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Background: The adoption of robotic bariatric surgery has increased dramatically over the last decade. While outcomes comparing bariatric and laparoscopic approaches are debated, little is known about patient factors responsible for the growing delivery of robotic surgery. A better understanding of these factors will help guide the planning of bariatric delivery and resource allocation. Methods: Data were extracted from the MBSAQIP registry from 2020 to 2021. The patient population was organized into primary robot-assisted sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) versus those who underwent laparoscopic procedures. Bivariate analysis and multivariable logistic regression modeling were conducted to characterize cohort differences and identify independent patient predictors of robotic selection. Results: Of 318,151, 65,951 (20.7%) underwent robot-assisted surgery. Patients undergoing robotic procedures were older (43.4 ± 11.8 vs. 43.1 ± 11.8; p < 0.001) and had higher body mass index (BMI; 45.4 ± 7.9 vs. 45.0 ± 7.6; p < 0.001). Robotic cases had higher rates of medical comorbidities, including sleep apnea, hyperlipidemia, gastroesophageal reflux disease (GERD), and diabetes mellitus. Robotic cases were more likely to undergo RYGB (27.4% vs. 26.4%; p < 0.001). Robotic patients had higher rates of numerous complications, including bleed, reoperation, and reintervention, resulting in higher serious complication rates on multivariate analysis. Independent predictors of robotic selection included increased BMI (aOR 1.02), female sex (aOR 1.04), GERD (aOR 1.12), metabolic dysfunction, RYGB (aOR 1.08), black racial status (aOR 1.11), and lower albumin (aOR 0.84). Conclusions: After adjusting for comorbidities, patients with greater metabolic comorbidities, black racial status, and those undergoing RYGB were more likely to receive robotic surgery. A more comprehensive understanding of patient factors fueling the adoption of robotic delivery, as well as those expected to benefit most, is needed to better guide healthcare resources as the landscape of bariatric surgery continues to evolve.
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BACKGROUND: In recent years, multiple guidelines on bariatric and metabolic surgery were published, however, their quality remains unknown, leaving providers with uncertainty when using them to make perioperative decisions. This study aims to evaluate the quality of existing guidelines for perioperative bariatric surgery care. METHODS: A comprehensive search of MEDLINE and EMBASE were conducted from January 2010 to October 2022 for bariatric clinical practice guidelines. Guideline evaluation was carried out using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) framework. RESULTS: The initial search yielded 1483 citations, of which, 26 were included in final analysis. The overall median domain scores for guidelines were: (1) scope and purpose: 87.5% (IQR: 57-94%), (2) stakeholder involvement: 49% (IQR: 40-64%), (3) rigor of development: 42.5% (IQR: 22-68%), (4) clarity of presentation: 85% (IQR: 81-90%), (5) applicability: 6% (IQR: 3-16%), (6) editorial independence: 50% (IQR: 48-67%), (7) overall impressions: 48% (IQR: 33-67%). Only six guidelines achieved an overall score >70%. CONCLUSIONS: Bariatric surgery guidelines effectively outlined their aim and presented recommendations. However, many did not adequately seek patient input, state search criteria, use evidence rating tools, and consider resource implications. Future guidelines should reference the AGREE II framework in study design.
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BACKGROUND: Anastomotic leak after esophagectomy is a major contributor to surgery-related morbidity and mortality. The purpose of this systematic review was to evaluate if positive-smoking status is associated with the incidence of this complication. METHODS: A systematic search of MEDLINE, EMBASE, Scopus, Web of Science and Cochrane Library was performed on April 4th, 2023. Inclusion criteria comprised human participants undergoing esophagectomy, age ≥ 18, n ≥ 5, and identification of smoking status. The primary outcome was incidence of anastomotic leak. Sub-group analysis by ex- or current smoking status was performed. Meta-analysis was performed with RevMan 5.4.1 using a Mantel-Haenszel random-effects model. Publication bias was evaluated visually with funnel plots and through the Egger test. RESULTS: A total of 220 abstracts were screened, of which 69 full-text studies were assessed for eligibility, with 13 studies selected for final inclusion. This included 16,103 patients, of which 4433 were ex- or current smokers, and 9141 were never smokers. Meta-analysis revealed an increased odds of anastomotic leak in patients with a positive-smoking status (current or ex-smokers) compared to never smokers (OR 1.44, 95% CI 1.18-1.76, I2 = 44%, p < 0.001. Meta-analysis of six studies comparing active smokers alone to never smokers identified a significant increased odds of anastomotic leak (OR 1.80, 95% CI 1.25-2.59, p = 0.002, I2 = 0%). Meta-analysis of five studies comparing ex-smokers to never smokers identified a significant increased odds of anastomotic leak (OR 1.36, 95% CI 1.02-1.82, p = 0.04, I2 = 0%). The odds of anastomotic leak decreased among ex-smokers compared to active smokers. CONCLUSION: The findings of this systematic review and meta-analysis support the association between positive-smoking status and the risk of anastomotic leak after esophagectomy. Results further emphasize the importance of preoperative smoking cessation to reduce post-operative morbidity.
