National trends in adolescent bariatric surgical procedures and implications for surgical centers of excellence

BACKGROUND: Bariatric surgery is indicated for severely obese adolescents who have failed nonsurgical treatment. Our objective was to examine national trends in the use of bariatric operations among adolescents. STUDY DESIGN: The Kids' Inpatient Database was used to identify bariatric surgery patients in the pediatric population (age younger than 18 years) for 1997, 2000, and 2003. Patients were identified by procedure codes for bariatric operations with confirmatory diagnosis codes for obesity. Nationally representative estimates of trends in bariatric procedures, patient characteristics, hospital characteristics, and in-hospital complication rates were calculated. We augmented our analysis with the 2003 Nationwide Inpatient Sample, to ascertain hospitals' overall bariatric surgical volume (adolescents and adults). RESULTS: From 1997 to 2003, the estimated number of adolescent bariatric procedures performed nationally increased 5-fold from 51 to 282 (p < 0.01). More than 100 hospitals performed bariatric procedures on adolescents in 2003, most of which (87%) performed 4 or fewer adolescent bariatric operations annually. Operations were predominantly performed in adult hospitals (85%). Although most hospitals had high overall bariatric operation volumes (> 200 bariatric procedures for patients of any age), 39% of adolescent bariatric procedures were performed at lower-volume centers. Patients were predominantly Caucasian (68%) and female (72%), with a mean age of 16 years (minimum age 12 years). In-hospital complications occurred in 6% of patients. There were no in-hospital deaths. CONCLUSIONS: Our findings indicate a recent, rapid increase in the frequency of adolescent bariatric procedures. Most hospitals that performed bariatric procedures on adolescents had limited experience with adolescent bariatric patients, although many of these hospitals appear to have been experienced adult centers with high overall bariatric volume (adolescents and adults). Future research must better clarify the institutional qualifications considered mandatory for treatment of eligible adolescents.     

Result of a national audit of bariatric surgery performed at academic centers: a 2004 University HealthSystem Consortium Benchmarking Project

HYPOTHESIS: Bariatric surgery performed at US academic centers is safe and associated with low mortality. DESIGN: Multi-institutional consecutive cohort study. SETTING: Academic medical centers. PATIENTS AND INTERVENTIONS: We audited the medical records from 40 consecutive bariatric surgery cases performed between October 1, 2003, and March 31, 2004, at each of the 29 institutions participating in the University HealthSystem Consortium Bariatric Surgery Benchmarking Project. All medical records that met inclusion criteria (patient age, >17 and <65 years; and body mass index [calculated as weight in kilograms divided by the square of height in meters], 35-70) and exclusion criteria (previous bariatric surgery) were reviewed and data were collected on a standardized form. MAIN OUTCOME MEASURES: Demographic data, operative time, blood loss, transfusion requirement, complications, readmission, reoperation, and in-hospital and 30-day mortality. RESULTS: Data from 1144 bariatric surgery cases were reviewed from 29 University HealthSystem Consortium institutions. The specific bariatric procedures included gastric bypass (91.7%), gastroplasty or gastric banding (8.2%), and biliopancreatic diversion (0.1%). For gastric bypass procedures (n = 1049), the mean patient age was 43 years and mean body mass index was 49; 76% of procedures were performed laparoscopically, with a conversion rate of 2.2%; the overall complication rate was 16%, with an anastomotic leakage rate of 1.6%; the 30-day readmission rate was 6.6%; and the 30-day mortality rate was 0.4%. For restrictive procedures (n = 94), the mean patient age was 45 years and mean body mass index was 45; 92% of procedures were performed laparoscopically with no conversion; the overall complication rate was 3.2%; the 30-day readmission rate was 4.3%; and the 30-day mortality rate was 0%. CONCLUSIONS: Within the context of the 2004 University HealthSystem Consortium Bariatric Surgery Benchmarking Project, the risk for death within 30 days after bariatric surgery at academic centers is less than 1%. In addition, the practice of bariatric surgery at these centers has shifted from open surgery to predominately laparoscopic surgery. These quality-controlled outcome data can be used as a benchmark for the practice of bariatric surgery at most US hospitals.     

