Quality of MBSAQIP data: bad luck, or lack of QA plan?

Prediction of 30-Day Morbidity and Mortality After Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass: Use of an Artificial Neural Network

BACKGROUND

Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass is indicated primarily for unsatisfactory weight loss or gastroesophageal reflux disease (GERD). This study aimed to use a comprehensive database to define predictors of 30-day reoperation, readmission, reintervention, or mortality. An artificial neural network (ANN) was employed to optimize prediction of the composite endpoint (occurrence of 1+ morbid event).

METHODS

Areview of 8895 patients who underwent conversion for weight-related or GERD-related indications was performed using the 2021 MBSAQIP national dataset. Demographics, comorbidities, laboratory values, and other factors were assessed for bivariate and subsequent multivariable associations with the composite endpoint (P ≤ .05). Factors considered in the multivariable model were imputed into a three-node ANN with 20% randomly withheld for internal validation, to optimize predictive accuracy. Models were compared using receiver operating characteristic (ROC) curve analysis.

RESULTS

39% underwent conversion for weight considerations and 61% for GERD. Rates of 30-day reoperation, readmission, reintervention, mortality, and the composite endpoint were 3.0%, 7.1%, 2.1%, .1%, and 9.1%, respectively. Of the nine factors associated with the composite endpoint on bivariate analysis, only non-white race (P < .001; odds ratio 1.4), lower body-mass index (P < .001; odds ratio .22), and therapeutic anticoagulation (P = .001; odds ratio 2.0) remained significant upon multivariable analysis. Areas under ROC curves for the multivariable regression, ANN training, and validation sets were .587, .601, and .604, respectively.

DISCUSSION

Identification of risk factors for morbidity after conversion offers critical information to improve patient selection and manage postoperative expectations. ANN models, with appropriate clinical integration, may optimize prediction of morbidity.

First Assistant In Bariatric Surgery: A Comparison Between Laparoscopic And Robotic Approaches: A 4-Year Analysis of the MBSAQIP Database (2016-2019)

PURPOSE

The first assistant (FA) plays an important role in the operating room for bariatric surgery. The aim of this study was to examine the relationship between the type of FA and operative time (OT) and postoperative outcomes comparing robotic and laparoscopic approaches in bariatric surgery.

METHODS AND MATERIALS

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data for 2016-2019 was queried. Log-normal regression was performed to evaluate the association of FAs and OT variations within and between groups. We used logistic regression to examine the relationship between the type of FA and 30-day outcomes across all procedures and approaches.

RESULTS

A total of 691,789 patients who underwent robotic (R), and laparoscopic (L) sleeve gastrectomy (SG), Roux-en-Y gastric-bypass (RYGB), and duodenal switch (DS) were included. The percentage variation of OT was higher in the laparoscopic group (L-SG: 8.18%, L-RYGB: 9.88%, and L-DS: 15.00%) compared to the robotic group (R-SG: 2.43%, R-RYGB: 5.76%, and R-DS: 0.80%). There was not a significant difference in 30-day outcomes between laparoscopic and robotic approaches for the same procedures.

CONCLUSIONS

The FA was associated with a decreased variability in OT in the robotic cohort compared to the laparoscopic group with no significant difference in complication rates. These results suggest that the robotic approach may decrease the need for skilled FAs in bariatric procedures.

MBSAQIP database: are the data reliable?

BACKGROUND

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database collects data from all accredited centers in the US. A prior study showed data quality issues limiting use of up to 20% of the 2015 database.

OBJECTIVES

To evaluate the completeness and data quality (internal validity, accuracy, and consistency) of the MBSAQIP database between 2015 and 2019.

SETTING

United States.

METHODS

All subsets of data from the MBSAQIP Participant User Data File (PUDF) were compiled into one main file. Completeness, internal validity, accuracy, and consistency were evaluated. Completeness was determined via missing values. Internal validity was assessed using the percentage of patients with a body mass index (BMI) < 30 kg/m2 who underwent primary bariatric surgery. Accuracy was evaluated using reported versus calculated BMI. Consistency was assessed using the percentage of patients with a gain of >5 or a loss of >20 units of BMI change in 30 days. Effects across years were assessed using a chi-squared test.

