Association of program-specific variation in bariatric surgery volume for Medicaid patients and access to care: a tale of inequality?

BACKGROUND: Although patients with lower socioeconomic status are at higher risk of obesity, bariatric surgery utilization among patients with Medicaid is low and may be due to program-specific variation in access. Our goal was to compare bariatric surgery programs by percentage of Medicaid cases and to determine if variation in distribution of patients with Medicaid could be linked to adverse outcomes. METHODS: Using a state-wide bariatric-specific data registry that included 43 programs performing 97,207 cases between 2006 and 2020, we identified all patients with Medicaid insurance (n = 4780, 4.9%). Bariatric surgery programs were stratified into quartiles according to the percentage of Medicaid cases performed and we compared program-specific characteristics as well as baseline patient characteristics, risk-adjusted complication rates and wait times between top and bottom quartiles. RESULTS: Program-specific distribution of Medicaid cases varied between 0.69 and 22.4%. Programs in the top quartile (n = 11) performed 18,885 cases in total, with a mean of 13% for Medicaid patients, while programs in the bottom quartile (n = 11) performed 32,447 cases in total, with a mean of 1%. Patients undergoing surgery at programs in the top quartile were more likely to be Black (20.2% vs 13.5%, p < 0.0001), have diabetes (35.1% vs 29.5%, p < 0.0001), hypertension (55.1% vs 49.6%, p < 0.0001) and hyperlipidemia (47.6% vs 45.2%, p < 0.0001). Top quartile programs also had higher complication rates (8.4% vs 6.6%, p < 0.0001), extended length of stay (5.6% vs 4.0%, p < 0.0001), Emergency Department visits (8.1% vs 6.5%, p < 0.0001) and readmissions (4.7% vs 3.9%, p < 0.0001). Median time from initial evaluation to surgery date was also significantly longer among top quartile programs (200 vs 122 days, p < 0.0001). CONCLUSIONS: Bariatric surgery programs that perform a higher proportion of Medicaid cases tend to care for patients with greater disease severity who experience delays in care and also require more resource utilization. Improving bariatric surgery utilization among patients with lower socioeconomic status may benefit from insurance standardization and program-centered incentives to improve access and equitable distribution of care.

Ceramide changes in abdominal subcutaneous and visceral adipose tissue among diabetic and nondiabetic patients.

BACKGROUND: This study profiles ceramides extracted from visceral and subcutaneous adipose tissue of human subjects by liquid chromatography-mass spectrometry to determine a correlation with status of diabetes and gender. METHODS: Samples of visceral and abdominal wall subcutaneous adipose tissue (n = 36 and n = 31, respectively) were taken during laparoscopic surgery from 36 patients (14 nondiabetic, 22 diabetic and prediabetic) undergoing bariatric surgery with a body mass index (BMI) >35 kg/m2 with ≥1 existing comorbidity or BMI ≥40 kg/m2 . Sphingolipids were extracted and analyzed using liquid chromatography-mass spectrometry. RESULTS: After logarithm 2 conversion, paired analysis of visceral to subcutaneous tissue showed differential accumulation of Cer(d18:1/16:0), Cer(d18:1/18:0), and Cer(d18:1/24:1) in visceral tissue of prediabetic/diabetic female subjects, but not in males. Within-tissue analysis showed higher mean levels of ceramide species linked to insulin resistance, such as Cer(d18:1/18:0) and Cer(d18:1/16:0), in visceral tissue of prediabetic/diabetic patients compared with nondiabetic subjects and higher content of Cer(d18:1/14:0) in subcutaneous tissue of insulin-resistant female patients compared with prediabetic/diabetic males. Statistically significant differences in mean levels of ceramide species between insulin-resistant African American and insulin-resistant Caucasian patients were not evident in visceral or subcutaneous tissue. CONCLUSIONS: Analysis of ceramides is important for developing a better understanding of biological processes underlying type 2 diabetes, metabolic syndrome, and obesity. Knowledge of the accumulated ceramides/dihydroceramides may reflect on the prelipolytic state that leads the lipotoxic phase of insulin resistance and may shed light on the predisposition to insulin resistance by gender.

Adopt or Abandon? Surgeon-Specific Trends in Robotic Bariatric Surgery Utilization Between 2010 and 2019.