Perioperative outcomes of bariatric surgery in adolescents compared with adults at academic medical centers.

BACKGROUND: To compare the perioperative outcomes of bariatric surgery between adolescent (12-18 years) and adult (>18 years) patients for the treatment of morbid obesity using an administrative database. METHODS: Using the International Classification of Diseases, 9th Revision, Clinical Modification diagnosis and procedural codes, we obtained data from the University HealthSystem Consortium for 55,501 morbidly obese patients (309 adolescents and 55,192 adults) who had undergone laparoscopic or open gastric bypass, laparoscopic gastric banding, or laparoscopic gastroplasty from 2002 to 2006. The outcome measures included demographics, length of hospital stay, intensive care unit stay, 30-day readmission, morbidity, and observed and expected (risk-adjusted) mortality. RESULTS: The overall 30-day complication rate was significantly lower in the adolescent group (5.5% adolescents and 9.8% adults). The in-hospital and observed/expected mortality ratios were similar between groups. The greatest morbidity was associated with open gastric bypass procedures (7.6% for adolescents and 11.1% for adults) followed by laparoscopic gastric bypass (4.3% and 7.5%, respectively). Open gastric bypass in adults had the greatest observed/expected mortality ratio (1.0). In adolescents, the 30-day morbidity and mortality rate was 0% for restrictive procedures (laparoscopic adjustable gastric banding and gastroplasty). CONCLUSION: Bariatric surgery in adolescents represents a small subset of all bariatric operations performed at academic centers, although the number has increased threefold since 2002. Gastric bypass is the most commonly performed bariatric procedure in adolescents. The outcomes of bariatric surgery in adolescents appear to be as safe as those in adults, with lower 30-day morbidity.     

National trends in bariatric surgery, 1996-2002

BACKGROUND: Surgical therapy for the long-term treatment of obesity ("bariatric surgery") in individuals whose body mass index (calculated as weight in kilograms divided by the square of height in meters) is 40 or higher or in those who have significant obesity-related comorbidities and a body mass index of 35 or higher is one of few interventions shown to be effective. Many aspects of recent national bariatric surgery trends are unclear, including the ages of individuals undergoing such procedures and the economic burden borne by public vs private payers. HYPOTHESIS: Population-adjusted rates of bariatric surgery are rapidly increasing and have economic implications that differ for private vs public payers. DESIGN AND SETTING: We examined hospitalization and charge data from the Nationwide Inpatient Sample from 1996 through 2002, representative of national patterns for children and adults. We derived nationally weighted estimates of population-adjusted hospitalization rates and inflation-adjusted charges for bariatric surgery. We also examined the relative economic burden for public vs private payers for bariatric surgery discharges. RESULTS: Population-adjusted rates of bariatric surgery in the overall sample increased more than 7-fold in the study period, from 3.5 per 100 000 US population in 1996 to 24.0 per 100 000 in 2002. During this period, among youth (<20 years old), rates increased from 0.23 per 100 000 to 0.73 per 100 000; and among elderly persons (>65 years old), rates increased from 0.30 per 100 000 to 1.69 per 100 000. The rate increased most dramatically among those aged 20 to 65 years, who composed 97% or more of bariatric surgery discharges annually. Increases in bariatric surgical volume corresponded with increasing economic consequences overall, exceeding USD $2 billion in annual charges by 2002 (mean, USD $29,107 per discharge). Since 2000, private payers have been charged for more than 80% of the national total; annual charges to Medicare and Medicaid have been comparatively modest, but each exceeded USD $100 million by 2002. CONCLUSIONS: National rates of bariatric surgery have increased markedly among children and adults, with attendant economic consequences, principally for private insurers. This trend may reflect the dearth of effective primary care and preventive interventions to address the obesity epidemic.     