RESULTS

Missing data for age, BMI, and ASA was consistently low (<2.5%) with no significant difference across years. Only .02% of patients who underwent a primary bariatric procedure had a reported BMI <30 kg/m2. The mean difference between reported versus calculated BMI was -.02 units. A maximum of .33% of patients gained >5 units of BMI, and a maximum of .85% of patients lost > 20 units of BMI in early follow-up.

CONCLUSIONS

While the MBSAQIP is a database with acceptable data quality and minimal changes from 2015-2019, ongoing efforts are needed to improve data.

Outcomes of same-day discharge sleeve gastrectomy and Roux-en-Y gastric bypass: a systematic review and meta-analysis

Length of stay after bariatric surgery has progressively shortened. Same-day discharge (SDD) has been reported for the 2 most common bariatric procedures, Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). The aim of this study is to evaluate the safety and success of SDD following SG and RYGB. Systematic literature search on SDD after bariatric surgery was conducted in Medline, Cochrane library, Google Scholar, and Embase. SDD was defined as discharging the patient during the day of the bariatric operation, without an overnight stay. The primary outcomes of interest were successful SDD, readmission, and morbidity rates. The secondary endpoints included reoperation and mortality rates. A proportion meta-analysis was performed to assess the outcomes of interest. A total of 14 studies with 33,403 patients who underwent SDD SG (32,165) or RYGB (1238) were included in the qualitative synthesis. Seven studies with 5000 patients who underwent SDD SG were included in the quantitative analysis, and pooled proportions (PPs) were calculated for the outcomes of interest. The SDD success rate was 63%-100% (PP: 99%) after SG and 88%-98.1% after RYGB. The readmission rate ranged from .6% to 20.8% (PP: 4%) after SDD SG and 2.4%-4% after SDD RYGB. Overall morbidity, reoperation, and mortality were 1.1%-10% (PP:4%), .3%-2.1% (PP: 1%), and 0%-.1% (PP: 0%), respectively, for SDD SG, and 2.5%-4%,1.9%-2.5%, and 0%-.9%, respectively, for SDD RYGB. SDD after SG seems feasible and safe. The outcomes of SDDRYGB seem promising, but the evidenceis stilllimitedto draw definitive conclusions. Selection criteria and perioperative protocolsmust be standardized to adequately introduce this practice.

Operative Time and 30-Day Outcomes in Bariatric Surgery: Comparison between Robotic and Laparoscopic Approach: 4-Year MBSAQIP Database Analysis

BACKGROUND

The main criticism of robotic surgery is longer operative time (OT). The aim of this study was to examine the variables that determine OT, the association between OT and 30-day outcomes, and the effect of the robotic approach in bariatric surgery.

STUDY DESIGN

MBSAQIP data for 2016 to 2019 were queried. Logistic regression was performed to examine the association between OT and outcomes for each surgical approach while adjusting for patients' characteristics. The results of each fitted logistic regression model were reported as odds ratio and the associated 95% CI.

RESULTS

A total of 666,182 patients underwent robotic sleeve gastrectomy (R-SG), laparoscopic sleeve gastrectomy, robotic Roux-en-Y gastric bypass (R-RYGB), laparoscopic Roux-en-Y gastric bypass, robotic duodenal switch (R-DS), and laparoscopic duodenal switch). More patients underwent laparoscopic surgery (89.7%) than robotic surgery (10.3%). OT for robotic cases was longer than for laparoscopic cases (p < 0.0001). Longer OT was associated with increased odds of adverse 30-day outcomes irrespective of the surgical approach. The association between OT and adverse outcomes was stronger in the laparoscopic cohort. There was no significant difference in postoperative outcomes when comparing the laparoscopic and robotic approaches after adjusting for OT, except a lower reoperation rate for R-SG (p = 0.03) and readmission rates in R-RYGB and R-DS (p < 0.01). The variability of OT was higher in the laparoscopic group and was more affected by the first assistant.

CONCLUSIONS

The outcomes in robotic bariatric surgery were comparable with the laparoscopic approach despite longer OT. Use of robotic surgery decreased the variability in OT.