Subject(s)
Anastomotic Leak , Esophagectomy , Smoking , Anastomotic Leak/etiology , Anastomotic Leak/epidemiology , Humans , Esophagectomy/adverse effects , Smoking/adverse effects , Smoking/epidemiology , Esophageal Neoplasms/surgery , Risk Factors , IncidenceABSTRACT
Microbial-based therapeutics in clinical practice are of considerable interest, and a recent study demonstrated fecal microbial transplantation (FMT) followed by dietary fiber supplements improved glucose homeostasis. Previous evidence suggests that donor and recipient compatibility and FMT protocol are key determinants, but little is known about the involvement of specific recipient factors. Using data from our recent randomized placebo-control phase 2 clinical trial in adults with obesity and metabolic syndrome, we grouped participants that received FMT from one of 4 donors with either fiber supplement into HOMA-IR responders (n = 21) and HOMA-IR non-responders (n = 8). We further assessed plasma bile acids using targeted metabolomics and performed subgroup analyzes to evaluate the effects of recipient parameters and gastrointestinal factors on microbiota engraftment and homeostatic model assessment of insulin resistance (HOMA2-IR) response. The baseline fecal microbiota composition at genus level of recipients could predict the improvements in HOMA2-IR at week 6 (ROC-AUC = 0.70). Prevotella was identified as an important predictor, with responders having significantly lower relative abundance than non-responders (p = .02). In addition, recipients displayed a highly individualized degree of microbial engraftment from donors. Compared to the non-responders, the responders had significantly increased bacterial richness (Chao1) after FMT and a more consistent engraftment of donor-specific bacteria ASVs (amplicon sequence variants) such as Faecalibacillus intestinalis (ASV44), Roseburia spp. (ASV103), and Christensenellaceae spp. (ASV140) (p < .05). Microbiota engraftment was strongly associated with recipients' factors at baseline including initial gut microbial diversity, fiber and nutrient intakes, inflammatory markers, and bile acid derivative levels. This study identified that responders to FMT therapy had a higher engraftment rate in the transplantation of specific donor-specific microbes, which were strongly correlated with insulin sensitivity improvements. Further, the recipient baseline gut microbiota and related factors were identified as the determinants for responsiveness to FMT and fiber supplementation. The findings provide a basis for the development of precision microbial therapeutics for the treatment of metabolic syndrome.
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Bacteria , Bile Acids and Salts , Fecal Microbiota Transplantation , Feces , Gastrointestinal Microbiome , Metabolic Syndrome , Humans , Metabolic Syndrome/therapy , Metabolic Syndrome/microbiology , Male , Female , Adult , Middle Aged , Feces/microbiology , Bile Acids and Salts/metabolism , Bile Acids and Salts/blood , Bacteria/classification , Bacteria/isolation & purification , Bacteria/genetics , Bacteria/metabolism , Obesity/therapy , Obesity/microbiology , Dietary Fiber/administration & dosage , Dietary Fiber/metabolism , Insulin Resistance , Treatment OutcomeABSTRACT
PURPOSE: Small bowel obstruction (SBO) after bariatric surgery is an uncommon but important complication. We sought to characterize bariatric surgery patients who developed SBO, to compare 30-day complications, and to determine the influence of patient and procedure factors on the development of SBO. METHODS AND MATERIALS: All data was extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database using the 2020 operative year. Multivariable logistic regression modelling was used to determine the influence of patient and operative factors on the development of SBO. RESULTS: Of a total of 142 111 patients, 408 (0.3%) were identified as having developed an SBO. SBO patients were older (45.7 ± 11.5 vs. 43.5 ± 11.9 years; p = 0.0002), of reduced BMI (43.6 ± 6.8 vs. 45.1 ± 7.7; p = 0.0001), and more likely to be of female sex (92.2% vs. 81.1%; p < 0.0001). At 30 days post-operation, serious complications were increased in SBO patients. Roux-en-Y gastric bypass (RYGB) was the largest independent predicator of the development of SBO (OR 11.91; 95% CI 8.92-15.90; p < 0.0001). With regard to patient factors, COPD (OR 2.60; 95% CI 1.54-4.38; p < 0.0001) and prior DVT (OR 2.37; 95% CI 1.49-3.77; p < 0.0001) were found to be independently predictive of the development of SBO. Additionally having a lower BMI and being of female sex were found to be independently predictive. CONCLUSION: SBO occurred in approximately 0.3% of MBSAQIP cases. SBO is associated with serious outcome measures and patients of female sex and reduced index BMI, and those undergoing RYGB may be at an increased risk.