Revisional surgery after failed laparoscopic adjustable gastric banding

BackgroundLaparoscopic adjustable gastric banding (LAGB) is a restrictive procedure that achieves weight loss without anatomic alteration. However, morbidity requiring surgical reintervention can occur.MethodsA retrospective review of a prospectively maintained database of primary LAGB and revisional surgery after failed LAGB was performed from January 2001 to October 2006 at an academic private clinic.ResultsOf 2467 bariatric procedures, primary LAGB was performed in 242 patients. A total of 53 revisional procedures were performed in 40 patients and 16 in 9 patients who were referred from other centers after failed primary LAGB. The mean follow-up was 45.7 ± 15.8 months (range 9.5–70). The early surgical reintervention rate was 6.1%. The revisional procedures included band removal only in 27 (39%), band removal and conversion to sleeve gastrectomy in 10 (14.5%), band removal and conversion to Roux-en-Y gastric bypass in 5 (7.2%), band repositioning in 7 (10%), device-related reintervention in 6 (8.7%), subsequent conversion to another bariatric procedure in 3 (4.3%), and other procedures in 11 (15.9%). Of the 49 patients, 21 (43%) presented with acute band-related morbidity. A total of 55 procedures (96.5%), amenable to minimal invasive surgery, excluding wound and port site-related procedures, were completed laparoscopically. The major early and late complication rate was 4.1% and 2%, respectively.ConclusionPrimary LAGB was associated with acceptable major early complication and surgical reintervention rates. However, a late surgical reintervention rate of 15.2% was observed. Band removal was required in 14% of our primary LAGB patients because of band-related morbidity, with conversion to another bariatric procedure in 6.2%. Our results have shown that LAGB can be associated with significant morbidity and that revisional surgery is common.     

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.     

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.     

National Surgical Quality Improvement Program analysis of bariatric operations: modifiable risk factors contribute to bariatric surgical adverse outcomes

BACKGROUND: The increase in obesity coupled with greater acceptance of the field of bariatric surgery has resulted in a substantial rise in the number of weight-loss operations. Because obese individuals are at high risk for surgical complications, concern about the safety of bariatric procedures exists. Earlier investigations of the clinical features associated with surgical complications have produced conflicting results. We sought to identify risk factors for surgical complications in a large, nationally representative population of US veterans. STUDY DESIGN: We analyzed data on bariatric procedures performed at 12 Veterans' Affairs medical centers approved to perform weight-loss operations between 1998 and 2004. Detailed pre-, intra-, and postoperative information and longterm mortality data were prospectively collected using the National Surgical Quality Improvement Program methodology. We used multivariable logistic regression to identify clinical features associated with postoperative complications. RESULTS: Among 575 bariatric patients assessed between 1998 and 2004, 74% were men with a mean age of 51 years. Thirty-day mortality was 1.4%. Overall complication rate was 19.7%. Of those with complications, one-half were of considerable clinical importance, as they were associated with prolonged length of stay. Clinical features that were predictive of adverse events in our multivariable analyses were superobesity, weight>350 pounds, and smoking. A more than 20 pack-year history of smoking was also associated with difficulty in weaning from a ventilator postoperatively. CONCLUSIONS: We identified smoking and superobesity as preoperative risk factors associated with postoperative complications. Future studies should examine the effect of preoperative weight loss and smoking cessation on bariatric procedure outcomes.     

Who are today’s bariatric surgeons and which ones join the ASBS?