Safety of Primary Versus Revisional Biliopancreatic Diversion with Duodenal Switch in Patients with Super Obesity Using the MBSAQIP database

INTRODUCTION

For patients with super obesity (BMI > 50 kg/m²), biliopancreatic diversion/duodenal switch (BPD/DS) can be an effective bariatric operation. Technical challenges and patient safety concerns, however, have limited its use as a primary procedure. This study sought to assess the safety of primary versus revisional BPD/DS.

MATERIALS AND METHODS

The MBSAQIP database was queried for primary and revisional BPD/DS (2015-2018). Inclusion criteria were patients ≥ 18 years of age, BMI > 50 kg/m², and with no concurrent procedures. Preoperative variables were compared using a chi-square test or Wilcoxon two-sample tests. Multivariate logistic or robust linear regression models were used to compare outcomes.

RESULTS

There were 3,378 primary BPD/DS and 487 revisional BPD/DS patients. Primary BPD/DS patients had higher BMI (56.5 [IQR4.4] versus 54.8 [IQR4] kg/m², p < 0.0001) and had more diabetes mellitus type II (29.1% versus 17.2%, p < 0.0001). Intraoperatively, revisional BPD/DS had longer operative time (165 [IQR47] min versus 139 [IQR100] min, p < 0.0001). After adjusting for preoperative characteristics, there was no difference in 30-day readmission or ED visits (primary 12.9% versus revisional 14.6%), reoperation or reintervention (primary 5.7% versus revisional 7.8%), or mortality (primary 0.4% versus revisional 0.6%). In contrast, the revisional BPD/DS patients had higher odds of major morbidity (primary 3.4% versus revisional 5.3%, OR 1.9, CI 1.1-3.2, p = 0.019).

CONCLUSIONS

Revisional BPD/DS is associated with higher morbidity than primary BPD/DS in patients with super obesity. These patients should thus be counselled appropriately when choosing a primary or revisional bariatric procedure.

Racial disparity in causes for readmission following bariatric surgery

BACKGROUND

Readmission after bariatric surgery is not cost-effective and is a preventable quality metric within standardized practices. However, reasons for readmission among racial/ethnic bariatric cohorts are less explored and understood.

OBJECTIVE

Our study objective was designed to compare reasons for readmission among racial/ethnic cohorts of bariatric patients.

SETTING

Academic hospital.

METHODS

We performed a retrospective analysis of the 2015-2018 MBSAQIP databases to identify Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) cases. Regression analyses determined predictors of all-cause and bariatric-related readmissions. Reasons for readmission were compared between racial/ethnic cohorts using propensity score matching.

RESULTS

More than 550 000 RYGB and SG cases were analyzed. The readmission rate was 3%-4%. Black race, RYGB, robot-assisted approach, and numerous co-morbidities were independently associated with readmission (P <.05). In RYGB cases, black (versus white) patients were at decreased odds of leak-related (P < .001) and cardiovascular-related (P < .001) readmissions but at increased odds of readmissions related to renal complications (P < .001). Hispanic (versus white) patients had a higher likelihood of venous thromboembolism-related readmissions (P < .001). In SG cases, black (versus white) patients had a similar lower likelihood of readmission related to leaks or cardiovascular complications but higher odds of readmission related to renal complications (P < .001). Hispanic (versus black) patients had a higher likelihood of leak-related readmissions (P < .001).

CONCLUSION

Readmission reasons after bariatric surgery vary by race/ethnicity. Perioperative pathways to mitigate complications, including readmissions, should consider these disparate findings.

Racial disparities in complications and mortality after bariatric surgery: A systematic review

BACKGROUND

Studies have shown racial discrepancies in the rates of postoperative adverse events following bariatric surgery (BS). We aim to systematically review the literature examining racial disparities in postoperative adverse events.

METHODS

PubMed, Embase, and SCOPUS databases were searched for studies that reported race, postoperative adverse events and/or length of stay.

