Importance of hospital versus surgeon volume in predicting outcomes for gastric bypass procedures

Black-vs-white racial disparities in 30-day outcomes following primary and revisional metabolic and bariatric surgery: a MBSAQIP database analysis

BACKGROUND

Previous studies have demonstrated Black-vs-White disparities in postoperative outcomes following primary metabolic and bariatric surgery (MBS). With the rising prevalence of MBS, it is important to examine racial disparities using quality indicators in primary and revisional procedures. This study explores Black-vs-White disparities in postoperative outcomes following primary and revisional MBS.

METHODS

We performed an observational cohort study using the 2015-2020 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database of adults who underwent primary or revisional Roux-en-Y gastric bypass, sleeve gastrectomy, duodenal switch, or one-anastomosis gastric bypass. Black and White patients were 1:1 matched using propensity scores across 19 covariates for primary and revisional MBS groups. McNemar's tests were used to compare 11 postoperative outcomes from the MBSAQIP semi-annual report and death, between matched cohorts.

RESULTS

We identified 112,495 Black and 434,266 White primary MBS and 10,838 Black and 37,075 White revisional MBS patients. A total of 219,114 primary and 21,314 revisional patients were matched. Following primary MBS, Black patients had higher rates of death (0.1% vs. 0.06%, p < 0.001), all occurrences morbidity (5.6% vs. 4.7%, p < 0.001), serious events (2.2% vs. 1.9%, p < 0.001), and all cause and related reoperations (1.2% vs. 1.1%, p = 0.006; 0.2% vs. 0.1%, p = 0.01), readmissions (4.6% vs. 3.4%, p < 0.001; 2.8% vs. 1.9%, p < 0.001), and interventions (1.4% vs. 1.1%, p < 0.001; 0.8% vs. 0.6%, p < 0.001) compared to White patients. In contrast, there were no significant Black-vs-White disparities in death, morbidity, serious events, reoperations, interventions, and bleeding following revisional MBS. Interestingly, Black patients had higher rates of all cause and related readmissions (7.4% vs. 6.2%, p = 0.005; 4.4% vs. 3.6%, p = 0.01), but lower surgical site infection rates (1.6% vs. 2.1%, p = 0.04).

CONCLUSIONS

Our findings demonstrate a measurable contrast between racial disparities in postoperative outcomes following primary and revisional MBS. Equity-focused measures in national MBS assessments are needed to elucidate and address these disparities.

Roux-en-Y gastric bypass and sleeve gastrectomy as revisional bariatric procedures after adjustable gastric banding: a retrospective cohort study

INTRODUCTION

The frequency of revisional bariatric surgery is increasing, but its effectiveness and safety are not yet fully established. The aim of our study was to compare short-term outcomes of primary (pRYGB and pSG) and revisional bariatric surgeries (rRYGB and rSG).

METHODS

We performed a retrospective cohort study assessing all patients submitted to primary and revisional (after a failed AGB) RYGB and SG in 2019. Each patient was followed-up at 6 months and 12 months after surgery. We compared pRYGB vs. rRYGB, pSG vs. rSG and rRYGB vs. rSG on weight loss, surgical complications, and resolution of comorbidities.

RESULTS

We assessed 494 patients, of which 18.8% had undergone a revisional procedure. Higher weight loss at 6 and 12 months was observed in patients undergoing primary vs. revisional procedures. Patients submitted to rRYGB lost more weight than those with rSG (%EWL 12 months = 82.6% vs. 69.0%, p < 0.001). Regarding the resolution of obesity-related comorbidities, diabetes resolution was more frequent in pRYGB than rRYGB (54.2% vs. 25.0%; p = 0.038). Also, 41.7% of the patients who underwent rRYGB had dyslipidemia resolution vs. 0% from the rSG group (p = 0.035). Dyslipidemia resolution was also more common in pSG vs. rSG (68.6% vs. 0.0%; p = 0.001). No significant differences in surgical complications were found.

CONCLUSION

Revisional bariatric surgery is effective and safe treating obesity and related comorbidities after AGB. Primary procedures appear to be associated with better weight loss outcomes. Further prospective studies are needed to better understand the role of revisional bariatric surgery.

