Pulmonary embolism and gastrointestinal leak following bariatric surgery: when do major complications occur?

Cumulative Incidence of Venous Thromboembolic Events In-Hospital, and at 1, 3, 6, and 12 Months After Metabolic and Bariatric Surgery: Systematic Review of 87 Studies and Meta-analysis of 2,731,797 Patients

Systematic review/meta-analysis of cumulative incidences of venous thromboembolic events (VTE) after metabolic and bariatric surgery (MBS). Electronic databases were searched for original studies. Proportional meta-analysis assessed cumulative VTE incidences. (PROSPERO ID:CRD42020184529). A total of 3066 records, and 87 studies were included (N patients = 4,991,683). Pooled in-hospital VTE of mainly laparoscopic studies = 0.15% (95% CI = 0.13-0.18%); pooled cumulative incidence increased to 0.50% (95% CI = 0.33-0.70%); 0.51% (95% CI = 0.38-0.65%); 0.72% (95% CI = 0.13-1.52%); 0.78% (95% CI = 0-3.49%) at 30 days and 3, 6, and 12 months, respectively. Studies using predominantly open approach exhibited higher incidence than laparoscopic studies. Within the first month, 60% of VTE occurred after discharge. North American and earlier studies had higher incidence than non-North American and more recent studies. This study is the first to generate detailed estimates of the incidence and patterns of VTE after MBS over time. The incidence of VTE after MBS is low. Improved estimates and time variations of VTE require longer-term designs, non-aggregated reporting of characteristics, and must consider many factors and the use of data registries. Extended surveillance of VTE after MBS is required.

Markers for Major Complications at Day-One Postoperative in Fast-Track Metabolic Surgery: Updated Metabolic Checklist

INTRODUCTION

In fast-track metabolic surgery, the window to identify complications is narrow. Postoperative checklists can be useful tools in the decision-making of safe early discharge. The aim of this study was to evaluate the predictive value of a checklist used in metabolic surgery.

METHODS

Retrospective data from June 2018 to January 2021 was collected on all patients that underwent metabolic surgery in a high-volume bariatric hospital in the Netherlands. Patients without an available checklist were excluded. The primary outcome was major complications and the secondary outcomes were minor complications, readmission, and unplanned hospital visits within 30 days postoperatively.

RESULTS

Major complications within 30 days postoperatively occurred in 62/1589 (3.9%) of the total included patients. An advise against early discharge was significantly more seen in patients with major complications compared to those without major complications (90.3% versus 48.1%, P < 0.001, respectively), and a negative checklist (advice for discharge) had a negative predictive value of 99.2%. The area under the curve for the total checklist was 0.80 (P < 0.001). Using a cut-off value of ≥3 positive points, the sensitivity and specificity were 65% and 82%, respectively. Individual parameters from the checklist: oral intake, mobilization, calf pain, willingness for discharge, heart rate, drain (>30 ml/24 h), hemoglobin, and leukocytes count were also significantly different between groups.

CONCLUSION

This checklist is a valuable tool to decide whether patients can be safely discharged early. Heart rate appeared to be the most predictive parameter for the development of major complications. Future studies should conduct prediction models to identify patients at risk for major complications.

When do leaks occur? An analysis of the metabolic and bariatric surgery accreditation and quality improvement program

BACKGROUND

Leak is a feared complication of bariatric surgeries. Time to presentation is important in their management. We used the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) to evaluate the rate and timing of leaks.

OBJECTIVES

To determine when leaks present after bariatric surgery.

SETTING

MBSAQIP database.

METHODS

The MBSAQIP Participant Use Files (PUF) for the years 2015-2020 were evaluated. Outcomes of interest were "organ space infection" and "leak." We evaluated the time to presentation for these variables as well as patient characteristics, operative time, complication rates and 30-day outcomes.

RESULTS

There were 370,369 sleeve gastrectomies (SG) and 159,280 Roux-en-Y gastric bypasses (RYGB). We identified 598 (.16%) SG leaks with an average time to presentation of 13.2 ± 7.8 days. For RYGB, there were 520 leaks (.32%) with an average time to presentation of 9.5 ± 7.4 days. Both procedures had longer operative times for the patients with leak; RYGB was 115 minutes versus 131 minutes and SG was 67 minutes versus 77 minutes (both P < .01). SG and RYGB patients with a leak had a higher relative risk (RR) of grade 4 and 5 Clavien-Dindo complication rates. RR of mortality rates in SG patients with leak was 35.2 (confidence interval (CI): 20-61) and in RYGB with leak was 31.4 (CI: 19-50).