Background: It is unknown if surgeons are more likely to adopt or abandon robotic techniques given that bariatric procedures are already performed by surgeons with advanced laparoscopic skills. Methods: We used a statewide bariatric-specific data registry to evaluate surgeon-specific volumes of robotic bariatric cases between 2010 and 2019. Operative volume, procedure type, and patient characteristics were compared between the highest utilizers of robotic bariatric procedures (adopters) and surgeons who stopped performing robotic cases, despite demonstrating prior use (abandoners). Results: A total of 44 surgeons performed 3149 robotic bariatric procedures in Michigan between 2010 and 2019. Robotic utilization peaked in 2019, representing 7.24% of all bariatric cases. We identified 7 surgeons (16%) who performed 95% of the total number of robotic cases (adopters) and 12 surgeons (27%) who stopped performing bariatric cases during the study period (abandoners). Adopters performed a higher proportion of gastric bypass both robotically (22.9% versus 3.1%, P < .001) and laparoscopically (27.5% versus 15.1%, P < .001), when compared with abandoners. Surgeon experience (no. of years in practice), type of practice (teaching versus nonteaching hospital), and patient populations were similar between groups. Conclusions: Robotic bariatric utilization increased during the study period. The majority of robotic cases were performed by a small number of surgeons who were more likely to perform more complex cases such as gastric bypass in their own practice. Robotic adoption may be influenced by surgeon-specific preferences based upon procedure-specific volumes and may play a greater role in performing more complex surgical procedures in the future.

Association of Race With Bariatric Surgery Outcomes.

Importance: The outcomes of bariatric surgery vary considerably across patients, but the association of race with these measures remains unclear. Objective: To examine the association of race on perioperative and 1-year outcomes of bariatric surgery. Design, Setting, and Participants: Propensity score matching was used to assemble cohorts of black and white patients from the Michigan Bariatric Surgery Collaborative who underwent a primary bariatric operation (Roux-en-Y gastric bypass, sleeve gastrectomy, or adjustable gastric banding) between June 2006 and January 2017. Cohorts were balanced on baseline characteristics and procedure. Conditional fixed-effects models were used to evaluate the association of race on outcomes within hospitals and surgeons. Data analysis occurred from June 2006 through August 2018. Main Outcomes and Measures: Thirty-day complications and health care resource utilization measures, as well as 1-year weight loss, comorbidity remission, quality of life, and satisfaction. Results: In each group, 7105 patients were included. Black patients had a higher rate of any complication (628 [8.8%] vs 481 [6.8%]; adjusted odds ratio, 1.33 [95% CI, 1.17-1.51]; P = .02), but there were no significant differences in the rates of serious complications (178 [2.5%] vs 135 [1.9%]; adjusted odds ratio, 1.32 [95% CI, 1.05-1.66]; P = .29) or mortality (5 [0.10%] vs 7 [0.10%]; adjusted odds ratio, 0.73 [95% CI, 0.23-2.31]; P = .54). Black patients had a greater length of stay (mean [SD], 2.2 [3.0] days vs 1.9 [1.7] days; adjusted odds ratio, 0.30 [95% CI, 0.20-0.40]; P < .001), as well as a higher rate of emergency department visits (541 [11.6%] vs 826 [7.6%]; adjusted odds ratio, 1.60 [95% CI, 1.43-1.79]; P < .001) and readmissions (414 [5.8%] vs 245 [3.5%]; adjusted odds ratio, 1.73 [95% CI, 1.47-2.03]; P < .001). At 1 year, black patients had lower mean total body weight loss and as a percentage of weight (32.0 kg [26%]; vs 38.3 kg [29%]; P < .001) and this held true across procedures. Remission of hypertension was lower for black patients (564 [40.0%] vs 1096 [56.0%]; P < .001), but the rate of sleep apnea remission (467 [62.6%] vs 615 [56.1%]; P = .005) and gastroesophageal reflux disease (309 [78.6%] vs 453 [75.4%]; P = .049) were higher. There were no significant differences in remission of diabetes with insulin dependence, diabetes without insulin dependence,or hyperlipidemia hyperlipidemia. Fewer black patients than white patients reported a good or very good quality of life (1379 [87.2%] vs 2133 [90.4%]; P = .002) and being very satisfied with surgery (1908 [78.4%] vs 2895 [84.2%]; P < .001) at 1 year. Conclusions and Relevance: Black patients undergoing bariatric surgery in Michigan had significantly higher rates of 30-day complications and resource utilization and experienced lower weight loss at 1 year than a matched cohort of white patients. While sleep apnea and gastroesophageal reflux disease remission were higher and hypertension remission lower in black patients, comorbidity remission was otherwise similar between matched cohorts. Racial and cultural differences among patients should be considered when designing strategies to optimize outcomes with bariatric surgery.

