The safety profile of one-anastomosis gastric bypass compared to Roux-en-Y gastric bypass: a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program analysis.

BACKGROUND: One anastomosis gastric bypass (OAGB) is an American Society for Metabolic and Bariatric Surgery (ASMBS)-endorsed bariatric surgery. As utilization of OAGB increases, it is important that the safety profile of OAGB be rigorously assessed. OBJECTIVES: We studied the 30-day safety of OAGB compared to a similar gastro-jejunal anastomotic procedure, Roux-en-Y gastric bypass (RYGB). SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) participating bariatric centers in the United States. METHODS: A matched case-control study was conducted of patients who underwent primary gastric bypass surgery 2021-2022, identified in the MBSAQIP database. Each patient who underwent OAGB was matched to 4 controls who underwent RYGB on age (±10), sex, race, body mass index (BMI) (±5 kg/m2), preoperative functional status, American Society of Anesthesiologists (ASA) classification, and 13 comorbidities. Univariate and multivariate regression analyses were performed. RESULTS: A total of 1569 patients who underwent OAGB were matched to 6276 controls. Matched baseline characteristics were similar between groups. Operative time, length of stay (LOS), and overall complication rate were lower in the OAGB cohort (P < .001) with higher 30-day BMI loss percentage (P = .048). Specifically, OAGB was associated with a significantly lower bowel obstruction rate, as compared to RYGB (.1% versus 1.0%, P < .001). On logistic regression adjusting for all variables used in matching, OAGB was associated with a 27% decrease in overall complication rate (odds ratio [OR] .73, 95% confidence interval [CI] .62-.87, P < .001). CONCLUSIONS: Although OAGB is minimally utilized, the 30-day safety profile appears favorable. As compared to RYGB, OAGB was associated with shorter operative time and LOS, and a lower complication rate, partially due to minimization of small bowel obstructions with a loop anatomy. Further evidence in the comparative long-term safety profile is still needed.

Six-year analysis of 30-day post-operative leaks for primary sleeve gastrectomy: a MBSAQIP database study.

BACKGROUND: Sleeve gastrectomy is the most performed bariatric surgery. Post-operative gastric sleeve leaks, although rare, are dreaded complications. This study aims to perform an updated investigation of the factors associated with sleeve leaks. METHODS: This retrospective cohort study analyzed 692,554 cases from the MBSAQIP database (2016-2021) with CPT code 43,775 for primary sleeve gastrectomy. We excluded emergency operations, conversions/revisions, endoscopic interventions, patient with prior foregut surgery, and open operations. Multivariate logistic regression analysis (STATA version 15) was performed to identify factors associated with sleeve gastrectomy leaks. RESULTS: Out of 692,554 patients, 600,910 (86.77%) patients underwent laparoscopic sleeve gastrectomy, and 91,644 (13.23%) patients underwent robotic sleeve gastrectomy. 1179 (0.17%) developed leaks within 30 days; 177(0.19%) were in the robotic group and 1002 (0.17%) in the laparoscopic group with no significant difference in leak rates between two groups on multivariate analysis. Black patients had lower odds of having leaks as compared to white patients (Odds Ratio (OR): 0.68 (0.56-0.82); p < 0.01). Hispanic patients had lower odds of having leak as compared to non-Hispanics. Factors associated with higher leak odds (p < 0.05) included hypertension, GERD, smoking, immunosuppression, increased operating time, and albumin < 3.5 g/dl. Higher odds of leaks were observed in years 2016-2019 vs 2020-2021 (OR: 1.44 (1.25-1.65), p < 0.01). Higher odds of leak in operations with general surgeons compared to bariatric surgeons was found (OR: 1.46 (1.04-2.02), p = 0.02); observed only on robotic group on subgroup analysis (OR: 2.2 (1.2-4.2), p = 0.02). Staple line reinforcement, oversewing, and performance of leak test showed no differences in leak rate. Bougie size and distance from pylorus were not associated with changes in leak rate. CONCLUSION: This study provides updated insights into the factors associated with sleeve leaks, reinforcing information gained from prior studies. A higher association of leak among general surgeons could represent a learning curve for new robotic general surgeons. The overall decreasing trend for gastric sleeve leak is encouraging and may be a sign of improved techniques.

Bariatric surgery in patients with preoperative therapeutic anticoagulation: a 2015-2021 MBSAQIP database study.