BACKGROUND: This study was undertaken to describe bariatric surgeons in the United States today and to determine whether those who are members of a major bariatric surgery specialty society differ from nonmembers. METHODS: We performed a national survey of a 50% cross-sectional random sample of all general surgeons in the United States to determine how many performed bariatric procedures. Through record linkage, we identified which surgeons were members of the American Society of Bariatric Surgeons (ASBS). We used bivariate tests of association (Pearson's chi2, Fisher's exact test, and the Student t-test) to compare demographic, training, and surgical practice characteristics of ASBS members and nonmembers. RESULTS: Of the 2906 survey respondents, 359 (12%) were bariatric surgeons. We estimated response rates of 55% among bariatric surgeons and 27% among others; 46% (n = 163) of those performing bariatric procedures were ASBS members. Members were more likely to be board-certified in general surgery, to perform newer surgical techniques, and to have a higher procedural volume. The years of bariatric experience were similar in the two groups. CONCLUSIONS: Continuing medical education opportunities afforded by specialty society membership allow surgeons to remain abreast of the most recent advances in bariatric surgery technique and effectively address the complex health and psychosocial issues associated with morbid obesity. However, we found that only about half of all surgeons performing bariatric procedures in the United States are ASBS members. Standardization in the form of mandatory involvement in education and training activities or even specialty board certification in bariatric surgery might be necessary to ensure bariatric surgery skills and qualifications across the United States.     

Bariatric and Associated Operations in Private and Academic Practices

Background: The types of bariatric and the associated operations performed by academic and private surgeons were surveyed. Methods: A survey containing 8 questions regarding type of practice, type of surgery, associated procedures during bariatric surgery, years in practice and bariatric training was e-mailed to all members of the American Society for Bariatric Surgery. Results: 46% of the members responded and were divided between those who performed their procedures laparoscopically and those who performed open procedures. Laparoscopic adjustable gastric banding was almost exclusively performed in academic centers and encompassed 20% of their bariatric operations, while the gastric bypass was the most common operation performed (65%), followed by vertical banded gastroplasty and duodenal switch. Operations performed simultaneously indicated that cholecystectomies were performed equally in private practice (92.5%) and the academic sector (95%), with higher incidence in open procedures (95%) compared to laparoscopic (40%). Of the surgeons performing appendectomies, 20% were in private practice and 10% in academic. Liver biopsy was performed with the same incidence in private and academic practices (60%). A minority of responders had formal fellowship training (17%), and many had learned from a partner (40%). The approach was dictated by the surgical training (85%) and background. Conclusion: No significant difference was found between the private and academic surgeons in performing operations. Appendectomy is rarely performed academically, and cholecystectomy is mostly performed in the open procedure.     

Objective comparison of complications resulting from laparoscopic bariatric procedures

BACKGROUND: Several surgical treatment options for morbid obesity exist. Currently, there are no studies that objectively compare complication rates after laparoscopic bariatric operations performed at a single institution. We objectively classify and compare complications resulting from laparoscopic adjustable gastric banding (LABG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion (BPD) with duodenal switch (DS). STUDY DESIGN: A retrospective review of a prospective database of all patients undergoing laparoscopic bariatric operation was performed. Complications were categorized according to severity score using a well-described classification system and compared between procedures. RESULTS: From September 2000 to July 2003, 780 laparoscopic bariatric operations were performed: 480 LAGB, 235 RYGB, and 65 BPD+/-DS. There was one late death. Total complication rates were: 9% for LAGB, 23% for RYGB, and 25% for BPD+/-DS. Complications resulting in organ resection, irreversible deficits, and death (grades III and IV) occurred at rates of 0.2% for LAGB, 2% for RYGB, and 5% for BPD+/-DS. LAGB group had a statistically significant lower overall complication rate, both by incidence and severity, as compared with other groups (p < 0.001). After controlling for differences of admission body mass index, gender, and race, the LAGB group had an almost three and a half times lower likelihood of a complication compared with the RYGB group (odds ratio, 3.4; 95% CI, 2.2-5.3, p < 0.001) and had an over three and a half times lower likelihood of a complication compared with the BPD with DS group (odds ratio, 3.6; 95% CI, 1.8-7.1, p < 0.001). There was no statistically significant difference between complication rates of RYGB and BPD+/-DS. CONCLUSIONS: Bariatric operation complication rates range from 9% to 25%; very few complications are serious. Laparoscopic adjustable gastric banding is the safest operation in terms of complication rate and severity when compared with laparoscopic Roux-en-Y gastric bypass or laparoscopic malabsorptive operations.     