RESULTS

Thirty-five studies were included. Most compared Black and White patients using standardized databases. Racial/ethnic terminology varied. The majority found increased 30-day mortality and morbidity and length of stay in Black relative to White patients. Differences between White and Hipanic patients were mostly non-significant in these outcomes.

CONCLUSIONS

Black patients may experience higher rates of adverse events than White patients within 30 days following bariatric surgery. Given the limitations in the large multicenter databases, explanations for this disparity were limited. Future research would benefit from longer-term studies that include more races and ethnicities and consider socioeconomic factors.

Role of Robotic Surgery in Complex Revisional Bariatric Procedures

PURPOSE

Revisional bariatric surgery (RBS) is becoming more common, with an estimated increase of more than 300% from 2017 to 2018. For these complex procedures, the role of robotics is still debated. The purpose of our study is to report the safety and effectiveness of robotic-assisted RBSs.

MATERIALS AND METHODS

A retrospective review of electronic medical records was conducted for robotic-assisted RBSs performed at the Mayo Clinic in Florida, between January 1, 2016, and January 1, 2020. Peri- and postoperative data were analyzed, reviewing patient characteristics, indications for surgery, and outcomes.

RESULTS

From 160 RBSs performed during the study period, 67 were robotic-assisted and met inclusion criteria. Primary procedures included sleeve gastrectomy (26 [38.8%]), adjustable gastric band (24 [35.8%]), Roux-en-Y gastric bypass (14 [20.9%]), vertical-banded gastroplasty (2 [3.0%]), and duodenal switch (1 [1.5%]). RBSs performed were Roux-en-Y gastric bypass (49 [73.1%]), redo gastrojejunostomy (14 [20.9%]), and duodenal switch (4 [6.0%]). Rate of conversion to open procedure and rate of readmission 1 month after surgery were 6.0% and 7.5%, respectively. Rate of 30-day Clavien-Dindo grade III or higher adverse events was 4.5%. No anastomotic leaks were documented. Fifty-two patients presented with preoperative symptoms, and 69.2% reported improvement after RBS. Mean (SD) excess weight loss was 57.62% (23.80) 12 months after RBS.

CONCLUSION

Robotic-assisted RBSs are safe with low major adverse event rates. Symptom resolution and weight loss outcomes are acceptable.

Poor glycemic control in bariatric patients: a reason to delay or a reason to proceed?

BACKGROUND

More than 90% of patients with type 2 diabetes (T2D) have obesity, and over 85% of diabetic patients who undergo metabolic and bariatric surgery (MBS) will see improvement or resolution of diabetes. However, diabetes is a known risk factor for surgical complications.

OBJECTIVES

To determine whether poor preoperative glycemic control confers an increased perioperative risk after MBS.

SETTING

Academic Hospital.

METHODS

Retrospective review of data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). From the 2017-2018 MBSAQIP databases, we identified patients with diabetes who underwent Roux-en-Y gastric bypass or gastric sleeve surgery. Unmatched and propensity-matched univariate analyses, as well as multivariate logistic regressions, were performed to compare 30-day postoperative outcomes and complication rates between patients with poor (glycated hemoglobin [HbA1C] > 7.0) and good (HbA1C ≤ 7.0) glycemic control.

RESULTS

Of 40,132 T2D patients, 19,094 (52.42%) had an HbA1C level ≤ 7.0. Patients with poor glycemic control had slightly higher rates of overall morbidity (6.53% versus 5.49%, respectively; relative risk = 1.188; P < .001). However, in a 1:1 matched analysis of 23,930 patients controlling for body mass index, surgery type, approach, and co-morbidities, the findings of poorer outcomes were largely mitigated. In a multivariate analysis, poor glycemic control was not associated with morbidity.

CONCLUSIONS

In T2D patients, poor glycemic control does not independently increase the risk of 30-day morbidity following MBS. Adverse outcomes in the setting of poor glycemic control appear to be largely mediated by associated co-morbidities. Performing MBS in the setting of suboptimal glycemic control may be justified, with the understanding that delaying or refusing surgery can contribute to worsening of diabetes-related co-morbidities that, in turn, may ultimately have a more deleterious effect on outcomes.