BACKGROUND: The link between obesity and adverse cardiovascular events is well-established. With the rising prevalence of metabolic and bariatric surgery (MBS), a greater number of patients undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) may present with preoperative therapeutic anticoagulation (AC). OBJECTIVES: This study evaluated perioperative outcomes of SG and RYGB in patients on preoperative AC. SETTING: Patients reported to the 2015-2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. METHODS: Adults undergoing primary SG or RYGB with and without preoperative anticoagulation (SG-AC or RYGB-AC and non-SG-AC or non-RYGB-AC, respectively) were analyzed from the 2015-2021 MBSAQIP database. Differences in baseline characteristics by AC status for each MBS were adjusted using entropy-balanced weights. Multivariable logistic and linear regressions were developed to analyze the independent association between AC and outcomes of interest. RESULTS: Of 1,178,090 patients included, 72.0% (n = 850,682) had SG and 28.0% (n = 327,408) had RYGB, of which 1.8% (n = 15,021) and 1.9% (n = 6201) had AC, respectively. Compared to non-SG-AC and non-RYGB-AC, both SG-AC and RYGB-AC encountered higher absolute 30-day rates of anastomotic leak, deep vein thrombosis and gastrointestinal bleeding. Following multivariable adjustment, SG-AC was associated with significantly greater odds of adverse cardiovascular events, anastomotic leak, gastrointestinal bleeding, and greater operative length and length of stay. RYGB-AC was associated with higher odds of readmission, unplanned ICU admission, and ED visit. CONCLUSIONS: While preoperative AC may confer distinct outcomes between SG and RYGB, this 7-year study of MBSAQIP demonstrated an overall association with greater postoperative morbidity. Management of MBS patients with preoperative AC requires consideration of thrombohemorrhagic risks.

Perioperative outcomes of same-day discharge laparoscopic Roux-en-Y gastric bypass using the MBSAQIP database.

BACKGROUND: There has been a rising trend of outpatient bariatric surgery, particularly accelerated by the COVID-19 pandemic. The aim of this study was to evaluate the safety and outcomes of same-day discharge laparoscopic Roux-en-Y gastric bypass (LRYGB) using the MBSAQIP database. METHODS: In this retrospective study, the MBSAQIP was queried for patients undergoing non-revisional LRYGB between 2020 and 2021. Two cohorts were established: same-day discharge (SDD; length of stay = 0 days) and next-day discharge (POD1; length of stay = 1 day), with the latter serving as a control group. Univariate analysis and multivariate logistic regression were employed to compare outcomes between cohorts. RESULTS: A total of 48,408 patients underwent LRYGB, with 1,918 (4.0%) SDD and 46,490 (96.0%) POD1. The two cohorts were similar in mean age (SDD 44.2 ± 11.3 years vs POD1 44.0 ± 11.3 years; p = 0.61) and female sex (SDD 83.8% vs POD1 83.1%; p = 0.43). However, the POD1 cohort had a higher preoperative body mass index (45.4 ± 7.3 vs 44.9 ± 7.3 kg/m2; p < 0.01). Preoperative anticoagulation and obstructive sleep apnea were more prevalent in the POD1 group. There was no difference in overall 30-day overall complication rates (SDD 2.0% vs POD1 2.3%; p = 0.51), reintervention, reoperations, mortality, and emergency department visits between the two cohorts. Readmissions were lower in the SDD cohort (2.9% vs 4.0%; p = 0.02), whereas the need for outpatient intravenous hydration was higher in the SDD cohort (6.7% vs 3.6%; p < 0.01). This finding remained significant even after adjustment for confounders. CONCLUSION: Same-day LRYGB is safe and feasible, with comparable complication rates to next-day discharge. Notably, SDD is associated with lower readmission rate and higher need for outpatient intravenous hydration, possibly reflecting rigorous bariatric protocols and thorough patient follow-up. Further investigations are warranted to elucidate the selection criteria and optimize postoperative care for outpatient LRYGB.

Venous Thromboembolic Events Following Revisional Gastric Bypass: An Analysis of the MBSAQIP Database from 2015 to 2019 Using Propensity Matching.