Effect of perioperative management on short-term outcomes after sleeve gastrectomy: a 600-patient single-center cohort study

BackgroundReports on the postoperative outcomes of sleeve gastrectomy (SG) have only been from small, single-center series and meta-analyses of studies with variable SG management. The objective of this study was to evaluate post-SG outcomes in a specialized bariatric surgery center with a routinely performed standardized procedure.MethodsThe postoperative complication rate, operating times, and postoperative data were evaluated from all patients undergoing a primary SG between November 2004 and February 2012. Results were analyzed for 3 separate surgical periods, which differed with perioperative management.ResultsOf 600 patients (mean age: 41.8±11.3; mean body mass index [BMI]: 47.2±16 kg/m²; 80% were women who underwent primary SG), 26.8% had a BMI≥50 kg/m². The mean operating time was 84 minutes. The rate of conversion was 1%. There were no postoperative deaths. The overall complication rate was 8.5%; the major complication rate was 5.6%; the revisional surgery rate was 4.6% and the gastric leak rate was 2.5%. Over the course of the 3 study periods, the operating time fell from 91±32 to 79±22 minutes (P≤.001); the length of hospital stay decreased from 4.5±4.9 to 3.4±4.3 days (P = .02); the major complication rate fell from 6.4% to 5.5% (P = NS); and the gastric fistula rate decreased from 4.6% to 1.9% (P = NS).ConclusionIn a specialist bariatric surgery center, SG had an acceptable complication rate. Modifications in the perioperative management of SG were associated with a shorter mean operating time and hospital stay and did not increase the major complication or gastric fistula rates.     

Total knee arthroplasty in morbidly obese patients treated with bariatric surgery: a comparative study

Our objective was to compare outcomes (anesthesia time, total operative time, tourniquet time, duration of hospital stay, 90-day complication rate, and transfusion rates) of patients with total knee arthroplasty (TKA) who underwent bariatric surgery before or after TKA. One hundred twenty-five patients were included: TKA before bariatric surgery (group 1; n = 39), TKA within 2 years of bariatric surgery (group 2; n = 25), and TKA more than 2 years after bariatric surgery (group 3; n = 61). Patients with TKA more than 2 years after bariatric surgery had shorter anesthesia and total operative and tourniquet times than other groups; differences were significant between groups. Ninety-day complication and transfusion rates approached but did not meet statistical significance. Ninety-day complication rates and duration of hospital stay did not differ significantly between the 3 groups. The level of evidence was level II (cohort study).     