CONCLUSIONS

The length of time for SG leak presentation was more delayed than RYGB leak presentation. Surgeons should be vigilant for leaks for at least 3 weeks after surgery. Leaks increase the mortality rate and overall serious complications.

Timing of symptomatic venous thromboembolism after surgery: meta-analysis

BACKGROUND

The timing at which venous thromboembolism (VTE) occurs after major surgery has major implications for the optimal duration of thromboprophylaxis. The aim of this study was to perform a systematic review and meta-analysis of the timing of postoperative VTE up to 4 weeks after surgery.

METHODS

A systematic search of MEDLINE, Scopus, and CINAHL databases was performed between 1 January 2009 and 1 April 2022. Prospective studies that recruited patients who underwent a surgical procedure and reported at least 20 symptomatic, postoperative VTE events by time were included. Two reviewers independently selected studies according to the eligibility criteria, extracted data, and evaluated risk of bias. Data were analysed with a Poisson regression model, and the GRADE approach was used to rate the certainty of evidence.

RESULTS

Some 6258 studies were evaluated, of which 22 (11 general, 5 urological, 4 mixed, and 2 orthopaedic postoperative surgical populations; total 1 864 875 patients and 24 927 VTE events) were eligible. Pooled evidence of moderate certainty showed that 47.1 per cent of the VTE events occurred during the first, 26.9 per cent during the second, 15.8 per cent during the third, and 10.1 per cent during the fourth week after surgery. The timing of VTE was consistent between individual studies.

CONCLUSION

Although nearly half of symptomatic VTE events in first 4 weeks occur during the first postoperative week, a substantial number of events occur several weeks after surgery. These data will inform clinicians and guideline developers about the duration of postoperative thromboprophylaxis.

Robotic vs laparoscopic approach for single anastomosis duodenal-ileal bypass with sleeve gastrectomy: a propensity score matching analysis

Biliopancreatic diversion with duodenal switch and single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) are technically demanding hypo-absorptive bariatric procedures. They are often indicated in superobese patients (BMI ≥ 50 kg/m²), as robotic platform could improve ergonomics against a thick abdominal wall, preventing bending of instruments and simplifying hand-sewn anastomoses. We aimed to report our experience with robotic SADI-S (R-group) and to compare outcomes with the laparoscopic (L-group) approach. Among 2143 patients who underwent bariatric procedures at our institution between July 2016 and June 2021, 116 (5.4%) consenting patients were scheduled for SADI-S as primary or revisional procedure: 94 L-group, 22 R-group. R-group and L-group patients were matched using PSM analysis to overcome patients selection bias. Postoperative complications, operative time (OT), post-operative stay (POS) and follow-up data were compared. After PSM, 44 patients (22 patients for each group) were compared (Chi-square 0.317, p = 0.985). Median age, gender, median BMI, preoperative rates of comorbidities, previous abdominal bariatric and non-bariatric surgeries and type of surgical procedures (SADI-S/SADI) were comparable. Median OT was shorter in the L-group (130 Vs 191 min, p < 0.001). 30-days' re-operative complications and late complications rates were comparable. At 25-months' mean follow-up, the median Percentage Excess Weight Loss (72%) was comparable between the groups (p = 0.989). L-group and R-group were comparable in terms of re-operative complication rate and short-term outcomes. The robotic platform may increase the rate of single step procedure in challenging cases. Larger studies with longer follow-up and cost-analysis are necessary to draw definitive conclusions.

Venous thromboembolism: risk factors in the sleeve gastrectomy era

BACKGROUND

Of complications after bariatric surgery, venous thromboembolism (VTE) has the greatest impact on mortality.

OBJECTIVES

To examine risk factors for postoperative VTE and identify high-risk patients who may benefit from prolonged prophylaxis.

SETTING

National Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database METHODS: Patients who underwent primary, laparoscopic bariatric surgery 2015-2019 were identified. Risk factors were sex, age, body mass index (BMI), history of VTE, immobility, venous stasis disease, operative time greater >3 hours, and procedure type. Multivariable logistic regression was used to examine associations between factors and the outcome of postoperative VTE. We examined contributions of each factor through average marginal effects and E-values. We added Black versus White race to the same regression model to understand whether race acted as a moderating factor.