BACKGROUND: Primary bariatric surgery is associated with moderate-to-high risk of venous thromboembolic events (VTE); however, the risk for revisional surgery lacks granularity. Our primary objective was to define the risk of VTE following revisional Roux-en-Y gastric bypass (RYGB) compared to primary RYGB. METHODS: Adults who underwent primary or revision/conversion RYGB between January 1, 2015, and December 31, 2019, with a BMI ≥ 35 kg/m2 were identified in a bariatric specific database. VTE was defined as pulmonary embolus and/or deep venous thrombosis. Thirty-day VTE and transfusion rates were compared between the two groups using propensity score matching of 3:1. RESULTS: Primary RYGB was performed in 197,186 (92.4%) patients compared to 16,144 (7.6%) in the revisional group. Patients in the revisional group had fewer comorbidities than those undergoing primary RYGB. In the matched cohort of 64,258 procedures, there were 48,116 (74.9%) primary RYGB cases compared to 16,142 (25.1%) RYGB revisions. The rate of VTE was similar in the revisional surgery group compared to the propensity matched primary RYGB group (0.4% vs. 0.3%, p > 0.580); however, transfusion was more common in the revisional group (1.4% vs. 1.0%, p = 0.005). Revisional group had higher rates of readmission, reoperation, increased length of stay, and operation length ≥ 180 min compared to matched primary RYGB group (p < 0.001). CONCLUSIONS: VTE rates for both primary and revisional RYGB are similar. Revisional RYGB cases impose increased risk of bleeding among other outcomes. Thus, identifying those at higher risk of complications is critical.

Robotic bariatric surgery reduces morbidity for revisional gastric bypass when compared to laparoscopic: outcome of 8-year MBSAQIP analysis of over 40,000 cases.

INTRODUCTION: Robotic-assisted metabolic and bariatric surgery (MBS) is gaining popularity. Revisional MBS is associated with higher perioperative morbidity compared to primary MBS. The optimal surgical approach to minimize complications in these complex cases is unclear. The goal of this study was to assess robot utilization in revisional MBS and compare laparoscopic and robotic revisional MBS outcomes in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. METHODS: A retrospective review of the MBSAQIP database was performed identifying revisional sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) cases from 2015 to 2022. Primary MBS, open/emergent cases, cases converted to another approach, and combined cases other than esophagogastroduodenoscopy were excluded. 30-Day outcomes for laparoscopic and robotic cases were compared using multivariate logistic regression adjusting for patient demographics, comorbidities, and operative variables. RESULTS: 41,404 Cases (14,474 SG; 26,930 RYGB) were identified. From 2015 to 2022, the percentage of revisional SG and RYGB cases performed robotically increased from 6.1% and 7.3% to 24.2% and 32.0% respectively. Laparoscopic SG had similar rates of overall morbidity, leak, bleeding, readmission, reoperation, and length of stay compared to robotic. Laparoscopic RYGB had significantly higher rates of overall morbidity (6.2% vs. 4.8%, p < 0.001, AOR 0.80 [0.70-0.93]), blood transfusion (1.5% vs. 1.0%, p < 0.05, AOR 0.74 [0.55-0.99]), superficial incisional SSI (1.2% vs. 0.4%, p < 0.001, AOR 0.30 [0.19-0.47]), and longer length of stay (1.87 vs. 1.76 days, p < 0.001) compared to robotic. Laparoscopic operative times were significantly shorter than robotic (SG: 86.4 ± 45.8 vs. 113.5 ± 51.7 min; RYGB: 130.7 ± 64.7 vs. 165.5 ± 66.8 min, p < 0.001). CONCLUSION: Robot utilization in revisional bariatric surgery is increasing. Robotic surgery has lower postoperative morbidity and shorter length of stay in revisional RYGB when compared to laparoscopic. Robotic platforms may have the capacity to improve the delivery of care for patients undergoing revisional bariatric surgery.

Rare events model of the MBSAQIP database: risk of early bowel obstruction following metabolic surgery.