Volume creates value: The volume-outcome relationship in Scandinavian obesity surgery

This study establishes the relationship between surgical volume and cost and quality outcomes, using patient-level clinical data from a national quality registry for bariatric surgery in Sweden. Data include patient characteristics with comorbidities, surgical and follow-up data for patients that underwent gastric bypass or gastric sleeve operations between 2007 and 2016 (52,703 patients in 51 hospitals). The relationships between surgical volume (annual number of bariatric procedures) and several patient-level outcomes were assessed using multilevel, mixed-effect regression models, controlling for patient characteristics and comorbidities. We found that hospitals with higher volumes had lower risk of intraoperative complications as well as complications within 30 days post-surgery (odds ratios per 100 procedures are 0.78 and 0.87, respectively, p<0.01). In addition, higher-volume hospitals had substantially shorter procedure time (17 min per 100 procedures, p<0.01) and length of stay (0.88 incidence-rate ratio per 100 procedures p<0.01). Our results support the claim that increased surgical volume significantly improves quality. Further, the results strongly suggest that increased volume leads to lower cost per surgery, by reducing cost drivers such as procedure time and length of stay.

Hospital Variation in Preference for a Specific Bariatric Procedure and the Association with Weight Loss Performance: a Nationwide Analysis

PURPOSE

Hospitals performing a certain bariatric procedure in high volumes may have better outcomes. However, they could also have worse outcomes for some patients who are better off receiving another procedure. This study evaluates the effect of hospital preference for a specific type of bariatric procedure on their overall weight loss results.

METHODS

All hospitals performing bariatric surgery were included from the nationwide Dutch Audit for Treatment of Obesity. For each hospital, the expected (E) numbers of sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and one-anastomosis gastric bypass (OAGB) were calculated given their patient-mix. These were compared with the observed (O) numbers as the O/E ratio in a funnel plot. The 95% control intervals were used to identify outlier hospitals performing a certain procedure significantly more often than expected given their patient-mix (defined as hospital preference for that procedure). Similarly, funnel plots were created for the outcome of patients achieving ≥ 25% total weight loss (TWL) after 2 years, which was linked to each hospital's preference.

RESULTS

A total of 34,558 patients were included, with 23,154 patients completing a 2-year follow-up, of whom 79.6% achieved ≥ 25%TWL. Nine hospitals had a preference for RYGB (range O/E ratio [1.09-1.53]), with 1 having significantly more patients achieving ≥ 25%TWL (O/E ratio [1.06]). Of 6 hospitals with a preference for SG (range O/E ratio [1.10-2.71]), one hospital had significantly fewer patients achieving ≥ 25%TWL (O/E ratio [0.90]), and from two hospitals with a preference for OAGB (range O/E ratio [4.0-6.0]), one had significantly more patients achieving ≥ 25%TWL (O/E ratio [1.07]). One hospital had no preference for any procedure but did have significantly more patients achieving ≥ 25%TWL (O/E ratio [1.10]).

CONCLUSION

Hospital preference is not consistently associated with better overall weight loss results. This suggests that even though experience with a procedure may be slightly less in hospitals not having a preference, it is still sufficient to achieve similar weight loss outcomes when surgery is provided in centralized high-volume bariatric institutions.

Bariatric Center Designation and Outcomes Following Repeat Abdominal Surgery in Bariatric Patients

INTRODUCTION

Repeat abdominal surgery in the bariatric surgery patient population may be challenging for non-bariatric-accredited institutions. The impact of regionalized bariatric care on clinical outcomes for bariatric surgery patients requiring repeat abdominal surgery is currently unknown. This study aims to investigate the association between bariatric center designation and clinical outcomes following hepatobiliary, hernia, and upper and lower gastrointestinal operations among patients with prior bariatric surgery.

METHODS

This is a cohort study of a large sample of Ontario residents who underwent primary bariatric surgery between 2010 and 2017. A comprehensive list of eligible abdominal operations was captured using administrative data. The primary outcome was 30-d complications. Secondary outcomes included 30-d mortality, readmission, and length of stay.

RESULTS

Among the 3301 study patients, 1305 (40%) received their first abdominal reoperation following bariatric surgery at a designated bariatric center. Nonbariatric center designation was not associated with significantly higher rates of 30-d complications (5.73% versus 5.72%), mortality (0.80% versus 0.77%), readmissions (1.11% versus 1.85%), or median postoperative length of stay (4 versus 4 d). After grouping the category of reoperations, upper gastrointestinal (odds ratio [OR] 0.66, confidence interval [CI] 0.39-1.11) and abdominal wall hernia surgery (OR 0.52, CI 0.27-0.99) showed a lower adjusted OR for complications among bariatric centers.