Subject(s)
Bariatric Surgery , Gastric Bypass , Intestinal Obstruction , Laparoscopy , Obesity, Morbid , Humans , Female , Obesity, Morbid/surgery , Postoperative Complications/etiology , Retrospective Studies , Gastric Bypass/methods , Intestinal Obstruction/etiology , Bariatric Surgery/adverse effects , Treatment Outcome , Gastrectomy/adverse effects , Laparoscopy/methodsABSTRACT
INTRODUCTION: Gastroesophageal reflux disease (GERD) is a well-established potential consequence of bariatric surgery and can require revisional surgery. Our understanding of the population requiring revision is limited. In this study, we aim to characterize patients requiring revisional surgery for GERD to understand their perioperative risks and identify strategies to improve their outcomes. METHODS: Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry, a retrospective cohort of patients who required revisional surgery for GERD in 2020 was identified. Multivariable logistic regression modelling was used to assess correlations between baseline characteristics and morbidity. RESULTS: 4412 patients required revisional surgery for GERD, encompassing 24% of all conversion procedures. In most cases, patients underwent sleeve gastrectomy (SG) as their original surgery (n = 3535, 80.1%). The revisional surgery for most patients was a Roux-en-Y gastric bypass (RYGB) (n = 3722, 84.4%). Major complications occurred in 527 patients (11.9%) and 10 patients (0.23%) died within 30 days of revisional surgery. Major complications included anastomotic leak in 31 patients (0.70%) and gastrointestinal bleeding in 38 patients (0.86%). Multivariable analyses revealed that operative length, pre-operative antacid use, and RYGB were predictors of major complications. CONCLUSION: GERD is the second most common indication for revisional surgery in patients who have undergone bariatric surgery. Patients who underwent SG as their initial procedure were the primary group who required revisional surgery for GERD; most underwent revision via RYGB. Further inquiry is needed to tailor operative approaches and pre-operative optimization for revisional surgery patients.
Subject(s)
Bariatric Surgery , Gastric Bypass , Gastroesophageal Reflux , Laparoscopy , Obesity, Morbid , Humans , Retrospective Studies , Reoperation/adverse effects , Weight Loss , Gastric Bypass/methods , Bariatric Surgery/adverse effects , Bariatric Surgery/methods , Gastroesophageal Reflux/etiology , Gastroesophageal Reflux/surgery , Gastrectomy/adverse effects , Gastrectomy/methods , Obesity, Morbid/surgery , Treatment Outcome , Laparoscopy/methodsABSTRACT
BACKGROUND: The management of early-stage esophageal cancer is nuanced. A multidisciplinary approach may optimize management through selection of candidates for surgical or endoscopic therapies. The objective of this research was to examine long-term outcomes of patients with early-stage esophageal cancer who undergo treatment with endoscopic resection or surgery. METHODS: Data on patient demographics, co-morbidities, pathology results, OS and RFS were obtained for both the endoscopic resection group and esophagectomy group. Univariate analysis of OS and RFS were conducted using the Kaplan-Meier method with calculation of the log-rank test. Multivariate cox-proportional hazards models were created for OS and RFS using a hypothesis-driven approach. A multivariate logistic regression model was created to identify predictors of esophagectomy among patients undergoing initial endoscopic resection. RESULTS: A total of 111 patients were included. The median OS for the surgery group was 67.0 months compared to 74.0 months in the endoscopic resection group (log-rank p = 0.93). The median RFS for the surgery group was 109.4 months compared to 63.3 months in the endoscopic resection group (log-rank p = 0.0127). On multivariable analysis, patients undergoing endoscopic resection had significantly worse RFS (HR 2.55, 95% CI 1.09-6.00; p = 0.032), but equivalent OS (HR 1.03, 95% CI 0.46-2.32; p = 0.941), compared to patients undergoing esophagectomy. High-grade disease (OR 5.43, 95% CI 1.13-26.10; p = 0.035) and submucosal involvement (OR 7.75, 95% CI 1.90-31.40; p = 0.004) were identified as significant predictors of proceeding to esophagectomy. CONCLUSIONS: Through a multidisciplinary approach, patients with early-stage esophageal cancer achieve excellent RFS and OS. Submucosal involvement and high-grade disease place patients at increased risk for local disease recurrence; these patients may undergo endoscopic resection safely if treated with a multidisciplinary approach incorporating endoscopic surveillance and surgical consultation. Further risk-stratification models may enable better patient selection and optimization of long-term outcomes.
Subject(s)
Adenocarcinoma , Endoscopic Mucosal Resection , Esophageal Neoplasms , Humans , Esophageal Neoplasms/pathology , Adenocarcinoma/pathology , Esophagoscopy/adverse effects , Endoscopic Mucosal Resection/adverse effects , Esophagectomy/methods , Retrospective Studies , Neoplasm Staging , Treatment OutcomeABSTRACT
BACKGROUND: The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) Bariatric Surgical Risk/Benefit Calculator was developed to provide patient-specific information to assist surgical decision-making. To date, no study has characterized which patients are being evaluated with this tool. OBJECTIVE: We sought to characterize the use and impact of the MBSAQIP calculator. SETTING: MBSAQIP collects data from 955 centers in North America. METHODS: The 2021 MBSAQIP database was evaluated for the use of the calculator on preoperative counseling for patients undergoing bariatric surgery. Patient characteristics, operative techniques, and outcomes were compared with bivariate analysis. Multivariable modeling evaluated factors including use of the calculator independently associated with serious complications and mortality. RESULTS: Our study included 210,710 patients, 35,158 (16.7%) of whom were evaluated using the calculator. Patients with whom the calculator was used preoperatively were older (43.8 ± 11.6 yr versus 43.6 ± 11.7 yr; P < .001) and were more likely to have insulin-dependent diabetes, hypertension, gastroesophageal reflux disease, renal insufficiency, and sleep apnea. More patients underwent Roux-en-Y gastric bypass in the calculator cohort compared with the cohort that did not use the calculator (29.6% versus 28.6%; P < .003). The rate of serious complication was significantly less in the calculator cohort (3.1% versus 3.4%; P < .030). Multivariable modeling evaluating serious complications showed that use of the calculator was independently associated with reduced risk of serious complications (odds ratio .87, CI .82-.93, P < .001) but was not associated with mortality. CONCLUSION: The use of the risk calculator may help to reduce the incidence of complications by opening a dialogue between healthcare professionals and patients, setting realistic expectations, and identifying modifiable risk factors.