BACKGROUND: Early small bowel obstruction (eSBO) (within 30-days) is a rare but important complication that is associated with high rates of morbidity, including readmission, reintervention, and reoperation. OBJECTIVES: To identify patient-specific and operation-specific characteristics that predispose patients to eSBO and to identify at-risk individuals preoperatively. SETTING: 2015-2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). METHODS: Utilizing the 2015-2021 MBSAQIP PUF, 1,016,484 records were analyzed. Pediatric, revisional, open-conversion, and cases with incomplete data in sex, body mass index, operative-time, 30-day-follow-up variables were excluded. Case details were compared using Fisher's exact & Wilcoxon -Mann -Whitney tests to identify at-risk patients. The likelihood of eSBO was modeled with rare event logistic regression. RESULTS: Incidence of eSBO was .40%. Of the 4103 occurrences of eSBO, RYGB (Roux-en-Y gastric bypass), SG (sleeve gastrectomy), and DS (duodenal switch) accounted for 79.4%, 19.3%, and 1.3%, respectively. Many patient-specific characteristics were significantly associated with eSBO. History of prior foregut surgery, a non-metabolic surgery trained operator, and longer operative times were all associated with increased eSBO (P < .0001). While simultaneously controlling for these factors, eSBO remained higher in DS (OR 9.55, P < .0001) and RYGB (OR 5.18, P < .0001) compared to SG. Increased length of operation (OR 1.03, P < .0001) and non -MS-trained operators (OR 1.33, P < .0001) remained highly significant. Male-sex (OR .70, P < .0001) and diabetes (OR .78, P < .0001) were both protective. CONCLUSIONS: In the largest analysis to date, eSBO remains a rare event. RYGB accounts for the largest proportion of eSBO, however, DS has a higher risk adjusted rate of eSBO.

Robotic-Assisted and Laparoscopic Bariatric Surgeries Still Have Clinically Comparable Outcomes.

PURPOSE: Bariatric surgery is considered the main treatment option for patients with severe obesity. The objective of our study is to compare intra- and postoperative outcomes between the robotic and laparoscopic approaches within the sleeve gastrectomy (SG), duodenal switch (DS), and Roux-en-Y gastric bypass (RYGB). MATERIALS AND METHODS: The data from the MBSAQIP were collected for patients who underwent SG, DS, and RYGB between 2015 and 2021. The postoperative and procedural outcomes including 30-day morbidity and mortality as well as operation length were analyzed using regression models. RESULTS: Our analysis included 1,178,886 surgeries with SG comprising the majority (70%) followed by RYGB (28%) and DS (1%). Other than a higher adjusted risk of unplanned reoperation for robotic RYGB (relative risk (RR) 1.07) and a statistically significant higher rate of postoperative wound disruption in robotic SG for robotic surgery (RR 1.56), there were no statistically significant between-approach differences including infection, wound disruption, death, or reoperation for DS, RYGB, or SG. Our data showed no significant difference in anastomotic leak rate between laparoscopic and robotic approaches in either the DS (p = 0.521) or RYGB (p = 0.800) procedures. Across our study period, the median operation lengths decreased significantly per year for both the robotic SG and DS. CONCLUSIONS: Robotic and laparoscopic bariatric surgical procedures have statistically similar 30-day patient outcomes. Robotic bariatric procedures do have significantly longer median operative times than laparoscopic procedures. The decision to use a robotic approach or laparoscopic approach should be made based upon surgeon experience and possibly cost.

Sociodemographic factors leading to preventable emergency department visits after bariatric surgery: a single-institution analysis.

BACKGROUND: An important quality benchmark after bariatric surgery is 30-day emergency department (ED) visits. OBJECTIVES: We aimed to identify risk factors for ED visits not requiring readmission and thus deemed preventable. SETTING: University Hospital. METHODS: Patients who underwent a minimally invasive sleeve gastrectomy between 2017 and 2022 at a single institution were identified. Among these patients, those who presented to the ED within 30 days after surgery were matched 3:1 to controls. Sociodemographic and clinical variables were collected from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database and the electronic medical record. Univariate conditional logistic regression analysis was performed to determine predictive factors of ED visits. RESULTS: Overall, 648 patients underwent sleeve gastrectomy, of which 53 (8.2%) presented to the ED within 30 days postoperatively without requiring readmission. Patients who presented to the ED were more likely to be unemployed (42% versus 24%, P = .04) and have government insurance (68% versus 41%, P = .001). Significant risk factors included lower versus upper socioeconomic bracket (odds ratio [OR] 3.6, P = .042), primary care physician (PCP) outside the health system versus within (OR 2.15, P = .032), greater number of PCP visits within the past year (OR 1.27, P < .001), and greater number of postoperative clinic phone calls (OR 2.04, P < .001). The number of ED visits within 1 year before surgery was a significant risk factor, with an OR of 1.44 for each visit (P < .001). CONCLUSIONS: Modifiable and unmodifiable risk factors contribute to ED visits after bariatric surgery. Identifying these risk factors can aid in the development of quality improvement initiatives.

