Reliability of Non-invasive Liver Fibrosis Assessment Tools Versus Biopsy in Pre- and Post-bariatric Surgery Patients with Non-alcoholic Fatty Liver Disease.

PURPOSE: Liver biopsy (LBx) remains the gold standard to assess fibrosis in non-alcoholic fatty liver disease (NAFLD). Biochemical markers are also useful, but their reliability is not clear in patients with morbid obesity. We assessed the performance of six non-invasive fibrosis assessment tools before and after bariatric surgery (BSx) using LBx. MATERIALS AND METHODS: This is a cross-sectional and prospective cohort study. LBx was performed at the time of BSx and 12-month post-operatively and assessed using the Brunt system. Clinical and biochemical measurements were collected at the same time points and six non-invasive fibrosis assessment tools were calculated. RESULTS: One hundred seventy patients had BSx; 79.4% female; age was 46.6 ± 9.8 years, and BMI was 48.6 ± 7.5 kg/m2. From liver histology, 88% had F0-F2 and 11.2% F3-F4. At BSx, aspartate aminotransferase to platelet ratio index (APRI) and FIB-4 had better accuracy (0.86 and 0.88) with specificity of 96.6% and 94.0% and negative predictive values (NPV) of 88.9% and 93.7%. However, sensitivity (6.7% and 40.0%) and positive predictive values (PPV) (20.0% and 46.2%) were low. Twelve months post-surgery (n = 54), 88.9% of patients had F0-F2 and 11.1% had F3-F4. Fibrosis-4 index (FIB-4) and NAFLD fibrosis score (NFS) had the best accuracy (0.79 and 0.77) with specificity of 83.7% and 86.9% and NPV of 92.3% and 86.9%. However, sensitivity (25% and 0%) and PPV (12.5% and 0%) were low. CONCLUSION: Overall, FIB-4, APRI, and NFS showed similar performances with higher accuracy, specificity, and NPV. Sensitivity and PPV were low. These tests are more useful at excluding advanced fibrosis.

Utilization of Public System for Gastric Bands Placed by Private Providers: a 4-Year Population-Based Analysis in Ontario, Canada.

Laparoscopic adjustable gastric band (LAGB) placement remains a common bariatric procedure. While LAGB procedure is performed within private clinics in most Canadian provinces, public health care is often utilized for LAGB-related reoperations. We identified 642 gastric band removal procedures performed in Ontario from 2011 to 2014 using population-level administrative data. The number of procedures performed increased annually from 101 in 2011 to 220 in 2014. Notably, 54.7% of the patients required laparotomy, and 17.6% of patients underwent a subsequent bariatric surgery. Our findings demonstrated that LAGB placement in private clinics resulted in a large number of band removal procedures performed within the public system. This represents a significant public health concern that may result in significant health care utilization and patient morbidity.

The effect of the Ontario Bariatric Network on health services utilization after bariatric surgery: a retrospective cohort study.

BACKGROUND: In 2009, the Ontario Bariatric Network was established to address the exploding demand by Ontario residents for bariatric surgery services outside Canada. We compared the use of postoperative hospital services between out-of-country surgery recipients and patients within the Ontario Bariatric Network. METHODS: We conducted a population-based, comparative study using administrative data held at the Institute for Clinical Evaluative Sciences. We included Ontario residents who underwent bariatric surgery between 2007 and 2012 either outside the country or at one of the Ontario Bariatric Network's designated centres of excellence. The primary outcome was use of hospital services in Ontario within 1 year after surgery. RESULTS: A total of 4852 patients received bariatric surgery out of country, and 5179 patients underwent surgery through the Ontario Bariatric Network. After adjustment, surgery at a network centre was associated with a significantly lower utilization rate of postoperative hospital services than surgery out of country (rate ratio 0.90, 95% confidence interval [CI] 0.84 to 0.97). No statistically significant differences were found with respect to time in critical care or mortality. However, the physician assessment and reoperation rates were significantly higher among patients who received surgery at a network centre than among those who had bariatric surgery out of country (rate ratio 4.10, 95% CI 3.69 to 4.56, and rate ratio 1.84, 95% CI 1.34 to 2.53, respectively). INTERPRETATION: The implementation of a comprehensive, multidisciplinary provincial program to replace outsourcing of bariatric surgical services was associated with less use of postoperative hospital services by Ontario residents undergoing bariatric surgery. Future research should include an economic evaluation to determine the costs and benefits of the Ontario Bariatric Network.

Inequity to the utilization of bariatric surgery: a systematic review and meta-analysis.

This systematic review explores the sociodemographic factors associated with the utilization of bariatric surgery among eligible patients. Electronic databases were searched for population-based studies that explored the relationship between sociodemographic characteristics of patients eligible for bariatric surgery to those who actually received the procedure. Twelve retrospective cohort studies were retrieved, of which the results of 9 studies were pooled using a random effects model. Patients who received bariatric surgery were significantly more likely to be white versus non-white (OR 1.54; 95% CI 1.08, 2.19), female versus male (OR 2.80; 95% CI 2.46, 3.22), and have private versus government or public insurance (OR 2.51; 95% CI 1.04, 6.05). Prospective cohort studies are warranted to further determine the relative effect of these factors, adjusting for confounding factors.