Use of laparoscopy in general surgical operations at academic centers

BackgroundLaparoscopy is commonly being used in many different types of general surgical procedures. The aim of the present study was to examine the use of laparoscopy and perioperative outcomes in 7 general surgical operations commonly performed at U.S. academic medical centers.MethodsThe clinical data of patients who underwent 1 of the 7 general surgical operations from 2008 to 2012 were obtained from the University HealthSystem Consortium database. The University HealthSystem Consortium database contains data from all major teaching hospitals in the United States. The 7 analyzed operations included only elective, inpatient procedures (except for appendectomy): open and laparoscopic antireflux surgery for gastroesophageal reflux, colectomy for colon cancer or diverticulitis, bariatric surgery for morbid obesity, ventral hernia repair for incisional hernia, appendectomy for acute appendicitis, rectal resection for rectal cancer, and cholecystectomy for cholelithiasis. The outcome measures included the number of procedures, rate of laparoscopy, rate of conversion to laparotomy, and in-hospital mortality.ResultsDuring the 3.5-year period, 53,958 patients underwent bariatric surgery, 13,918 patients underwent antireflux surgery, 8654 patients underwent appendectomy, 8512 patients underwent cholecystectomy, 29,934 patients underwent colectomy, 17,746 patients underwent ventral hernia repair, and 4729 patients underwent rectal resection. The present rate of laparoscopic use was 94.0% for bariatric surgery, 83.7% for antireflux surgery, 79.2% for appendectomy, 77.1% for cholecystectomy, 52.4% for colectomy, 28.1% for ventral hernia repair, and 18.3% for rectal resection. In-hospital mortality was greatest for colorectal resection (.38%–.58%). In-hospital mortality for bariatric surgery (.06%) was comparable to that for appendectomy (.01%), cholecystectomy (.27%), antireflux surgery (.15%), and ventral hernia repair (.20%). The rate of laparoscopic conversion to open surgery was lowest for bariatric surgery (.89%) and greatest for rectal resection (16.4%).ConclusionWithin the context of academic centers and elective, inpatient procedures, bariatric surgery had the greatest use of laparoscopy and the lowest rate of laparoscopic conversion to open surgery. The mortality for laparoscopic bariatric surgery is now comparable to that of laparoscopic cholecystectomy, ventral hernia repair, appendectomy, and antireflux surgery.     

Outcomes of bariatric surgery in the elderly

The Medicare Coverage Advisory Committee recently concluded that evidence supports the safety and effectiveness of bariatric surgery in the general adult population. However, more information is needed on the role of bariatric surgery in the elderly. The aim of this study was to examine the outcome of bariatric surgery in the elderly performed at academic centers. Using International Classification of Diseases, 9th Revision diagnosis and procedure codes, we obtained data from the University HealthSystem Consortium Clinical Data Base for all elderly (>60 years) and nonelderly (19-60 years) patients who underwent bariatric surgery for the treatment of morbid obesity between 1999 and 2005. Outcome measures, including patient characteristics, length of stay, 30-day readmission, morbidity, and observed and expected (risk-adjusted) mortality, were compared between groups. Bariatric surgery in the elderly represents 2.7 per cent (n = 1,339) of all bariatric operations being performed at academic centers. Of the 99 University HealthSystem Consortium centers performing bariatric surgery, 78 centers (79%) perform bariatric surgery in the elderly. Compared with nonelderly patients, elderly patients who underwent bariatric surgery had more comorbidities, longer lengths of stay (4.9 days vs 3.8 days, P < 0.01), more overall complications (18.9% vs 10.9%, P < 0.01), pulmonary complications (4.3% vs 2.3%, P < 0.01), hemorrhagic complications (2.5% vs 1.5%, P < 0.01), and wound complications (1.7% vs 1.0%). The in-hospital mortality rate was also higher in the elderly group (0.7% vs 0.3%, P = 0.03). When risk adjusted, the observed-to-expected mortality ratio for the elderly group was 0.9. In a subset of elderly patients with a pre-existing cardiac condition (n = 236), the in-hospital mortality was 4.7 per cent. Bariatric surgery in the elderly represents only a small fraction of the number of bariatric operations performed at academic centers. Although the morbidity and mortality is higher in the elderly, bariatric surgery in the elderly is considered as safe as other gastrointestinal procedures because the observed mortality is better than the expected (risk-adjusted) mortality.     