Identifying the optimal STOP-Bang screening score for obstructive sleep apnea among bariatric surgery patients.

BACKGROUND: Undiagnosed obstructive sleep apnea (OSA) increases the risk of perioperative complications in bariatric patients. Validated screening methods exist, but are not specific to patients with severe obesity. OBJECTIVES: Determine the ideal OSA screening tool for bariatric surgery patients balancing accuracy and cost-effectiveness. SETTING: University Hospital. METHODS: Bariatric surgery patients from January 2018 to September 2023 were identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. For patients with a STOP-Bang score of ≥4 referred for polysomnogram additional variables were collected from the electronic medical record. The Berlin Score was retrospectively calculated. RESULTS: Out of 484 patients who underwent bariatric surgery, 167 (34.5%) had a STOP-Bang score ≥4. The receiver operating characteristic (ROC) curve for STOP-Bang scores ≥4 had an area under the curve (AUC) of 78.5% for predicting OSA and 83.7% for OSA requiring treatment (Apnea Hypopnea Index [AHI] ≥ 15), compared to Berlin Scores' AUC of 80.7% and 88.6%, respectively. A STOP-Bang score of 4 had a sensitivity of 55.6% and specificity of 36.8%, while a score of 5 had 29.3% and 66.2%, respectively. A Berlin Score of 3 had a sensitivity of 47.5% and specificity of 69.1%, with 30 patients (44.1%) starting OSA treatment. Thirty-five patients (21%) experienced a delay in insurance submission, averaging 41.5 days, related to OSA workup. CONCLUSION: The Berlin questionnaire outperforms STOP-Bang in predicting OSA requiring treatment. Raising the polysomnography referral score from STOP-Bang ≥4 to ≥5 or utilizing a Berlin Score of ≥3, may alleviate resource burden, reduce costs, and expedite medical optimization for bariatric surgery.

Early marginal ulceration prevalence following primary RYGB: a rare events model of the MBSAQIP 2015-2021.

PURPOSE: Marginal ulceration (MU) following Roux-en-Y gastric bypass (RYGB) is an established complication, with early MU (within 30-days of operation) being less understood compared to its late counterpart. This study aims to identify risk factors for early MU in patients undergoing primary RYGB. METHODS: Utilizing data from the Metabolic and Bariatric Surgery Accreditation Quality Improvement Project (MBSAQIP 2015-2021), 1,346,468 records were evaluated. After exclusions for revisions, conversions, pediatric cases, nonbinary gender, missing body mass index (BMI) data, and missing operative time; 291,625 cases of primary RYGB were included for full analysis and rare events modeling of early MU. RESULTS: The prevalence of early MU was .29% (n = 850). Higher rates of early MU were associated with BMI, race, history of diabetes mellitus (DM), prior thrombotic complications (deep vein thrombosis (DVT) and pulmonary embolism (PE)), prior percutaneous cardiac intervention (PTC), immunosuppressive therapy, and anticoagulation status. Additionally, procedural aspects like the nonspecialization of the surgeon and longer operative times also correlated with higher early MU rates. Rare-events regression modeling noted significant associations of early MU with younger age, diabetes requiring insulin, history of PTC, DVT, immunosuppressive therapy, and anticoagulation status. CONCLUSION: Early MU remains a relatively rare complication. The lower than previously reported occurrence suggests possible improvements in both patient preparation and surgical technique. The identification of relevant risk factors enables better perioperative and intraoperative management of patients at risk of developing early MU.

Prevalence, Indications, and Complications of Conversional Surgery After Vertical Banded Gastroplasty: A MBSAQIP Analysis.