CONCLUSIONS

Our study demonstrates that after adjustment for case-mix and patient characteristics, bariatric surgery patients undergoing repeat abdominal surgery at nonbariatric centers is not associated with higher proportion of complications or mortality. Complex hernia surgery may be considered the most appropriate for referral.

Patient Risk Factors Associated with Increased Morbidity and Mortality Following Revisional Laparoscopic Bariatric Surgery for Inadequate Weight Loss or Weight Recidivism: an Analysis of the ACS-MBSAQIP Database

PURPOSE

Revisional bariatric operations are associated with increased morbidity and mortality compared with primary bariatric operations. The purpose of this study was to determine if preoperative patient variables are associated with an increased risk of 30-day morbidity and mortality following revisional laparoscopic bariatric surgery for inadequate weight loss or weight recidivism and to generate expected model probabilities in order to risk stratify individual patients undergoing these operations.

MATERIALS AND METHODS

All patients undergoing revisional laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) from 2015 to 2016 were identified with the American College of Surgeons Metabolic and Bariatric Surgery Quality Improvement Program (ACS-MBSAQIP) database. The association of preoperative patient variables with 30-day morbidity and mortality was investigated using multivariable logistic regression analysis. Predictive outcome models were developed for each outcome of interest.

RESULTS

A total of 13,551 patients met inclusion criteria; 5310 (39.2%) underwent revisional RYGB. Each of the available preoperative variables was associated with one or more of the 30-day morbidity and mortality outcomes of interest. The strength of the predictive models, as reflected by the area under the curve, ranged from 0.63 for 30-day unplanned hospital readmission to 0.92 for cardiac events.

CONCLUSION

Preoperative patient and surgical variables are associated with an increased risk of 30-day morbidity and mortality following laparoscopic revisional bariatric surgery. With these results, we have built a risk calculator that can be used as a resource for prehabilitation and patient counseling prior to revisional bariatric surgery.

Revisional Roux-en-Y Gastric Bypass: a Safe Surgical Opportunity? Results of a Case-Matched Study

OBJECTIVE

To evaluate the safety and efficacy of revisional Roux-en-Y gastric bypass (RYGB) after adjustable gastric banding (AGB) or sleeve gastrectomy (SG) compared with primary RYGB, in regard to early and late morbidity, weight, and resolution of obesity-related comorbidities.

METHODS

The group of patients undergoing revisional RYGB was matched in a 1:1 ratio with control patient who underwent a primary RYGB, based on age, gender, American Society of Anesthesiologist (ASA) score, preoperative body mass index (BMI), and diabetes mellitus. Demographics, anthropometrics, preoperative work-up, and perioperative data were retrieved.

RESULTS

One hundred fifteen patients (16 males and 99 females) with a mean age of 45.5 ± 1.5 years underwent revisional RYGB following either LAGB in 82 patients (71.3%) or laparoscopic sleeve gastrectomy (LSG) in 33 patients (28.7%). There was no conversion and no mortality in either group. Revisional RYGB was associated with similar early (16.5 vs 15.6%, ns) and late (42.6% vs 32.2%, ns) morbidity rates with a mean follow-up of 25.3 ± 16.6 months compared to primary laparoscopic Roux-en-Y gastric bypass. The revisional RYGB group had significantly less weight loss (mean %EWL 67.4 ± 20.7 vs 72.7 ± 22.9, p = 0.023 and mean %EBMI 68.1 ± 22 vs 78.3 ± 25.7, p = 0.01) at the time of 1 year. Improvement of comorbidities including hypertension (62.5 vs 70.5%; p > 0.05), diabetes (73.7 vs 79%; p > 0.05), and obstructive sleep apnea syndrome (100 vs 97%; p > 0.05) was similar.

CONCLUSION

This large case-matched study suggests that conversion of SG or AGB to RYGB is feasible with early and late comparable morbidity in an accredited center; even weight results might be inferior.

30-Day Outcomes of Revisional Bariatric Stapling Procedures: First Report Based on MBSAQIP Data Registry

INTRODUCTION

The number of bariatric revisional cases has nearly doubled since 2011, and now comprises 13.6% of the total number of cases. The objective of this study is to evaluate the outcomes and safety of the two most common stapling revisional procedures, namely, sleeve and gastric bypass in comparison to primary stapling procedures using the MBSAQIP data registry.

