005 and 2018 at our institution. Basic demographics, preoperative body mass index (BMI), and co-morbidities were described. We identified all patients age ≥65 years and subsequently divided them into 2 groups based on type of bariatric procedure performed. Analysis and comparison of outcomes between these groups were completed. Postoperative BMI was reviewed at 6, 12, and 24 months and percent excess BMI loss (%EBMIL, as defined by the ASMBS clinical committee) was calculated accordingly. The t test and χ² analysis were performed for nominal and categorical variables, respectively.ResultsFrom 2486 patients reviewed, 22.7% (n = 565) were aged ≥65 years. From these, 43.1% (n = 244) underwent SG and 56.8% (n = 321) underwent RYGB. White and female patients were predominant in both groups. Mean age was similar for both populations (SG: 71.1 ± 4.0, RYGB: 71.7 ± 4.5; P = .12). Pre-procedure mean BMI for both groups was close in value, but the difference was statistically significant (40.5 ± 5.5 for SG versus 43.7 ± 7.2 for RYGB; P < .0001). Postoperative follow-up rates were similar in both groups at 12 and 24 months (SG: 51.2% and 31.6%; RYGB: 48.3% and 34.3%; P = .49 and P = .5). The %EBMIL at 6, 12, and 24 months was higher for the RYGB group than the SG group (59.3 ± 27.9, 72.1 ± 29.5, 77.4 ± 26.1 versus 50.2 ± 21.9, 55.2 ± 25.6, 43.9 ± 32.2; P < .01, P < .01, and P < .01, respectively). Complication rates were significantly higher in RYGB versus SG (27.7% versus 9.4%; P < .01). We observed significantly higher anastomotic ulcer and stricture rates for RYGB versus SG (7.2% and 5.9 versus 0% and 0%; P < .01 and P < .01, respectively). RYGB had a higher rate for gastrointestinal obstruction requiring intervention (2.2% versus .4%; P = .07). A similar de novo gastroesophageal reflux disease rate was noted in both procedures (3.7% versus 3.7%; P = .98). No leaks were reported in either group.ConclusionsBoth SG and RYGB are effective weight loss procedures for patients aged ≥65 years. RYGB seems to have higher %EBMIL at 1 and 2 years; however, when compared with SG, complication rates appear to be almost 3 times higher.     

Is same-day discharge associated with increased 30-day postoperative complications and readmissions in patients undergoing laparoscopic adrenalectomy?

BackgroundAdvances in minimally invasive surgery and perioperative care have decreased substantially the duration of time that patients spend recovering in hospital, with many laparoscopic procedures now being performed on an ambulatory basis. There are limited studies, however, on same-day discharge after laparoscopic adrenalectomy. The objectives of this study were to investigate the outcomes and trends of ambulatory laparoscopic adrenalectomy in a multicenter cohort of patients.MethodsAdult patients who underwent elective laparoscopic adrenalectomy between 2005 and 2016 were identified in the database of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Baseline demographics and 30-day outcomes were compared between patients who underwent ambulatory laparoscopic adrenalectomy and those who were discharged after an inpatient stay. Multivariable logistic regression and Cox proportional hazards modelling were used to investigate the association between same-day discharge and 30-day complications and unplanned readmissions.ResultsOf the 4,807 patients included in the study, 88 (1.8%) underwent ambulatory laparoscopic adrenalectomy and 4,719 (98.2%) were admitted after the adrenalectomy. The same-day discharge group contained fewer obese patients (37.2% vs 50%; P = .04), a lesser proportion of American Society of Anesthesiologists class III patients (45.5% vs 61%; P = .003), and more patients with primary aldosteronism (14.8% vs 6%; P = .002) compared with the inpatient group. After adjustment for confounders, same-day discharge was not associated with 30-day overall complications (OR 1.17, 95% CI 0.35–3.85; P = .80) or unplanned readmissions (HR 2.77, 95% CI 0.86–8.96; P = .09). The percentage of laparoscopic adrenalectomies performed on an ambulatory basis at hospitals participating in the ACS NSQIP remained low throughout the study period (0–3.1% per year) with no evidence of an increasing trend over time (P = .21).ConclusionAmbulatory laparoscopic adrenalectomy is a safe and feasible alternative to inpatient hospitalization in selected patients. Further study is needed to determine the cost savings, barriers to uptake, and optimal selection criteria for this approach.