RESULTS

In our study, 1677 of 605,782 (.28%) patients experienced postoperative VTE. On multivariable analysis, previous history of VTE had the greatest association, increasing risk of postoperative VTE by +.90% points (95% CI [confidence interval] +.73% to +1.07%). Lower-95% CI E-value bounds were 1.43 for men, 1.11 preoperative BMI, 7.38 history of VTE, and 2.15 operative length >3 hours. Black patients had an additional +.18% (95% CI +.14 to +.22%) risk of postoperative VTE, corresponding to a lower E-value bound of 2.50.

CONCLUSION

In this study using recent years' national bariatric surgery data, we find history of VTE is the greatest driver of postoperative VTE. Most importantly, Black patients are more likely to suffer postoperative VTE. Now is the time to use the power of quality improvement programs to ensure health equity for all our patients.

Postoperative Remote Monitoring with a Transcutaneous Biosensing Patch: Preliminary Evaluation of Data Collection

Introduction. Connected systems transmitting vital parameters could well represent a tool to shorten postoperative hospital stay while providing continuous remote patient monitoring and potentially detect the onset of complications. Our aim was to analyze the functionality of a transcutaneous biosensing data collection patch in morbidly obese patients. Materials and Methods. An adhesive patch (The HealthPatch MD™) was applied to patients' chests postoperatively. The patch was connected to a tablet via a bluetooth network to collect the heart rate, respiratory rate, skin temperature, and posture recognition data. The tablet conveyed data to a secure health data central server by means of a WiFi or 3G/4G transmission. Data were stored in a digital health platform to which health care professionals could connect. The evaluation focused on the volume, quality, and security of data transmission. A pilot phase involved 10 patients. Thirty-three additional patients undergoing bariatric surgery were included in the experimental phase. Results. The mean length of stay was 2.28 days (range: 2-5 days). The mean time of patch application was 51 ± 25.2 hours per patient (range: 19-139 hours), totalizing 1,683 hours of recording for the 33 patients included. During this time, a total of 7.562.531 data measurement points were collected and transmitted to the e-health platform via the patch. Two total disconnections and two partial disconnections were observed. The acquisition of patient postural data was unreliable. Conclusions. Connected telemetry for remote postoperative monitoring is promising. However, it is still limited by data transmission problems.

Early Routine Upper Gastrointestinal Contrast Study Following Bariatric Surgery: an Indispensable Postoperative Care or a Medicolegal Heritage?

Concerns still exist regarding the role of early routine upper gastrointestinal contrast study (UGI) after bariatric procedures for detection of early complications. We reviewed our database to identify patients who underwent laparoscopic primary or redo surgery (previously placement of adjustable gastric banding), between January 2012 and December 2017. All the patients underwent UGI within 48 h after surgery. Among 1094 patients, early UGI was abnormal in 5 patients: in 4 cases a leak (one false positive) and in one case stenosis (one true positive) were suspected. In this clinical setting, five leaks were observed and required surgical re-exploration: 3 correctly identified and 2 not detected at UGI. Overall, 3 patients developed anastomotic stenosis. Our data suggest that early routine UGI after bariatric procedures has limited utility.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

The effect of fibrin glue in preventing staple-line leak after sleeve gastrectomy. An experimental study in rats

Purpose

To evaluate the effect of fibrin glue on staple-line leak after sleeve gastrectomy.

Methods

Fourteen adult wistar rats 300 gr were randomized into two groups: Control group (n=7) and study group (n=7). All the rats underwent sleeve gastrectomy using lineer stapler. In the study group, fibrin glue was used to reinforce the staple-line. The rats were sacrificed 7 days after surgery. The stomach was resected, submerged in saline and exposed to excess pressure to obtain a burst pressure value. The gastric staple line was evaluated histopathologically according to the Ehrlich Hunt scale. The results of the two groups were compared.

Results

The mean Ehrlich-Hunt scores for inflammation, fibroblastic activity and neo-angiogenesis were similar between the groups (p>0.05). Collagen deposition was significantly higher in study group (3.42±0.53) when compared with control group (2.57±0.78) (p=0.035). The mean burst pressure was 137.8±8.5 mmHg for control group and 135.0±8.1 mmHg for study group (p=0.536).

Conclusion

Reinforcement of the staple-line with fibrin glue has no effect on the burst pressure after sleeve gastrectomy. More studies are needed to evaluate the precautions against leak after sleeve gastrectomy.