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INTRODUCTION: Endoscopic plication offers an alternative to surgical fundoplication for treatment of gastroesophageal reflux disease (GERD). This systematic review and meta-analysis evaluate outcomes following endoscopic plication compared to laparoscopic fundoplication. METHODS AND PROCEDURES: Systematic search of MEDLINE, Embase, Scopus, and Web of Science was conducted in September 2022. Study followed PRISMA guidelines. Studies comparing endoscopic plication to laparoscopic fundoplication with n > 5 were included. Primary outcome was PPI cessation, with secondary outcomes including complications, procedure duration, length of stay, change in lower esophageal sphincter (LES) tone, and DeMeester score. RESULTS: We reviewed 1544 studies, with five included comparing 105 (46.1%) patients receiving endoscopic plication (ENDO) to 123 (53.9%) undergoing laparoscopic fundoplication (LAP). Average patient age was 47.6 years, with those undergoing plication being younger (46.4 ENDO vs 48.5 LAP). BMI (26.6 kg/m2 ENDO vs 26.2 kg/m2 LAP), and proportion of females (42.9% ENDO vs 37.4% LAP) were similar. Patients undergoing laparoscopic procedures had worse baseline LES pressure (12.8 mmHg ENDO vs 9.0 mmHg LAP) and lower preoperative DeMeester scores (34.6 ENDO vs. 34.1 LAP). The primary outcome demonstrated that 89.2% of patients undergoing laparoscopic fundoplication discontinued PPI compared to 69.4% for those receiving plication. Meta-analysis revealed that plication had significantly reduced odds of PPI discontinuation (OR 0.27, studies = 3, 95% CI 0.12 to 0.64, P = 0.003, I2 = 0%). Secondary outcomes demonstrated that odds of complications (OR 1.46, studies = 4, 95% CI 0.34 to 6.32, P = 0.62, I2 = 0%), length of stay (MD - 1.37, studies = 3, 95% CI - 3.48 to 0.73, P = 0.20, I2 = 94%), and procedure durations were similar (MD 0.78, studies = 3, 95% CI - 39.70 to 41.26, P = 0.97, I2 = 98%). CONCLUSIONS: This is the first meta-analysis comparing endoscopic plication to laparoscopic fundoplication. Results demonstrate greater likelihood of PPI discontinuation with laparoscopic fundoplication with similar post-procedural risk.
Subject(s)
Gastroesophageal Reflux , Laparoscopy , Female , Humans , Middle Aged , Fundoplication/methods , Treatment Outcome , Gastroesophageal Reflux/etiology , Esophageal Sphincter, Lower/surgery , Laparoscopy/methodsABSTRACT
BACKGROUND: The North American population with severe obesity is aging and with that so will the number of elderly patients (≥ 65 years) meeting indications for metabolic surgery. Trends in bariatric delivery in this population are poorly characterized and outcomes remain conflicting, limiting potential uptake and delivery. METHODS: The MBSAQIP database was used to identify elderly patients (≥ 65 years) undergoing elective bariatric surgery from 2015 to 2019. Our objectives were to analyze their unique characteristics, surgical operative trends, and outcomes by comparing to a non-elderly cohort. Multivariable logistic regression identified independent predictors of serious complications and 30-day mortality. RESULTS: There was a total of 751,607 patients, 5.3% (n = 39,854) were elderly. Mean ages were 43 ± 11 years (non-elderly) versus 68 ± 3 years (elderly). Elderly patients were less likely to be female (70.7% elderly; 80.1% non-elderly) and had lower BMI (43.17 ± 6.64 kg/m2 elderly; 45.42 ± 7.87 kg/m2 non-elderly). They had higher American Society of Anesthesiologists classification, lower functional status, more insulin dependent diabetes, and hypertension, among other comorbidities. There were no clinically significant differences between the most frequently performed bariatric surgery. Sleeve gastrectomy remained the most common (73.7% non-elderly; 72.3% elderly); however, operative time was longer among the elderly. Functional status was most predictive for both serious complications (OR 1.72; CI 1.53-1.94) and mortality (OR 2.92; CI 1.98-4.31). Surgery among elderly patients was associated with poorer 30-day postoperative outcomes across all categories and was independently associated with serious complications (OR 1.23; CI 1.17-1.30, p < 0.001; AR 4.64%) and 30-day mortality (OR 2.49; CI 2.00-3.11, p < 0.001; AR 0.27%), after adjusting for comorbidities. CONCLUSIONS: After adjusting for comorbidities, functional status remains the most predictive factor for poor outcomes; however, elderly patients have increased 30-day odds of serious complications and 30-day mortality, suggesting a need to tailor our approach to these individuals that carry a unique operative risk.