Missing something? A scoping review of venous thromboembolic events and their associations with bariatric surgery. Refining the evidence base

Background

Venous thromboembolic events (VTE) post-bariatric surgery (BS) lead to morbidity and mortality.

Methods

This scoping review assessed whether reported VTE post-BS could be under/over-estimated; suggested a possible number of VTE post-BS; appraised whether VTE are likely to decrease/increase; examined BS as risk/protective factor for VTE; and mapped the gaps, proposing potential solutions.

Results

VTE appears under-estimated due to: identification/coding of BS and VTE; reporting of exposure (BS); and reporting of outcomes (VTE). The review proposes a hypothetical calculation of VTE post-BS. VTE are unlikely to decrease soon. BS represents risk and protection for VTE. Better appreciation of VTE-BS relationships requires longer-term strategies.

Conclusion

VTE are underestimated. Actions are required for understanding the VTE-BS relationships to in order to crease VTE by better-informed prevention strategy/ies.

Safety of Single Stage Revision Laparoscopic Sleeve Gastrectomy Compared to Laparoscopic Roux-Y Gastric Bypass after Failed Gastric Banding

Background

Reoperation, after failed gastric banding, is a controversial topic. A common approach is band removal with conversion to laparoscopic Roux-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) in a single-step procedure.

Objective

This study aimed to assess the safety of revisional surgery to LSG compared to LRYGB after failed laparoscopic adjustable gastric banding (LAGB) based on MBSAQIP Participant User File from 2015 to 2018.

Methods

Patients who underwent a one-stage conversion of LAGB to LSG (Conv-LSG) or LRYGB (Conv-LRYGB) were identified in the MBSAQIP PUF from 2015 to 2017. Conv-LRYGB cases were matched (1:1) with Conv-LSG patients using propensity scoring to control for potential confounding. The primary outcome was all-cause mortality.

Results

A total of 9974 patients (4987 matched pairs) were included in the study. Conv-LRYGB, as compared with conv-SG, was associated with a similar risk of mortality (0.02% vs. 0.06%; relative risk [RR], 0.33; 95% confidence interval [CI], 0.03 to 3.20, p = 0.32). Conversion to LRYGB increased the risk for readmission (6.16% vs. 3.77%; RR, 1.63; 95%CI, 1.37 to 1.94, p < 0.01); reoperation (2.15% vs. 1.36%; RR, 1.57; 95%CI, 1.17 to 2.12, p = <0.01); leak (1.76% vs. 1.02%; RR, 1.57; 95%CI, 1.72 to 2.42, p < 0.01); and bleeding (1.66% vs. 1.00%; RR, 1.66; 95%CI, 1.7 to 2.34, p < 0.01).

Conclusions

The study shows that single-stage LRYGB and LSG as revisional surgery after gastric banding, are safe in the 30-day observation with an acceptable complication rate and low mortality. However, conversion to LRYGB increased the risk of perioperative complications.

Safety of same-day discharge after laparoscopic sleeve gastrectomy: propensity score-matched analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Registry

BACKGROUND

Information on the safety of outpatient sleeve gastrectomy is sparse.

OBJECTIVE

This study aimed to assess the safety of sleeve gastrectomy as a day case surgery.

SETTING

University health network, United States.

METHODS

Patients who underwent primary sleeve gastrectomy were identified in the 2015-2017 MBSAQIP database. Day case surgery procedure was defined as having a hospital length of stay of 0 days. Day case surgery patients were matched with inpatient controls using propensity score matching. The primary outcome was 30-day mortality.

RESULTS

A total of 271,658 sleeve gastrectomy patients met the inclusion criteria. Of these, only 7825 (2.88 %) were day case surgery procedures. There was no mortality in the group. Day case surgery, compared with inpatient sleeve gastrectomy, was associated with a similar risk of a leak (.56% versus .40%; relative risk [RR], 1.419; 95% CI, .896-2.245; P = .133), bleeding (.38% versus .31%; RR, 1.250; 95% CI, .731-2.138; P = .414), 30-day reoperation (.81% versus .56%; RR, 1.432; 95% CI, .975-2.104; P = .066), and 30-day morbidity (1.15% versus 1.01%; RR, 1.139; 95% CI, .842-1.541; P = .397). Outpatients' SG increased the risk for 30-day readmission (3.35% versus 2.79%; RR, 1.202; 95% CI, 1.009-1.432; P = .039).