Results of Sleeve Gastrectomy—Data from a Nationwide Survey on Bariatric Surgery in Germany

Background  Beginning January 1, 2005, the status and outcomes of bariatric surgery were examined in Germany. Data are registered in cooperation with the An-Institute of quality assurance in surgery at the Otto-von-Guericke-University Magdeburg. The objective of this study was to examine the morbidity and mortality rates secondary to sleeve gastrectomy (SG) in Germany since 2006. Methods  Data collection occurred prospectively in an online data bank. All primary bariatric procedures performed were recorded as were all re-operations in patients that had already undergone a primary operation. Specific data compiled on the sleeve gastrectomy procedure were evaluated with a focus on operative details and complication rates. Results  The total study cohort contains 3,122 patients. From January 2006 to December 2007, 144 sleeve gastrectomy procedures were performed in the 17 hospitals participating in the study. The mean body mass index (BMI) of all patients was 48.8 kg/m². The BMI of patients undergoing SG was 54.5 kg/m². In total, 73.8% of the patients were female and 26.2% of the patients were male. There were no significant differences between patients undergoing SG. The general complication rate after SG was 14.1%, and the surgical complication rate was 9.4%. The postoperative mortality rate was 1.4%. Conclusions  The complication rate during the first 2 years after SG in Germany is similar to that published in the literature. In order to improve the quality of bariatric surgery, an evaluation of data from a German multicenter trial is necessary to evaluate the position of SG in the bariatric algorithm.     

Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery

HYPOTHESIS: An increase in national utilization of bariatric surgery correlates with the dissemination of laparoscopic bariatric surgery. DESIGN: Evaluation of Nationwide Inpatient Sample data from 1998 through 2002. SETTING: National database. PATIENTS: A total of 188,599 patients underwent bariatric surgery for the treatment of morbid obesity. MAIN OUTCOME MEASURES: Annual total number of bariatric operations, the proportion of Roux-en-Y gastric bypass vs gastroplasty, the proportion of laparoscopic cases, postoperative length of stay, crude in-hospital mortality, and the number of institutions that perform bariatric surgery. RESULTS: Between 1998 and 2002, the number of bariatric operations increased from 12,775 cases to 70,256 cases. The rate of bariatric surgery increased from 6.3 to 32.7 procedures per 100,000 adults. Laparoscopic bariatric surgery increased from 2.1% to 17.9%. The number of bariatric surgeons with membership in the American Society for Bariatric Surgery increased from 258 to 631, and the number of institutions that perform bariatric surgery increased from 131 to 323. During this 5-year period, the annual rate of laparoscopic bariatric surgery increased exponentially (by 44-fold) compared with a linear growth in open bariatric surgery (by 3-fold). CONCLUSIONS: Between 1998 and 2002, there was a 450% increase in the number of bariatric operations performed in the United States, a 144% increase in the number of American Society for Bariatric Surgery bariatric surgeons, and a 146% increase in the number of bariatric centers. The growth of laparoscopic bariatric surgery during this 5-year period greatly exceeds that of open bariatric surgery.     

Fast-track laparoscopic bariatric surgery: a systematic review

This study aimed to systematically evaluate the evidence-based literature on fast-track laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) to determine the feasibility and safety of fast-track laparoscopic bariatric surgery. A literature search of PubMed, EMBASE and Cochrane Library using the MeSH terms “bariatric surgery”, “ambulatory surgical procedures” and related terms as keywords was performed. The study included articles that reported on intended next-day discharge for LRYGB and same-day discharge for LAGB. Data were extracted on study design and size, patient demographics, patient-selection criteria, patient preparation, perioperative management, operative details, clinical outcomes, and follow-up. The review included 13 studies classified as level 3b or 4 evidence. There were seven studies that investigated LAGB, five studies investigated LRYGB and one study detailed outcomes from both LRYGB and LAGB. Next-day discharge rate ranged from 81 to 100 % for LRYGB. Same-day discharge rate ranged from 76 to 98 % for LAGB. In LRYGB and LAGB complication, re-admission and mortality rates (≤10.5, ≤7.5, ≤0.1 %, respectively) were comparable with the conventional perioperative care. From our results, the fast-track management of patients undergoing LRYGB and LAGB is feasible. With careful patient selection and preparation within high-volume centres, and application of care pathways including close outpatient follow-up, outcomes for fast-track bariatric procedures can compare favourably with those reported in the literature for standard management, but with decreased cost. However, further studies from independent researchers are required to determine the safety of a generalised adoption of this approach outside of dedicated bariatric units, and to formally demonstrate the cost-benefit of fast-track bariatric surgery.     