Subject(s)
Bariatric Surgery , Gastric Bypass , Laparoscopy , Obesity, Morbid , Humans , Female , Middle Aged , Adult , Male , Gastric Bypass/adverse effects , Bariatric Surgery/adverse effects , Obesity, Morbid/complications , Obesity/surgery , Comorbidity , Gastrectomy/adverse effects , Treatment Outcome , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Postoperative Complications/surgery , Retrospective Studies , Laparoscopy/adverse effectsABSTRACT
BACKGROUND: Revisional bariatric surgery in an option for patients who experience weight regain or inadequate weight loss after primary elective bariatric procedures. However, there is conflicting data on safety outcomes of revisional procedures. We aim to characterize patient demographics, procedure type, and safety outcomes for those undergoing revisional compared to initial bariatric interventions to guide management of these patients. METHODS: The 2020 Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) registry was analyzed, comparing primary elective to revisional bariatric procedures for inadequate weight loss. Bivariate analysis was performed to determine between group differences. Multivariable logistic regression determined factors associated with serious complications or mortality. RESULTS: We evaluated 158,424 patients, including 10,589 (6.7%) revisional procedures. Patients undergoing revisional procedures were more like to be female (85.5% revisional vs. 81.0% initial; p < 0.001), had lower body mass index (43.6 ± 7.8 kg/m2 revisional vs. 45.2 ± 7.8 kg/m2 initial; p < 0.001), and less metabolic comorbidities than patients undergoing primary bariatric surgery. The most common revisional procedures were Roux-en-Y gastric bypass (48.4%) and sleeve gastrectomy (32.5%). Revisional procedures had longer operative duration compared to primary procedures. Patients undergoing revisional procedures were more likely to experience readmission to hospital (4.8% revisional vs. 2.9% initial; p < 0.001) and require reoperation (2.4% revisional vs. 1.0% initial; p < 0.001) within 30 days of the procedure. Revisional procedures were independently associated with increased serious complications (OR 1.49, CI 1.36-1.64, p < 0.001) but were not a significant predictor of 30-day mortality (OR 0.74, CI 0.36-1.50, p = 0.409). CONCLUSIONS: In comparison to primary bariatric surgery, patients undergoing revisional procedures have less metabolic comorbidities. Revisional procedures have worse perioperative outcomes and are independently associated with serious complications. These data help to contextualize outcomes for patients undergoing revisional bariatric procedures and to inform decision making in these patients.
Subject(s)
Bariatric Surgery , Gastric Bypass , Laparoscopy , Obesity, Morbid , Humans , Female , Obesity, Morbid/surgery , Retrospective Studies , Treatment Outcome , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Postoperative Complications/surgery , Laparoscopy/methods , Obesity/surgery , Gastric Bypass/methods , Bariatric Surgery/adverse effects , Bariatric Surgery/methods , Reoperation/methods , Weight Loss , Gastrectomy/methodsABSTRACT
INTRODUCTION: It is important to appropriately risk stratify bariatric surgery patients, as these patients often have obesity-related comorbidities which can increase postoperative complication risk but also benefit the most from bariatric surgery. We aimed to evaluate the utility of risk stratification using ASA class for bariatric surgery patients and assessed predictive factors of postoperative complications. METHODS: The 2020 MBSAQIP database was analyzed, and an ASA-deemed high-risk cohort (class IV) and normal-risk (ASA class II and III) cohort were compared. Univariate analysis was performed to characterize differences between cohorts and to compare complication rates. Multivariate logistic regression analysis was performed to determine factors associated with increased odds of postoperative complications. RESULTS: We evaluated 138 612 patients with 5380 (3.9%) considered high-risk and 133 232 (96.1%) normal-risk. High-risk patients were more likely to be older (46.2 ± 12.0vs.43.4 ± 11.9, p < 0.001), male (30.9%vs.18.4%, p < 0.001), have higher BMI (51.4 ± 10.2vs.44.9 ± 7.4, p < 0.001), and have more comorbidities. High-risk patients were more likely to have increased 30-day serious complications (4.5%vs.2.8%, p < 0.001) and death (0.2%vs.0.1%, p = 0.001) but not anastomotic leak (0.2%vs.0.2%, p = 0.983). Multivariate models showed ASA class IV patients were at higher odds for any serious complication by 30 days (aOR 1.36, 95%CI 1.18-1.56, p < 0.001) but not for death (aOR 1.04, 95%CI 0.49-2.21, p = 0.921). The factor independently associated with the highest odds of complication in both models was functional status preoperatively (partially dependent aOR 2.06, 95%CI 1.56-2.72, p < 0.001; fully dependent aOR 3.19, 95%CI 1.10-9.28, p = 0.033 for any serious complication; partially dependent aOR 5.08, 95%CI 2.16-12.00, p < 0.001 for death). CONCLUSIONS: While elevated ASA class correlates with increased serious complications, pre-operative functional status appears to have a much greater contribution to odds of serious complications and mortality. These findings question the utility of using ASA to risk stratify patients peri-operatively and provides evidence for using a simpler and more practical functional status approach.