METHODS

We reviewed all the sleeve and gastric bypass cases entered between January 1, 2015, and December 31, 2015, in the MBSAQIP data registry. We, then, identified sleeve and bypass patients who have had a previous bariatric procedure. Demographics and 30 day outcomes of all sleeve and gastric bypass patients were analyzed. We conducted within group comparisons comparing primary sleeve gastrectomy (PS) and primary gastric bypass (PB) patients to revisional sleeve (RS) and revisional gastric bypass (RB) patients, respectively. We, then, conducted group comparisons comparing RS to RB patients.

RESULTS

The total number of patients analyzed was 141,577 (98,292 or 69% sleeve patients and 43,285 or 31% gastric bypass patients). Among the sleeve patients, 92,666 (94%) had a PS and 5626 (6%) had RS. Among the bypass patients, 39,567 (91%) had a PB and 3718 patients (9%) had RB. 30-day readmission rate of RS was significantly higher as compared to PS (4.1 vs 0.4%, p < 0.05). The incidence of at least one complication requiring reoperation or reintervention within 30 days following RS was twice as high as compared to PS (1.9 and 2% for RS vs 0.9 and 1.1% for PS respectively, p < 0.05). Length of stay and 30 day mortality rates for PS and RS were the same. 30-day readmission rate of RB as compared to PB was 8.3 vs 6.3% (p < 0.05). Also, the incidence of at least one complication requiring reoperation or reintervention following RB was 3.9 and 4%, respectively vs 2.4 and 2.7% for PB (p < 0.05). In addition, readmission rates and unplanned admission rates to the ICU were significantly higher for RB compared to RS (8.3 and 2% for RB vs 4.1 and 0.9% for RS respectively, p < 0.05). The incidence of at least one reoperation or one intervention following RB were also significantly higher compared to RS (3.9 vs 1.9% and 4 vs 2% respectively, p < 0.05).

CONCLUSION

Revisional stapling procedures are safe but the rates of complications following RS and RB are twice as high compared to PS and PB. Also, RB are more likely to develop complications compared to RS.

A novel risk prediction model for 30-day severe adverse events and readmissions following bariatric surgery based on the MBSAQIP database

BACKGROUND

Although bariatric surgery is safe, some patients fear serious complications.

OBJECTIVES

This retrospective study used the 2015 Metabolic and Bariatric Surgery Accreditation Quality Improvement Project (MBSAQIP) database to evaluate patient outcomes for gastric bypass (GB) and sleeve gastrectomy and to develop a risk prediction model for serious adverse events (SAEs) and readmission rates 30 days after surgery.

SETTING

MBSAQIP national patient database.

METHODS

We created separate exploratory multivariable logistic regression models for SAEs and readmissions. We then externally validated both models using the 2016 MBSAQIP Participant Use Data File.

RESULTS

Significant predictors of SAEs were preoperative body mass index (adjusted odds ratio [AOR] 1.07, P < .0001); GB surgery (AOR 2.08, P < .0001); cardiovascular disease (AOR 1.43, P < .0001); smoking (AOR 1.12, P = .04); diabetes (AOR 1.15, P = .0001); hypertension (AOR 1.17, P < .0001); limited ambulation (AOR 1.48, P < .0001); sleep apnea (AOR 1.12, P = .001); history of pulmonary embolism (AOR 2.81, P < .0001); and steroid use (AOR 1.40, P = .001). Significant predictors of readmissions were GB surgery (AOR 1.81, P < .0001); female sex (AOR 1.26, P < .0001); diabetes (AOR 1.08, P = .04); hypertension (AOR 1.11, P = .004); preoperative body mass index (AOR 1.05, P < .0001); sleep apnea (AOR 1.11, P = .002); history of pulmonary embolism (AOR 2.35, P < .0001); cardiovascular disease (AOR 1.61, P < .0001); smoking (AOR 1.14, P = .01); and limited ambulation (AOR 1.55, P < .0001). External validation supported these covariates, with similar model discriminative power.

CONCLUSIONS

Our exploratory regression models may be used by clinicians to counsel patients about surgical risks, although future external validation should occur in non-North American populations.