PURPOSE: Vertical banded gastroplasty (VBG) was once the most popular bariatric procedure in the 1980's, with many patients subsequently requiring conversional surgery. However, knowledge regarding the prevalence and outcomes of these procedures remains limited. This study aims to determine the prevalence, indications, rate of 30-day serious complications, and mortality of conversional surgery after VBG. MATERIALS AND METHODS: A retrospective analysis of the MBSAQIP database from 2020 to 2022 was conducted. Individuals undergoing conversional or revisional surgery after VBG were included. The primary outcomes were 30-day serious complications and mortality. RESULTS: Of 716 VBG conversions, the common procedures included 660 (92.1%) Roux-en-Y gastric bypass (RYGB) and 56 (7.9%) sleeve gastrectomy (SG). The main indication for conversion was weight gain for RYGB (31.0%) and for SG (41.0%). RYGB had longer operative times than SG (223.7 vs 130.5 min, p < 0.001). Although not statistically significant, serious complications were higher after RYGB (14.7% vs 8.9%, p = 0.2). Leak rates were higher after SG (5.4 vs 3.5%) but this was not statistically significant (p = 0.4). Mortality was similar between RYGB and SG (1.2 vs 1.8%, p = 0.7). Multivariable regression showed higher body mass index, longer operative time, previous cardiac surgery and black race were independently associated with serious complications. Conversion to RYGB was not predictive of serious complications compared to SG (OR 0.96, 95%CI 0.34-2.67, p = 0.9). CONCLUSIONS: Conversional surgery after VBG is uncommon, and the rate of complications and mortality remains high. Patients should be thoroughly evaluated and informed about these risks before undergoing conversion from VBG.

Limitations of the 2015-2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database for emergency bariatric operations.

BACKGROUND: The Metabolic and Bariatric Surgery Quality Improvement Project (MBSAQIP) is the largest bariatric surgery-specific clinical data set. OBJECTIVES: In 2020, the definition of emergency cases was altered to include only revisional or conversion cases and not primary cases. The aim of this study was to examine how this change affects the utility of the data set for emergency case tracking. SETTING: MBSAQIP database. METHODS: Emergency cases were extracted from available MBSAQIP data (2015-2021). A comparison of co-morbidity profiles was done, specifically before and after the recent change to how "emergency" is defined in the data set. RESULTS: Eleven thousand and twenty-nine of the 1,048,575 total cases were coded as "emergency cases." From 2015 to 2019, 10,574 emergency cases were performed (∼2115 cases/yr), markedly decreasing in 2020 and 2021 to 455 cases (∼228 cases/yr). Before 2020, the most common procedures were the unlisted procedure of the stomach (45.14%, n = 3101), gastric band removal (25.3%, n = 2676), and reduction of internal hernia (11.8%, n = 1244). Between 2020 and 2021, this distribution changed with Roux-en-Y gastric bypass (RYGB), the most common emergency procedure (29.23%, n = 133). As expected from the change that captured only revisional cases, the average operative length was greater between 2020 and 2021 (127.6 versus 86.5 min). CONCLUSIONS: Capturable emergency cases declined in 2020, a trend related to changing the definition of emergency as part of MBSAQIP standards. This change excludes data on internal hernia reduction and does not likely reflect a real change in the prevalence of emergency bariatric cases. Because capture for emergency cases has diminished, so has any prior utility of using MBSAQIP data for studying emergency cases.

Early Marginal Ulcer After Roux-en-Y Gastric Bypass: MBSAQIP Database Analysis of Trends and Predictive Factors.

PURPOSE: Marginal ulcer (MU) is a known complication after Roux-en-Y gastric bypass (RYGB) that carries significant morbidity. First, we aimed to determine the trends and the rates of readmission, reintervention, and reoperation of 30-day MU. Second, we aim to determine the predictive factors associated with this complication. MATERIALS AND METHODS: Patients who had 30-day marginal ulcer (MU) after LRYGB were identified using the 2015-2021 MBSAQIP database. Those who had a 30-day complication other than MU were excluded. Bivariate and logistic regression analyses were performed. RESULTS: Among 213,104 patients undergoing laparoscopic RYGB, 638 (0.3%) showed 30-day MU. This group of patients required endoscopic interventions, readmissions, and reoperations at rates of 88%, 72%, and 9%, respectively. Predictive factors for 30-day MU after RYGB were renal insufficiency, history of DVT, previous cardiac stent, African American race, chronic steroid use, COPD, therapeutic anticoagulation, anastomotic leak test, GERD, and operative time > 120 min. Additionally, patients who had 30-day MU showed significantly higher rates of overall complications such as pulmonary, cardiac and renal complications, unplanned ICU admission, blood transfusions, venous thromboembolism (VTE), and non-home discharge (p < 0.05). The MU group showed similar rates of 30-day mortality as those without this complication (0.2% vs 0.1%, p = 0.587). CONCLUSIONS: The incidence of 30-day MU following RYGB was 0.3%. Patients with MU required endoscopic interventions, readmissions, and reoperations at rates of 88%, 72%, and 9%, respectively. Some preoperative and intraoperative factors contributed to an increased risk of 30-day MU.