Subject(s)
Bariatric Surgery , Obesity, Morbid , Humans , Male , Retrospective Studies , Risk Factors , Bariatric Surgery/adverse effects , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Obesity/complications , Obesity, Morbid/complications , Obesity, Morbid/surgery , Treatment OutcomeABSTRACT
INTRODUCTION: Patients undergoing bariatric surgery experience substantial risk of pre- and postoperative substance use. Identifying patients at risk for substance use using validated screening tools remains crucial to risk mitigation and operative planning. We aimed to evaluate proportion of bariatric surgery patients undergoing specific substance abuse screening, factors associated with screening and the relationship between screening and postoperative complications. METHODS: The 2021 MBSAQIP database was analyzed. Bivariate analysis was performed to compare factors between groups who were screened for substance abuse versus non-screened, and to compare frequency of outcomes. Multivariate logistic regression analysis was performed to assess the independent effect of substance screening on serious complications and mortality, and to assess factors associated with substance abuse screening. RESULTS: A total of 210, 804 patients were included, with 133,313 (63.2%) undergoing screening and 77,491 (36.8%) who did not. Those who underwent screening were more likely to be white, non-smoker, and have more comorbidities. The frequency of complications was not significant (e.g., reintervention, reoperation, leak) or similar (readmission rates 3.3% vs. 3.5%) between screened and not screened groups. On multivariate analysis, lower substance abuse screening was not associated with 30-day death or 30-day serious complication. Factors that significantly affected likelihood of being screened for substance abuse included being black (aOR 0.87, p < 0.001) or other race (aOR 0.82, p < 0.001) compared to white, being a smoker (aOR 0.93, p < 0.001), having a conversion or revision procedure (aOR 0.78, p < 0.001; aOR 0.64, p < 0.001, respectively), having more comorbidities and undergoing Roux-en-y gastric bypass (aOR 1.13, p < 0.001). CONCLUSION: There remains significant inequities in substance abuse screening in bariatric surgery patients regarding demographic, clinical, and operative factors. These factors include race, smoking status, presence of preoperative comorbidities, and procedure type. Further awareness and initiatives highlighting the importance of identifying at risk patients is critical for ongoing outcome improvement.
Subject(s)
Bariatric Surgery , Gastric Bypass , Laparoscopy , Obesity, Morbid , Humans , Obesity, Morbid/surgery , Cohort Studies , Retrospective Studies , Bariatric Surgery/adverse effects , Bariatric Surgery/methods , Gastric Bypass/adverse effects , Postoperative Complications/diagnosis , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Treatment Outcome , Gastrectomy/adverse effects , Laparoscopy/adverse effectsABSTRACT
BACKGROUND: Sleeve gastrectomy (SG) frequently requires conversion to Roux-en-Y gastric bypass (RYGB) due to gastroesophageal reflux disease (GERD) or weight recurrence. Current evidence evaluating the safety of conversion from SG to RYGB and its indications is limited to single centers. METHODS: The objective was to determine the rate of serious complications and mortality of conversion of SG to RYGB (SG-RYGB) compared to primary RYGB (P-RYGB). This was a retrospective analysis of the MBSAQIP database which includes 30-day outcomes. Individuals undergoing P-RYGB or SG-RYGB were included. Multivariable logistic regression was performed to determine if revisional surgery was an independent predictor of serious complications or mortality. RESULTS: In 2020 and 2021, 84,543 (86.3%) patients underwent P-RYGB and 13,432 (13.7%) underwent SG-RYGB. SG-RYGB cohort had lower body mass index, lower rates of diabetes and hypertension, and higher rates of GERD. GERD was the most common indication for revision (55.3%) followed by weight regain (24.4%) and inadequate weight loss (12.7%). SG-RYGB had longer operative times (145 vs. 125 min, p < 0.001) and a higher rate of serious complications (7.2 vs. 5.0%, p < 0.001). This included higher rates of anastomotic leak (0.5 vs. 0.4%, p = 0.002), bleeding (2.0 vs. 1.6%, p < 0.001), and reoperation (3.0 vs. 1.9%, p < 0.001) but not death (0.1 vs. 0.1%, p = 0.385). On multivariable analysis, SG-RYGB was independently predictive of serious complications (OR 1.21, 95%CI 1.12 to 1.32, p < 0.001) but not mortality (p = 0.316). CONCLUSIONS: While SG-RYGB is safe with a low complication rate, SG-RYGB was associated with a higher rate of serious complications compared to P-RYGB.
