Reintervention or mortality within 90 days of bariatric surgery: population-based cohort study

Mid-term Results of an ERAS Program of Bariatric Surgery in a Tertiary Referral Center

BACKGROUND

To identify preoperative risk factors for discharge failure beyond postoperative day two (POD-2) in bariatric surgery ERAS program in a tertiary referral center.

METHODS

all consecutive patients who underwent laparoscopic bariatric treated in accordance with ERAS protocol between January 2017 and December 2019 were included. Two groups were identified, failure of early discharge (> POD-2) (ERAS-F) and success of early discharge (≤ POD-2) (ERAS-S). Overall postoperative morbidity, unplanned readmission rates were analyzed at POD-30 and POD-90, respectively. Multivariate logistic regression was performed to determine the independent risk factors for LOS > 2 days (ERAS-F).

RESULTS

A total of 697 consecutive patients were included, 148 (21.2%) in ERAS-F group and 549 (78.8%) in ERAS-S group. All postoperative complications at POD 90, whether medical or surgical were significantly more frequent in ERAS-F group than in ERAS-S group. Neither readmission nor unplanned consultations rates at POD 90 were significantly different between both groups. History of psychiatric disorder (p = 0.01), insulin-dependent diabetes (p < 0.0001), use of anticoagulants medicine (p < 0.00001), distance to the referral center > 100 km (p = 0.006), gallbladder lithiasis (p = 0.02), and planned additional procedures (p = 0.01) were independent risk factors for delayed discharge beyond POD-2.

CONCLUSIONS

One in five patients with bariatric surgery failed to discharge earlier despite the ERAS program. Knowledge of these preoperative risk factors would allow us to identify patients who need more recovery time and a tailored approach to the ERAS protocol.

Bariatric surgery volume by hospital and long-term survival: population-based NordOSCo data

BACKGROUND

It is unclear whether annual hospital volume of bariatric surgery influences the long-term survival of individuals who undergo surgery for severe obesity. The hypothesis that higher annual hospital volume of bariatric surgery is associated with better long-term survival was evaluated.

METHODS

This retrospective population-based study included patients who underwent bariatric surgery in Sweden and Finland between 1989 and 2020. Annual hospital volume was analysed for risk of all-cause mortality. Multivariable Cox regression provided HRs with 95 per cent confidence intervals adjusted for age, sex, co-morbidity, country, and type of bariatric procedure.

RESULTS

Weight loss surgery was performed in 77 870 patients with a 0.5 per cent risk of postoperative death (mortality rate (MR) per 100 000 people 592.7, 95 per cent c.i. 575.0 to 610.9). Higher annual hospital volume of bariatric surgery was associated with a lower risk of all-cause mortality. The adjusted HRs were slightly more reduced for each quartile of annual hospital volume compared with the lowest quartile (MR per 100 000 people for lowest quartile 815.1, 95 per cent c.i. 781.7 to 849.9; for quartile II: HR 0.88, 95 per cent c.i. 0.81 to 0.96 (MR per 100 000 people 545.0, 512.0 to 580.1); for quartile III: HR 0.87, 0.78 to 0.97 (MR per 100 000 people 428.8, 395.5 to 465.0); for quartile IV: HR 0.82, 0.73 to 0.93 (MR per 100 000 people 356.0, 324.1 to 391.1)). In analyses restricted to laparoscopic surgery, volume and mortality were related only in the crude model (HR 0.86, 0.75 to 0.98), but not in the multivariable model (HR 0.97, 0.84 to 1.13) that compared highest and lowest quartiles.

CONCLUSION

If there was a survival benefit associated with hospital volume, it may have been due to a faster uptake of laparoscopic surgery in the busier hospitals.

Long-term complications after gastric bypass and sleeve gastrectomy: What information to give to patients and practitioners, and why?

Bariatric surgery is now recognized as the most effective treatment of morbid obesity, leading to durable weight loss and resolution of associated co-morbidities. Roux-en-Y gastric bypass and sleeve gastrectomy are the two most widely used operations today. However, potentially serious medical, surgical, and/or psychiatric complications can occur that raise questions regarding the benefits of this type of surgery. These complications can lead to surgical re-operations, iterative hospitalizations, severe nutritional deficiencies and psychological disorders. Indeed, death from suicide is said to be three times higher than in non-operated obese patients. These results are of concern, all the more because of the high prevalence of patients lost to follow-up (for various and multifactorial reasons) after bariatric surgery. However, better knowledge of post-surgical sequelae could improve the information provided to patients, the preoperative evaluation of the benefit/risk ratio, and, for patients undergoing surgery, the completeness and quality of follow-up as well as the detection and management of complications. The development of new strategies for postoperative follow-up such as telemedicine but also the mobilization of all the actors along the healthcare pathway can make inroads and warrant further study.

Are Geographical Health Accessibility and Socioeconomic Deprivation Associated with Outcomes Following Bariatric Surgery? A Retrospective Study in a High-Volume Referral Bariatric Surgical Center

PURPOSE

Few studies have evaluated the association between non-clinical determinants (socioeconomic status and geographic accessibility to healthcare) and the outcomes of bariatric surgery, with conflicting results. This study aimed to evaluate this association.

METHODS

The medical records of 1599 consecutive patients who underwent either laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy between June 2005 and December 2017 were retrieved. All relevant data, including patient characteristics, biometric values before and after surgery, related medical problems, surgical history, medications, and habitus, for each patient were prospectively collected in a database. Logistic regressions were used to assess the influence of non-clinical determinants on surgical indications and complications. Multilevel linear or logistic regression was used to evaluate the influence of non-clinical determinants on long-term %TWL and the probability to achieve adequate weight loss (defined as a %TWL > 20% at 12 months).