Effect of Surgeon Age on Bariatric Surgery Outcomes.

OBJECTIVE: This study sought to explore the relationship of bariatric surgeon age and patient outcomes. BACKGROUND: Regulators, policy makers, and patient advocacy groups have recently been pushing to establish clear guidelines for physician retirement in the United States. Although it is often assumed that increasing physician age leads to worse patient outcomes, the relationship is lacking robust evidence, and is still unclear. METHODS: We conducted a study analyzing all bariatric surgeons in Michigan who participated in a statewide collaborative quality improvement program (n = 71) who performed primary laparoscopic Roux-en-Y Gastric Bypass, or sleeve gastrectomy operations, and data on their patients (n = 60430) over the past 10 years. Our primary outcomes were 30-day postoperative complications. Odds ratios for overall complications and serious complications were calculated for each age group, and surgery type. RESULTS: Late career surgeons had more bariatric surgery experience and had a higher average annual case volume than early career surgeons. Considering all cases in the past 10 years, older surgeons performed more Roux-en-Y Gastric Bypass (40%) and less sleeve gastrectomy (38.8%) than younger surgeons (34.7% and 51.5%). When adjusting for patient and surgeon characteristics, there were no statistically significant differences in overall or serious complication rates for either procedure among surgeon age groups. CONCLUSIONS: When evaluating bariatric surgeons in the State of Michigan, we found no statistically significant association between surgeon age and patient outcomes. Our findings do not provide evidence for age-specific retirement cut-offs, but support the development of guidelines which are holistic, and focus on evaluating and improving physician outcomes at all career levels.

Variation in utilization of acid-reducing medication at 1 year following bariatric surgery: results from the Michigan Bariatric Surgery Collaborative.

BACKGROUND: Morbidly obese patients undergoing bariatric surgery have high rates of gastroesophageal reflux and are often treated with acid-reducing medications (ARM) such as proton pump inhibitors or H2-blockers. The objective of this study was to evaluate the effect of bariatric procedures on the utilization of ARM. We analyzed data from the clinical registry of the Michigan Bariatric Surgery Collaborative on 35,477 patients undergoing bariatric surgery between January 2006 and October 2012 who completed both baseline and 1-year follow-up surveys. Procedures included laparoscopic adjustable gastric banding (LAGB, n=2,627), Roux-en-Y gastric bypass (RYGB, n=6,410), sleeve gastrectomy (SG, n=1,567), and biliopancreatic diversion with duodenal switch (BPD/DS, n=162). METHODS: Rates of ARM at 1 year by procedure type were compared using logistic regression analysis. Models were adjusted for patient characteristics, baseline co-morbidities, weight loss, and hiatal hernia repair. RESULTS: Overall ARM use at baseline was 37.7% and declined to 29.6% at 1 year after bariatric surgery. The proportion of patients starting an ARM at 1 year when they were not using one at baseline by procedure was LAGB (13.9%), RYGB (19.2%), SG (21.6%), and BPD/DS (26.7%). The proportion of patients discontinuing an ARM at 1 year when they were using one at baseline by procedure was LAGB (55.6%), RYGB (56.2%), SG (37.3%), and BPD/DS (42.1%). Compared with LAGB on multivariable analysis, the likelihood of ARM use at 1 year was higher for SG (OR 1.70, 95% CI 1.45-1.99) and BDP/DS (OR 1.53, CI .97-2.40) but not different for RYGB (OR 1.02, CI .90-1.16). CONCLUSION: Overall ARM use decreases after bariatric surgery; however, it is not uniform and depends on procedure type. SG is a significant predictor for ARM use at 1 year.

A comparison of outcomes between the traditional laparoscopic and totally robotic Roux-en-Y gastric bypass procedures.