Subject(s)
Gastric Bypass , Gastroesophageal Reflux , Obesity, Morbid , Humans , Gastric Bypass/adverse effects , Obesity, Morbid/surgery , Retrospective Studies , Prevalence , Gastroesophageal Reflux/epidemiology , Gastroesophageal Reflux/etiology , Gastroesophageal Reflux/surgery , Reoperation/adverse effects , Gastrectomy/adverse effects , Weight Loss , Treatment OutcomeABSTRACT
BACKGROUND: Tranexamic acid (TXA) has drawn growing interest over the last decade for its benefit in optimizing post-operative bleeding, yet its role in bariatric surgery is poorly understood. METHODS: The medical librarian developed and executed comprehensive searches on September 28, 2022. The population of interest included adults who underwent elective bariatric surgery. The intervention was tranexamic acid administration while the comparison was placebo or standard peri-operative therapy. The primary outcome of interest was post-operative bleeding which was defined a priori. RESULTS: A total of four studies were identified comprising of 475 patients. Of those, 207 (50%) received TXA at induction and all underwent laparoscopic sleeve gastrectomy (LSG). The majority of patients were female (n = 343, 80.7%) with ages ranging from 17 to 70 years of age and mean BMIs ranging from 37 to 56 kg/m2. Post-operative bleeding after LSG ranged from 0 to 28% depending on bleed definition and TXA administration with no differences in venous thromboembolic events or mortality between groups. Meta-analysis of post-operative bleeding demonstrated a statistically significant benefit with TXA administration (OR 0.40; 95% CI 0.23-0.70; p = 0.001) for patients undergoing elective LSG. CONCLUSIONS: Intravenous tranexamic acid at the time of laparoscopic sleeve gastrectomy is associated with a significant reduction of post-operative bleeding with no observed differences in thromboembolic events or mortality. Further high-quality studies are needed to better delineate the ideal bariatric population to receives TXA in addition to the optimal timing, dose, and duration of TXA therapy.
Subject(s)
Antifibrinolytic Agents , Obesity, Morbid , Tranexamic Acid , Venous Thromboembolism , Adult , Humans , Male , Female , Adolescent , Young Adult , Middle Aged , Aged , Tranexamic Acid/therapeutic use , Antifibrinolytic Agents/therapeutic use , Obesity, Morbid/surgery , Postoperative Hemorrhage/prevention & control , Gastrectomy/adverse effects , Blood Loss, Surgical/prevention & controlABSTRACT
PURPOSE: We sought to characterize the prevalence and subsequent impact of pre- and post-operative COVID-19 diagnosis on bariatric surgery outcomes. COVID-19 has transformed surgical delivery, yet little is known regarding its implications for bariatric surgery. MATERIALS AND METHODS: The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) database was evaluated with three cohorts described: those diagnosed with COVID-19 pre-operatively (PRE), post-operatively (POST), and those without a peri-operative COVID-19 (NO) diagnosis. Pre-operative COVID-19 was defined as COVID-19 within 14 days prior to the primary procedure while post-operative COVID-19 infection was defined as COVID-19 within 30 days after the primary procedure. RESULTS: A total of 176,738 patients were identified, of which 174,122 (98.5%) had no perioperative COVID-19, 1364 (0.8%) had pre-operative COVID-19, and 1252 (0.7%) had post-operative COVID-19. Patients who were diagnosed with COVID-19 post-operatively were younger than other groups (43.0 ± 11.6 years NO vs 43.1 ± 11.6 years PRE vs 41.5 ± 10.7 years POST; p < 0.001). Pre-operative COVID-19 was not associated with serious complications or mortality after adjusting for comorbidities. Post-operative COVID-19, however, was among the greatest independent predictors of serious complications (OR 3.5; 95% CI 2.8-4.2; p < 0.0001) and mortality (OR 5.1; 95% CI 1.8-14.1; p = 0.002). CONCLUSIONS: Pre-operative COVID-19 within 14 days of surgery was not significantly associated with either serious complications or mortality. This work provides evidence that a more liberal strategy which employs early surgery after COVID-19 infection is safe as we aim to reduce the current bariatric surgery case backlog.
Subject(s)
Bariatric Surgery , COVID-19 , Gastric Bypass , Obesity, Morbid , Humans , Gastric Bypass/methods , Obesity, Morbid/surgery , COVID-19 Testing , Gastrectomy/methods , COVID-19/epidemiology , Bariatric Surgery/methods , Postoperative Complications/etiology , Retrospective Studies , Treatment OutcomeABSTRACT
INTRODUCTION: With expansion of bariatric surgery indications to include Asian patients with diabetes and body mass index (BMI) ≥ 27.5, or BMI ≥ 32.5, it is important to characterize Asian patient population undergoing bariatric surgery and assess their postoperative outcomes. METHODS: This retrospective study analyzed the 2015-2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. All patients undergoing Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) who self-reported as Asian or White race were included. The primary outcomes were to characterize the Asian race population in North American and to identify if Asian race was associated with serious complications or mortality at 30 days. RESULTS: Overall, 594,837 patients met inclusion, with 4229 self-reporting Asian racial status. Patients of Asian race were younger (41.8 vs 45.5 years, p < 0.001) and had a lower BMI (42.8 vs 44.7 kg/m2 p < 0.001) than White patients. They were also more likely to have insulin dependent diabetes (10.9% vs 8.2%, p < 0.001), have received prior cardiac surgery (10.0% vs 1.2% p < 0.001), and suffer from renal insufficiency (1.0% vs 0.5%, p < 0.001). There were no significant differences between rates of RYGB (28.3% vs 28.9%, p = 0.4) and mean operative duration (87.7 vs 87.5 min, p = 0.7). Additionally, there were no differences in 30 day outcomes including leak (0.5% vs 0.5%, p = 0.625), bleeding (1.2% vs 1.0%, p = 0.1), serious complications (3.4% vs 3.5%, p = 0.6), or mortality (0.1% vs 0.1%, p = 0.7) and after confounder control, Asian race was not independently associated with serious complications (OR 1.0, CI 0.9-1.2, p = 0.7), or mortality (OR 1.1, CI 0.3-3.3, p = 0.1). CONCLUSIONS: Despite the increased metabolic burden of Asian patients, no differences in 30-day outcomes compared to White patients occurs. This data supports evidence suggesting these patients may safely undergo bariatric surgery independent of their increased metabolic burden.