RESULTS

Analysis of the 1599 medical records revealed that most geographically isolated patients were more likely to have undergone laparoscopic Roux-en-Y gastric bypass (odds ratio: 0.97; 95% confidence interval: 0.94 to 0.99; P = 0.018) and had a greater likelihood of adequate weight loss (β: 0.03; 95% CI: 0.01 to 0.05; P = 0.021). Conversely, socioeconomic status (measured by the European Deprivation Index) did not affect outcomes following bariatric surgery.

CONCLUSION

Geographical health isolation is associated with a higher probability to achieve adequate weight loss after 1 year of follow-up, while neither health isolation nor socioeconomic deprivation is associated with post-operative mortality and morbidity. This results suggests that bariatric surgery is a safe and effective tool for weight loss despite socioeconomic deprivation.

Revisional Adjustable Gastric Band in Roux-en-Y Gastric Bypass-Is It Worth It?

PURPOSE

A subset of patients undergoing Roux-en-Y gastric bypass (RYGB) presents with either insufficient weight loss or weight regain. Data on the revisional restrictive options including laparoscopic adjustable gastric band (LAGB) is scarce. This study analyzes the mid-term efficacy and safety of LAGB as a revisional procedure after RYGB.

METHODS

Data of all patients with revisional LAGB after primary RYGB between January 2011 and May 2019 were retrospectively reviewed. Outcomes included assessment of weight changes, resolution of comorbidities, and early and late complications during the study period.

RESULTS

Twenty patients were included. The median Body Mass Index (BMI) before revisional LAGB was 34.8 (interquartile range [IQR] 31.9-38.1) kg/m2. After a median follow-up of 33.5 (IQR 19.5-76.5) months, the median BMI was 28.7 (IQR 26.1-32.2) kg/m2. The median additional Excess Weight Loss (EWL) was 37.6% (IQR 23-44.4), leading to a median total EWL of 79.5% (IQR 54.4-94.6). BMI and EWL post-LAGB improved significantly compared to BMI and EWL pre-LAGB (p<0.001 and p<0.001, respectively). Obstructive sleep apnea syndrome resolved 6 months after LAGB in one patient. Three band deflations occurred during the follow-up. Six patients underwent band removal after a median time of 19 (IQR 15.8-26) months. Overall, thirteen patients underwent a reoperation. There was no loss of follow-up until 5 years. After that, two patients were lost to follow-up.

CONCLUSION

LAGB may be a salvage option after failed RYGB. However, the high rate of revisions after secondary LAGB needs to be taken into consideration.

Development of the "OS-SEV90 Score" to Predict Severe Postoperative Complications at 90 Days Following Bariatric Surgery

BACKGROUND

Bariatric surgery may be associated with severe postoperative complications (SPC). Factors associated with the risk of SPC have not been fully investigated.

OBJECTIVES

This study aimed to identify preoperative risk factors of SPC within 90 days and to develop a risk prediction model based on these factors.

METHODS

We conducted a retrospective single-center cohort study based on a prospectively maintained database of obese patients undergoing laparoscopic bariatric surgery from October 2005 to May 2019. All SPC occurring up to the 90th postoperative day were recorded according to the Dindo-Clavien classification. Associations between potential risk factors and SPC were analyzed using a logistic regression model, and the risk prediction ("OS-SEV90 score") was computed. Based on the OS-SEV90 score, the patients were grouped into 3 categories of risk: low, intermediate, and high.

RESULTS

Among 1963 consecutive patients, no patient died and 82 (4.2%) experienced SPC within 90 days. History of gastric or esophageal surgery (adjusted odds ratio (aOR) 3.040, 95% confidence interval; CI 1.78-5.20, p< 0.0001), past of thromboembolic event aOR 2.26, 95%; CI 1.12-4.55, p = 0.0225), and surgery performed by a junior surgeon (aOR 1.99, 95%; CI 1.26-3.13, p = 0.003) were all independently associated with risk for SPC, adjusting for ASA physical status system (ASA) score ≥ 3, severe OSA, psychiatric disease, asthma, a history of abdominal surgery, alcohol, cardiac disease, and dyslipidemia. "the OS-SEV90 score" based on these factors was constructed to classify patients into 3 risk groups: low (≤2), intermediate (3-4), and high (≥5). According to "the OS-SEV90 score," SPC increased significantly from 2.9% in the low-risk group, 7.7% in the intermediate-risk group, and 23.3% in the high-risk group.

CONCLUSIONS

A predictive model of SPC within 90 days "the OS-SEV90 score" has been developed using 9 baseline risk factors. The use of the OS-SEV90 score may help the multidisciplinary team to identify the specific risk of each patient and inform them about and optimize the comorbidities before the surgery. Further studies are warranted to validate this score in a new independent cohort before using it in clinical practice.

Is Laparoscopic Bariatric Surgery Safe and Effective in Patients over 60 Years of Age?" an Updated Systematic Review and Meta-Analysis

To evaluate, mid-term outcomes between elderly patients (EP, i.e., age > 60 years old) and young patients (YP, i.e., age < = 60 years old) who underwent laparoscopic bariatric surgery. Studies comparing EP versus YP for bariatric surgery published until April 2020 were selected and submitted to a systematic review and meta-analysis. After LSG, overall morbidity and specific post-operative complication rates (i.e., leak, abscess, hemorrhage, and reoperation) were significantly more frequent in EP compared with those in YP. Surgical outcomes were similar between EP and YP after LRYGB. Both procedures achieved weight loss, but it was statistically greater in YP compared with that in EP. In summary, this meta-analysis suggests that laparoscopic bariatric surgery is a safe and effective treatment in EP compared with that in YP.