Percutaneous management of large renal stones in a private practice community setting

PURPOSE: Recent evidence suggests that increasing numbers of patients with large renal stones are treated at tertiary care centers. Studies of practice patterns in the community have demonstrated that private practice urologists perform few percutaneous nephrolithotomies (PCNLs) and rely heavily on interventional radiologists to obtain renal access. We reviewed our series of PCNLs performed in a community setting, with a focus on success rates and complications, to compare results and effectiveness rates with those of tertiary care centers. PATIENTS AND METHODS: All patients undergoing PCNL for large renal calculi from 1993 to 2006 were included. All procedures were performed by a single surgeon who obtained percutaneous renal access without the assistance of a radiologist. Data were retrospectively reviewed to determine clinical success rates, intraoperative and postoperative complications, and rate of additional procedures. RESULTS: Two hundred and four PCNLs were performed in 170 patients. In 43 cases, more than one percutaneous tract was created. Mean blood loss was 260 mL (range 50-800 mL), and transfusion was necessary in 2% (4/204). In 194 (95.1%) procedures, treatment was considered successful with asymptomatic fragments of 4 mm or smaller. Of these, there was no significant stone burden after a single procedure in 117. Mean hospital stay was 3 days (range 1-15 days). No intraoperative complications occurred. The overall complication rate was 6.9%. CONCLUSIONS: The high success rate of our single, private practice experience is comparable to that of major academic centers. We believe PCNL can be safely and effectively performed in the private practice setting by urologists trained in the procedure.     

Early results of a prospective multicenter study on 500 consecutive cases of laparoscopic colorectal surgery

Background: Prospective randomized multicenter studies comparing laparoscopic with open colorectal surgery are not yet available. Reliable data from prospective multicenter studies involving consecutive patients are also lacking. On the basis of the personal caseloads of specialized surgeons or of retrospective analyses, it is difficult to judge the true effectiveness of this new technique. This study aims to investigate the results of laparoscopic colorectal surgery in consecutive patients operated on by unselected surgeons. Methods: This observational study was begun August 1, 1995, in the German-speaking part of Europe (Germany and Austria) and 43 centers initially agreed to participate. All consecutive cases were documented. All data were rendered anonymous. Analysis was performed on an intention-to-treat basis. The study committee was blinded to the participating center. Results: By the end of the 1st year, 500 patients (M:F ratio 0.83, mean age 62.9 years) had been treated by 18 centers; 269 operations were performed for benign indications and 231 for cancer (palliative and curative). Most operations were done on the distal colon or rectum. An anastomosis was performed in 84%, with an overall leakage rate of 5.3% (colon 3.6% and rectum 11.8%), which required surgical reintervention in 1.7%. The mean operating time was 176 min and showed a decreasing tendency over the period under study. The conversion rate was 7.0% and the overall complication rate 21.4%. The reoperation rate was 6.6%; the most common cause was bleeding. There was one ureteral lesion (0.2%), but urinary tract infections were fairly common (4.8%). A postoperative pneumonia was diagnosed in 1.6% of the cases. No thromboembolic complications were reported. The 30-day mortality rate was 1.4% and overall hospital mortality 1.8%. Conclusions: Laparoscopic colorectal operations are still rare (about 1% of all colorectal operations in Germany). Laparoscopic procedures are more common on the left colon and rectum than on the right colon. The surgical complication rate is acceptable, comparable with rates reported by others for open surgery. Cardiopulmonary and thromboembolic complications were rarely seen. Mortality and surgical morbidity rates do not differ significantly among participating centers. A learning curve, reflected by a shortening of the operating time and a somewhat lower conversion rate, was observed over the observation period. Received: 3 February 1997/Accepted: 22 April 1997