Subject(s)
Bariatric Surgery , Diabetes Mellitus , Gastric Bypass , Obesity, Morbid , Humans , Obesity, Morbid/complications , Quality Improvement , Retrospective Studies , Treatment Outcome , Bariatric Surgery/adverse effects , Gastric Bypass/adverse effects , Gastrectomy/adverse effects , Accreditation , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Postoperative Complications/surgerySubject(s)
Gastric Bypass , Laparoscopy , Obesity, Morbid , Humans , Obesity, Morbid/surgery , Patient Selection , Anastomosis, Roux-en-YABSTRACT
BACKGROUND: Effects of the COVID-19 pandemic on rates of early postoperative follow-up after bariatric surgery are poorly understood. Our study characterizes 30-day follow-up after bariatric surgery prior to COVID-19 (years 2015-2019) and during the pandemic of COVID-19 (year 2020) and evaluates general predictive factors of short-term follow-up. METHODS: Data was extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2015 to 2020. Cohorts were divided into pre-pandemic and pandemic years and patients with and without 30-day follow-up. Multivariable logistic regression analysis was used to identify general factors independently predictive of 30-day follow-up. The primary aim was to evaluate the impact of the COVID-19 pandemic on short-term 30-day follow-up adherence. A secondary outcome was to characterize general short-term postoperative 30-day follow-up associated with elective bariatric surgery and identify independent predictors of 30-day follow-up among bariatric surgery patients using multivariable logistic regression analysis. RESULTS: A total of 834,646 patients were identified. Follow-up rates significantly increased in the COVID era in 2020 (p < 0.0001). Patients who achieved 30-day follow-up were older and had an increased burden of medical comorbidities, including non-insulin and insulin-dependent diabetes mellitus, hypertension, dyslipidemia, as well as increased BMI compared to patients lacking follow-up. The cohort with successful 30-day follow-up was more likely to receive gastric bypass and had increased rates of metabolic comorbidities. After adjusting for comorbidities, the greatest independent predictors of follow-up were the 2020 COVID-19 era year, Asian race, black race, and gastroesophageal reflux disease. CONCLUSIONS: After adjusting for comorbidities, the 2020 COVID-19 era year was one of the greatest predictors of follow-up after bariatric surgery. Postoperative follow-up rates after elective bariatric surgery are excellent at > 95% and increased during the 2020 COVID-19 era year. Several independent predictors of follow-up were identified which may help in development of strategies aimed to mitigate lack of postoperative follow-up.
Subject(s)
Bariatric Surgery , COVID-19 , Gastric Bypass , Obesity, Morbid , Humans , Retrospective Studies , Obesity, Morbid/surgery , Follow-Up Studies , Quality Improvement , Pandemics , Treatment Outcome , COVID-19/epidemiology , Bariatric Surgery/adverse effects , Accreditation , Gastrectomy , Postoperative Complications/epidemiologyABSTRACT
INTRODUCTION: A paucity of literature exists regarding current opioid prescribing and use following bariatric surgery. We aimed to characterize opioid prescribing practices and use following bariatric surgery to inform future studies and optimized prescribing practices. METHODS AND PROCEDURE: We performed a systematic review of Ovid MEDLINE, Ovid Embase, Scopus, Web of Science Core Collection, and Cochrane Library (via WILEY) on August 20, 2021. Two reviewers reviewed and extracted data independently. Studies evaluating adult patients undergoing bariatric surgery that reported opioid prescriptions at discharge were included. Abstracts, non-English studies, and those with n < 5 were excluded. Primary outcomes assessed the amount of morphine milligram equivalents (MMEs) prescribed at discharge. Secondary outcomes evaluated opioids used following discharge, proportion of patients with unused opioid, and if unused opioids were properly discarded. RESULTS: We evaluated 2113 studies, with 18 undergoing full-text review, and 5 meeting inclusion criteria. Overall, 847 patients were included, with 450 (53%) undergoing sleeve gastrectomy and 393 (46%) receiving Roux-en-Y gastric bypass. Most patients were female (n = 484/589, 82.2%), and the average age and BMI were 44.6 (± 11.8) years and 48.1 kg/m2 (± 8.4 kg/m2), respectively. On average, 348.4 MMEs were prescribed to patients undergoing bariatric surgery. Patients used only 84.7 MMEs, with 87.0% (95% CI 66.0-99.0%) having unused opioid, and 41/120 (34.2%) retaining these excess opioids. CONCLUSION: Nearly 90% of all bariatric patients evaluated in our systematic review are prescribed excessive opioids at discharge. Further work characterizing current opioid prescribing practices and use may help guide development of standardized post-bariatric surgery prescription guidelines.