From database to practice: the MBSAQIP in the surgical literature.

BACKGROUND: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) has been a game changer for metabolic and bariatric surgery (MBS), with continuous improvements in safety and outcomes throughout the years of its usage. It allows in-depth evaluations of MBS procedures, presenting practitioners and researchers with unparalleled opportunities for quality assessment, research and clinical advancement. OBJECTIVES: To offer an updated overview of MBSAQIP-related publications. SETTING: United States. METHODS: PubMed was queried using keywords "MBSAQIP" and "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program." Letters to editors, duplicates, commentaries, and retracted articles were excluded. Studies that mentioned MBSAQIP but did not use the data within were also excluded. RESULTS: A total of 400 search items were returned as of August 2023. After exclusions, 289 studies were reviewed. Articles were published in a total of 28 unique journals, the majority of which were featured in Surgery for Obesity and Related Diseases (SOARD), with 114 articles (39.4%). Sixty-one articles were focused on creating predictive models or risk calculators, 58 on investigating the safety of procedures, and 52 on exploring complications. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) were the 2 most commonly discussed procedures, at 80.3% and 80% respectively. Forty-three studies included patients who underwent robotic-assisted MBS. CONCLUSIONS: The MBSAQIP is a valuable resource that has generated a wealth of studies in the literature. It has allowed for intense analysis of clinical issues and fostered a culture of safety and quality improvement. Participating surgeons must pledge commitment to extended follow-up periods to maximize its effectiveness.

Lessons learned from the metabolic and bariatric surgery accreditation and quality improvement program site surveys: common deficiencies and corrective actions.

BACKGROUND: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) is a joint program between the American Society for Metabolic and Bariatric Surgery (ASMBS) and the American College of Surgeons (ACS). On-site surveys of the applicant programs to determine adherence to the MBSAQIP standards are a hallmark of the accreditation process. OBJECTIVES: A retrospective review of 619 site surveys completed over 2 years was performed to include analysis of reviewer decisions, tabulation and cross-reference of identified deficiencies to the MBSAQIP standards and determine final disposition of corrective actions and overall accreditation rates. SETTING: Accredited Hospitals (Community and Academic) within MBSAQIP. METHODS: This is a retrospective review of site surveys by expert panel. RESULTS: ≥1 MBSAQIP Standards deficiencies were present at 149 of the 619 program site surveys (24.07%). The 3 leading Standards in Deficiency were in order: Commitment to Quality Care, Continuous Quality Improvement Process, and Data Collection. Within a year following initial site survey of the149 programs with Standards deficiencies, 59 programs demonstrated compliance, 83 programs were placed on probation (with a specific time-frame to demonstrate compliance) and 7 programs were denied accreditation. Ultimately, 98.9% of programs were able to gain or maintain MBSAQIP accreditation. CONCLUSIONS: The MBSAQIP accreditation through on-site surveys can identify and improve program adherence to MBSAQIP standards.

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program: Bariatric Surgical Risk/Benefit Calculator: 1-year comorbidity remission.

BACKGROUND: Clinical calculators can provide patient-personalized estimates of treatment risks and health outcomes. The American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) set out to create a publicly available tool to assess both short-term postoperative risk and long-term benefits for prospective adult patients eligible for 1 of 4 primary bariatric procedures. The calculator is comprised of multiple prediction elements: (1) 30-day postoperative risk, (2) 1-year body mass index projections, and (3) 1-year comorbidity remission. OBJECTIVES: To assess the performance of the 1-year comorbidity remission prediction feature of the calculator. SETTING: Not-for-profit organization clinical data registry. METHODS: MBSAQIP data across 4.5 years from 240,227 total patients indicating at least 1 comorbidity of interest present preoperatively and who had a 1-year follow-up record documenting their comorbidity status were included. Six models were constructed, stratified by the presence of the respective preoperative comorbidity: hypertension, hyperlipidemia, gastroesophageal reflux disease, sleep apnea, non-insulin-dependent diabetes, and insulin-dependent diabetes. A multinomial logistic regression model was used to predict 1-year remission (total, partial, or no remission) of insulin-dependent diabetes. All other outcomes were binary (yes or no at 1 yr), and ordinary logistic regression models were used. RESULTS: All models showed adequate discrimination (C statistics ranging from .58 to .68). Plots of observed versus predicted remission (%) showed excellent calibration across all models. CONCLUSION: All remission models were well calibrated with sufficient discrimination. The MBSAQIP Bariatric Surgical Risk/Benefit Calculator is a publicly available tool intended for integration into clinical practice to enhance patient-clinician discussions and informed consent.