Background Roux-en-Y gastric bypass is considered to be the gold standard of bariatric procedures. Minimally invasive surgical techniques have been demonstrated to decrease recovery time and provide for favorable cosmetic outcomes. The drawback of traditional laparoscopic techniques for the surgeon comes in the form of 2D monitoring of not always intuitive instrument manipulation. The da Vinci Surgical System provides surgeons with a 3D view and more intuitive instrument manipulation. This study was conducted in order to compare the surgical outcomes and assess the learning curve of traditional laparoscopic Roux-en-Y gastric bypasses (LRYGB) to totally robotic Roux-en-Y gastric bypasses (TRRYGB). A single surgeon's 100 most recent patients who underwent traditional LRYGB and the first 100 patients who underwent TRRYGB were included in this study. Data was collected on patient age, gender, body mass index (BMI), co-morbidities, surgical time, length of admission, and complication rates. No significant differences were found between study groups with respect to age, gender, BMI or any recorded co-morbidities. The mean operative times for patients 1-50 in the TRRYGB and LRYGB groups were 204.34 ± 90.19 min and 151.16 ± 47.16 min, respectively (P = 0.0004). Mean operative times were 159.60 ± 48.26 min and 166.66 ± 44.95 min for patients 51-100 in the TRRYGB and LRYGB groups, respectively (P = 0.45). No significant differences were found between study groups with respect to post-surgical complications or 30-day outcomes. Our data shows that TRRYGB compares favorably to the traditional laparoscopic approach, while maintaining patient safety.

Risks and benefits of prophylactic inferior vena cava filters in patients undergoing bariatric surgery.

BACKGROUND: The United States Food and Drug Administration recently issued a warning about adverse events in patients receiving inferior vena cava (IVC) filters. OBJECTIVE: To assess relationships between IVC filter insertion and complications while controlling for differences in baseline patient characteristics and medical venous thromboembolism prophylaxis. DESIGN: Propensity-matched cohort study. SETTING: The prospective, statewide, clinical registry of the Michigan Bariatric Surgery Collaborative. PATIENTS: Bariatric surgery patients (n=35,477) from 32 hospitals during the years 2006 through 2012. INTERVENTION: Prophylactic IVC filter insertion. MEASUREMENTS: Outcomes included the occurrence of complications (pulmonary embolism, deep vein thrombosis, and overall combined rates of complications by severity) within 30 days of bariatric surgery. RESULTS: There were no significant differences in baseline characteristics among the 1,077 patients with IVC filters and in 1,077 matched control patients. Patients receiving IVC filters had higher rates of pulmonary embolism (0.84% vs 0.46%; odds ratio [OR], 2.0; 95% confidence interval [CI], 0.6-6.5; P=0.232), deep vein thrombosis (1.2% vs 0.37%; OR, 3.3; 95% CI, 1.1-10.1; P=0.039), venous thromboembolism (1.9% vs 0.74%; OR, 2.7; 95% CI, 1.1-6.3, P=0.027), serious complications (5.8% vs 3.8%; OR, 1.6; 95% CI, 1.0-2.4; P=0.031), permanently disabling complications (1.2% vs 0.37%; OR, 4.3; 95% CI, 1.2-15.6; P=0.028), and death (0.7% vs 0.09%; OR, 7.0; 95% CI, 0.9-57.3; P=0.068). Of the 7 deaths among patients with IVC filters, 4 were attributable to pulmonary embolism and 2 to IVC thrombosis/occlusion. CONCLUSIONS: We have identified no benefits and significant risks to the use of prophylactic IVC filters among bariatric surgery patients and believe that their use should be discouraged.

Preventing surgical site infections after bariatric surgery: value of perioperative antibiotic regimens.

Bariatric surgery for obesity has emerged as an effective and commonly used treatment modality. This paper reviews the surgical site infections (SSIs) that occur post bariatric surgery and SSI prevention. The benefit of bariatric surgery resulting in profound weight loss brings with it consequences in the form of postoperative complications that can have profound effects on morbidity and mortality in these patients. This paper sets out to define different types of SSIs that occur following bariatric surgery and to discuss existing literature on the critical aspects of SSI prevention and the appropriate use of surgical antimicrobial prophylaxis for bariatric surgery.

Open versus laparoscopic Roux-en-Y gastric bypass: a comparative study of over 25,000 open cases and the major laparoscopic bariatric reported series.

BACKGROUND: Laparoscopic bariatric surgery has experienced a rapid expansion of interest over the past 5 years, with a 470% increase. This rapid expansion has markedly increased overall cost, reducing surgical access. Many surgeons believe that the traditional open approach is a cheaper, safer, equally effective alternative. METHODS: 16 highly experienced "open" bariatric surgeons with a combined total of 25,759 cases representing >200 surgeon years of experience, pooled their open Roux-en-Y gastric bypass (ORYGBP) data, and compared their results to the leading laparoscopic (LRYGBP) papers in the literature. RESULTS: In the overall series, the incisional hernia rate was 6.4% using the standard midline incision. Utilizing the left subcostal incision (LSI), it was only 0.3%. Return to surgery in <30 days was 0.7%, deaths 0.25%, and leaks 0.4%. Average length of stay was 3.4 days, and return to usual activity 21 days. Small bowel obstruction was significantly higher with the LRYGBP. Surgical equipment costs averaged approximately $3,000 less for "open" cases. LRYGBP had an added expense for longer operative time. This more than made up for the shorter length of stay with the laparoscopic approach. CONCLUSIONS: The higher cost, higher leak rate, higher rate of small bowel obstruction, and similar long-term weight loss results make the "open" RYGBP our preferred operation. If the incision is taken out of the equation (i.e. use of the LSI), the significant advantages of the open technique become even more obvious.