CONCLUSIONS

Sleeve gastrectomy in the outpatient setting as a day case surgery was associated with no mortality and no statistically significant risk of reoperation, leakage, or bleeding compared with patients admitted to inpatient units. The readmission rate was higher in the day case surgery group.

Trends and Outcomes of Laparoscopic Sleeve Gastrectomy Between 2015 and 2018 in the USA and Canada

BACKGROUND

Given there are approximately 100,000 primary laparoscopic sleeve gastrectomy (LSG) procedures performed a year in North America, there is a need to evaluate recent trends in LSG. The objective of this study was to analyze the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) to identify trends in technical factors and patient outcomes over time.

METHODS

The MBSAQIP prospectively collects data from 854 centers in the USA and Canada. Patients undergoing primary LSG were included. Statistical analysis was performed to characterize trends in patient factors, technical factors, and 30-day postoperative outcomes.

RESULTS

A total of 434,030 patients underwent primary LSG. The mean age was 44.2 (SD 12.0) years and mean body mass index was 45.1 (SD 7.8) kg/m². Baseline demographics did not vary appreciably by year. Operative time decreased from 2015 to 2018 (75.4 to 70.6 min, p < 0.001). Bougie size and stapling distance from the pylorus did not change by year. However, staple line reinforcement (66.8 to 63.2%, p < 0.001) and oversewing of the staple line (23.1 to 20.1%, p < 0.001) were less commonly performed. Postoperatively, from 2015 to 2018, there was a 45.8% relative reduction in leaks (0.48 to 0.26%, p < 0.001). There were also reductions in 30-day major complications (2.87 to 2.28%, p < 0.001), length of stay (1.72 to 1.44 days, p < 0.001), and readmissions (3.39 to 2.77%, p < 0.001).

CONCLUSIONS

From 2015 to 2018, there was a decrease in staple line reinforcement and oversewing. These changes correlated with reductions in operative time, length of stay, readmission, and major complications.

Safety of concurrent sleeve gastrectomy and hiatal hernia repair: a propensity score-matched analysis of the MBSAQIP registry

BACKGROUND

Hiatal hernia repair is an essential step to reduce the incidence of gastroesophageal acid reflux disease in patients undergoing sleeve gastrectomy. The safety of addition, a hiatal hernia repair to sleeve gastrectomy, is a critical question.

OBJECTIVES

Our study aimed to assess the safety of concurrent hiatal hernia repair and sleeve gastrectomy based on Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data.

SETTING

University health network, United States.

METHODS

This study was a registry-based analysis. Preoperative characteristics and 30-day outcomes from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Files 2015 to 2017 were selected for all patients who underwent sleeve gastrectomy with hiatal hernia repair. Propensity score matching (1:1) was used to control for potential confounding.

RESULTS

A total of 101,902 patients (50,951 patients matched pairs) were included in the study. The groups were closely matched as intended. Sleeve gastrectomy with hiatal hernia repair, compared with sleeve gastrectomy alone, was associated with similar risks of death (.02% versus .02%; relative risk [RR], 1.50; 95% confidence interval [CI], .61-3.67, P = .503), and higher risk of 30-day readmission (4.01% versus 2.96%; RR, 1.35; 95%CI, 1.27-1.45, P < .001), 30-day reoperation (1.10% versus .77%; RR, 1.42; 95% CI, 1.25-1.61, P < .001), 30-day intervention (1.24% versus .95%; RR, 1.31; 95%CI, 1.16-1.47, P < .001), and 30-day morbidity (1.85% versus 1.47%; RR, 1.25; 95%CI, 1.14-1.38, P < .001).

CONCLUSIONS

Sleeve gastrectomy with hiatal hernia repair is relatively safe in the short term with no increase in the risk of mortality. However, this additional procedure slightly increases the risk of readmission, reoperation, and postoperative intervention, as well as morbidity.