Third time's a charm: band to sleeve to bypass.

BACKGROUND: Adjustable gastric bands (AGB) are frequently converted to sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) due to weight recurrence or band complications. Such conversions carry a higher-risk than primary procedures. Some patients undergo two conversions-from AGB to SG, and subsequently from SG to RYGB. This presents a unique situation with limited literature on indications and complication rates associated with these double conversions. METHODS: We examined the 2020-2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use File to evaluate conversions from AGB to SG and then to RYGB. Patient and operative characteristics, along with outcomes, were evaluated. Descriptive statistics were applied. RESULTS: We identified 276 patients who underwent a conversion from AGB to SG and then to RYGB. The primary reason for the second conversion (SG to RYGB) was gastroesophageal reflux disease (GERD) at 55.1%, followed by inadequate weight loss or weight regain (IWL/WR) at 36.9%. The remaining reasons included dysphagia, nausea, vomiting, or others. Patients converted for IWL/WR demonstrated a higher baseline body mass index and prevalence of sleep apnea compared to other cohorts (both p < 0.001). Meanwhile, patients in the "other reasons" group had the highest rate of open surgical approaches (9.1%) and concurrent lysis of adhesions (p = 0.001 and p = 0.022), with correspondingly higher rates of anastomotic leak, reoperations, serious complications, and mortality. CONCLUSIONS: Patients undergoing double conversions (AGB to SG to RYGB) do so primarily for GERD or IWL/WR. Further research is required to better define the optimal primary operation for each patient, aiming to reduce the necessity for multiple conversions.

Concurrent paraesophageal hernia repair in revisional/conversional laparoscopic Roux-en-Y gastric bypass: propensity score-matched analysis of the MBSAQIP database.

BACKGROUND: Patients requiring concurrent paraesophageal hernia repair (CPHR) have been shown to have favorable outcomes in primary bariatric surgery. However, patients requiring revisional or conversional surgery represent a group of patients with higher perioperative risk. Currently, few reports on concurrent paraesophageal hernia repair utilizing the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database are available. The primary aim of this study was to determine perioperative complications associated with CPHR and the Roux-en-Y gastric bypass (RYGB) as a revisional/conversional operation. METHODS: In this study, patients undergoing revisional/conversional RYGB between 2015 and 2020 were accessed via the MBSAQIP database. Patients were categorized based on the presence of a paraesophageal hernia as a concurrent procedure. Patients who underwent revisional/conversional surgery without additional procedures were utilized for controls. A propensity score-matched cohort was generated and E-analysis utilized to assess unmeasured confounding. RESULTS: After exclusions, 35,698 patients were available. Patients receiving CPHR were more likely to be female (90.79% vs 87.37%; p < 0.001) and have increased frequency of gastroesophageal reflux disease (69.20% vs 51.69%; p < 0.001). However, these patients had lower frequencies of sleep apnea (24.12% vs 30.13%; p < 0.001), hypertension requiring medication (38.51% vs 42.59%; p < 0.001), and decreased frequency of hyperlipidemia (19.44% vs 21.60%;p < 0.001). After matching, 6,231 patient pairs were developed and showed that patients undergoing CPHR were at increased risk of readmission (9.44% vs 7.58%; p < 0.001), intervention (3.56% vs 2.79%; p = 0.018), increased requirement for outpatient dehydration treatment (5.87% vs 4.67%;p = 0.004), and overall increased operation time (169.3 min ± 76.0 vs 153.5 ± 73.3; p < 0.001). However, there were no significant increases in the rates of reoperation, death, postoperative leak complications, or bleeding complications after CPHR. CONCLUSION: Patients undergoing revisional/conversional RYGB with CPHR may be at higher risk for a small number of rare postoperative complications. CPHR is a safe procedure in patients undergoing revisional/conversional RYGB in the short-term postoperative period.