Anastomotic leak prophylaxis using a vapor-heated fibrin sealant: report on 738 gastric bypass patients.

BACKGROUND: Excluding pulmonary embolism, anastomotic leak is the leading cause of death and major morbidity in patients undergoing open or laparoscopic gastric bypass operations. We observed a number of these leaks (11 out of 1,120 Micropouch(SM) gastric bypass [MGB] patients; 0.9%). The majority (80%) required emergency laparotomy and drainage, massive fluid resuscitation, and aggressive nutritional support. Therefore, we designed a 2-year, prospective study to determine the therapeutic efficacy of vapor-heated fibrin sealant to prevent anastomotic leaks at the gastro-jejunostomy (GJS) site. METHODS: Between April, 2000 and March, 2002, 738 patients underwent a primary (n=671) or revisionary (n=67) MGB procedure. The gastric reservoir was limited to the cardia of the stomach. Vapor-heated fibrin glue 1 cc was applied circumferentially to a 12-mm, non-banded GJS anastomosis. Once activated, fibrin sealant polymerized into a soft, closely adherent gel. No omental patch was used to cover the fibrin-sealed anastomosis. RESULTS: Of 738 patients, 2 required emergency laparotomy for leaks and 2 for adhesive bands that contributed to a distal small bowel obstruction. There were no anastomotic leaks at the fibrin-sealed GJS sites. No gastro-gastric or gastro-enteric fistulas were recorded. CONCLUSION: Fibrin sealant applied to the GJS site appears to have eliminated anastomotic leaks in our Micropouch(SM) gastric bypass patients. These results suggest that fibrin glue application may contribute to "leak prophylaxis" in patients undergoing open Rouxen-Y gastric bypass. Glue placements may also benefit patients undergoing a laparoscopic Roux-en-Y procedure, wherein anastomotic leaks have been reported early in the learning curve.

Fatal pulmonary embolism after bariatric operations for morbid obesity: a 24-year retrospective analysis.

BACKGROUND: Pulmonary embolism (PE) is a leading cause of death following gastric bypass operations for morbid obesity. Although its incidence appears to be stable, the number of bariatric operations performed annually is increasing considerably; hence, the isolated fatal PE is no longer a rare occurrence. The records of patients undergoing bariatric surgical operations since 1979 were reviewed to determine specific factors that increased the risk of developing a fatal PE. Both recommended and optional indications for prophylactic inferior vena cava (IVC) filter placement in patients considered at high risk were also examined. MATERIALS AND METHODS: Between September, 1979 and March, 2003, 5,554 operations were performed for clinically severe obesity. These operations included jejuno-ileal bypass, horizontal gastroplasty, Roux-en-Y gastric bypass with a 30-cc pouch, modified biliopancreatic diversion, the Sapala-Wood Micropouch gastric bypass (Micropouch(SM)), Lap-Band, and revisions. 12 fatal pulmonary emboli (0.21 %) were identified. All but 1 embolus occurred within 30 days following surgery. RESULTS: In 11 of 12 patients, at least 1 co-morbidity known to increase the risk of postoperative venous thromboembolism (VTE) was identified. 4 co-morbidites were common to 4 patients (33%): venous stasis disease (VSD), BMI >/= 60, truncal obesity, and obesity hypoventilation syndrome/sleep apnea syndrome (OHS/SAS). 6 of 12 patients (50%) had a BMI >/= 60. Another 6 had chronic leg swelling with stasis dermatitis. 2 patients experienced a previous PE, and 1 patient reported a history of deep vein thrombosis (DVT). CONCLUSION: 4 patients (33%) demonstrated a combination of risk factors (VSD, BMI >/= 60, truncal obesity, OHS/SAS) recognized as significant for the development of postoperative VTE. In such patients, prophylactic IVC filter placement is highly recommended. Filter placement for other factors, such as age, body build, hypercoagulable state, etc., should be considered on an individual basis.