Analysis of patient attrition in a publicly funded bariatric surgery program.

BACKGROUND: Obesity is a global epidemic, and several surgical programs have been created to combat this public health issue. Although demand for bariatric surgery has grown, so too has the attrition rate. In this study we identify patient characteristics and operational interventions that have contributed to high attrition in a multistage, multidisciplinary bariatric surgery program. STUDY DESIGN: A retrospective study was conducted of 1,682 patients referred for bariatric surgery at the University Health Network in Toronto, Canada, from June 2008 to July 2011. Demographic information, presurgical assessment dates, and records describing operational changes were collected. Several penalized likelihood and mixed effects multivariable logistic regression models were used to determine whether patient characteristics, operational changes, and previous experience affected program completion and intermediate transitions between assessments. RESULTS: Although the majority of attrition appears to be the result of patient self-removal, males (odds ratio [OR] 0.511, 95% CI 0.392 to 0.663, p < 0.001), and individuals with active substance use (OR 0.223, 95% CI 0.096 to 0.471, p < 0.001) were less likely to undergo surgery. Operational practices had a detrimental effect on program completion (OR 0.590, 95% CI 0.456 to 0.762, p < 0.001). Conversely, patients with a BMI > 40 kg/m(2) (OR 1.756, 95% CI 1.233 to 2.515, p = 0.002) and those who lived within 25 to 300 km of the center (OR > 1.633, p < 0.001) were more likely to undergo surgery. CONCLUSIONS: Certain subgroups in the referral population were found to be at a higher risk of noncompletion. Specialized care pathways must be implemented to address this issue. Furthermore, careful consideration must be given to operational decisions because they may negatively affect access to care, as we have shown.

Health inequity in access to bariatric surgery: a protocol for a systematic review.

BACKGROUND: Bariatric surgery is the only weight-loss treatment available that results in both sustained weight loss and improvements of obesity-related comorbidities. Individuals who meet the eligibility criteria for bariatric surgery are generally older, come from racial or ethnic minorities, are economically disadvantaged, and have low levels of education. However, the population who actually receives bariatric surgery does not reflect the individuals who need it the most. The objective is to conduct a systematic review of the literature exploring the inequities to the access of bariatric surgery. METHODS/DESIGN: EMBASE and Medline databases will be searched for observational studies that compared at least one of the PROGRESS-PLUS sociodemographic characteristics of patients eligible for bariatric surgery to those who actually received the procedure. Articles published in the year 1980 to present with no language restrictions will be included. For inclusion, studies must only include adults (≥18 years old) who meet National Institutes of Health (NIH) eligibility criteria for bariatric surgery defined as having either (1) a body mass index (BMI) of 40 kg/m² or greater; or (2) BMI of 35 kg/m² or greater with significant weight-related comorbidities. Eligible interventions will include malabsorptive, restrictive, and mixed bariatric procedures. DISCUSSION: There appears to be inequities in access to bariatric surgery. In order to resolve the health inequity in the treatment of obesity, a synthesis of the literature is needed to explore and identify barriers to accessing bariatric surgery. It is anticipated that the results from this systematic review will have important implications for advancing solutions to minimize inequities in the utilization of bariatric surgery. http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42013004920.

A cost comparison of laparoscopic and open colon surgery in a publicly funded academic institution.

BACKGROUND: The objective of this study was to compare the total hospital cost of laparoscopic (lap) and open colon surgery at a publicly funded academic institution. METHODS: Patients undergoing elective laparoscopic or open colon surgery for all indications at the University Health Network, Toronto, Canada, from April 2004 to March 2009 were included. Patient demographic, operative, and outcome data were reviewed retrospectively. Hospital costs were determined from the Ontario Case Costing Initiative, adjusted for inflation, and compared using the Mann-Whitney U test. Linear regression was used to analyze the relationship between length of stay and total hospital cost. RESULTS: There were 391 elective colon resections (223 lap/168 open, 15.4 % conversion). There was no difference in median age, gender, or Charlson score. Body mass index was slightly higher for laparoscopic surgery (27.5/25.9 lap/open; p = 0.008), while the American Society of Anesthesiologists score was slightly higher for open surgery. Median operative time was greater for laparoscopic surgery (224/196 min, lap/open; p = 0.001). There was no difference in complication rates (21.6/22.5 % lap/open; p = 0.900), reoperations (5.8/6.5 % lap/open; p = 0.833) or 30-day readmissions (7.6/12.5 % lap/open; p = 0.122). Number of emergency room visits was greater with open surgery (12.6/20.8 % lap/open; p = 0.037). Operative cost was higher for laparoscopic surgery ($4,171.37/3,489.29 lap/open; p = 0.001), while total hospital cost was significantly reduced ($9,600.22/12,721.41 lap/open; p = 0.001). Median length of stay was shorter for laparoscopic surgery (5/7 days lap/open; p = 0.000), and this correlated directly with hospital cost. CONCLUSIONS: Laparoscopic colon surgery is associated with increased operative costs but significantly lower total hospital costs. The cost savings is related, in part, to reduced length of stay with laparoscopic surgery.