The Birmingham experience of high-pressure methylene blue dye test during primary and revisional bariatric surgery: A retrospective cohort study

INTRODUCTION

Leak following bariatric surgery continues to be associated with morbidity and rarely mortality. With improvement in surgical techniques and stapler design, leak rates have reduced drastically. Intra-operative high pressure Methylene blue leak test (HPMB) is one of the techniques employed to confirm integrity of anastomoses and staple lines. Despite this, evidence for its use remains limited. We evaluated the role of HPMB in detecting and preventing leaks.

METHODS

A retrospective cohort of consecutive patients who underwent primary or revisional Laparoscopic Sleeve Gastrectomy (SG) or Laparoscopic Roux-en-Y Gastric bypass (RYGB) under the care of five surgeons in three centres across Birmingham, UK, between 2012 and 2016 were assessed. All patients had routine HPMB at the end of the procedure. Demographics, HPMB positivity, and post operative leaks were recorded.

RESULTS

924 patients underwent bariatric surgery: 696(75.3%) RYGB, and 225(24.3%) SG. 85(9.2%) were revisional procedures. Two HPMB were positive, which necessitated staple or suture line reinforcement with sutures intra-operatively. The patients had an uneventful recovery. 5 patients had postoperative leaks, all of whom had negative intraoperative HPMB: 3 SG patients; and 2 RYGB patients (gastro-jejunostomy anastomotic leaks). There was no statistically significant relationship between positive HPMB and anastomotic leak (Fishers exact test; p = 1).

CONCLUSION

Despite routine use of methylene blue dye test in 924 patients, there were only two positive tests. Whilst HPMB may demonstrate technical failure, this study suggests that there is no role for its routine use in primary bariatric surgery. Discontinuation of this practice would reduce risk of anaphylaxis to the dye, cost, and intra-operative time.

Preventing Returns to the Emergency Department FollowingBariatric Surgery

BACKGROUND

Unnecessary emergency department (ED) visits following bariatric surgery represent a significant source of inefficient resource utilization. This study aimed to identify potential strategies aimed at preventing unnecessary returns to the ED following bariatric surgery. The study was conducted in University Hospital, USA.

METHODS

The electronic medical records of all patients who underwent bariatric surgery at our institution between January 2011 and October 2015 were retrospectively reviewed. Information regarding procedure, gender, age, preoperative BMI, obesity-related comorbid conditions, postoperative length of stay (LOS), and reasons for ED visits within 90 days of surgery were obtained. Six practitioners (four attending surgeons, one resident physician, and one physician assistant) independently reviewed patient chief complaint and clinical findings at the time of ED returns. Reasons for ED return were scored as either preventable or non-preventable. "Preventable" denoted that an ED return could potentially be avoided by means of a system change in our bariatric practice.

RESULTS

Our institution performed 361 bariatric procedures during the study period. Of these, 65 patients had 91 ED visits, 23 of which resulted in readmissions, and two of which required operative interventions. The ≤90-day all-cause postoperative ED visit rate was 18% (n = 65). Of the 91 ED visits, 47% were deemed preventable (n = 43). The most common preventable reasons for ED returns were nausea, vomiting, dehydration (NVD) (27.9%), postoperative pain (25.6%), wound evaluations (20.9%), and compliance issues (14%).

CONCLUSIONS

Postoperative ED visits following bariatric surgery are prevalent and costly. Many of these visits are potentially preventable. Implementing outpatient strategies to address these causes will likely attenuate inefficient resource utilization.

Outcomes after bariatric surgery according to large databases: a systematic review

PURPOSE

The rapid development of technological tools to record data allows storage of enormous datasets, often termed "big data". In the USA, three large databases have been developed to store data regarding surgical outcomes: the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). We aimed to evaluate the clinical impact of studies found in these databases concerning outcomes of bariatric surgery.

METHODS

We performed a systematic review using the Meta-analysis of Observational Studies in Epidemiology guidelines. Research carried out using the PubMed database identified 362 papers. All outcomes related to bariatric surgery were analysed.

RESULTS

Fifty-four studies, published between 2005 and February 2017, were included. These articles were divided into (1) outcomes related to surgical techniques (12 articles), (2) morbidity and mortality (12), (3) 30-day hospital readmission (10), (4) outcomes related to specific diseases (11), (5) training (2) and (6) socio-economic and ethnic observations in bariatric surgery (7). Forty-two papers were based on data from ACS-NSQIP, nine on data from NIS and three on data from MBSAQIP.

CONCLUSIONS

This review provides an overview of surgical management and outcomes of bariatric surgery in the USA. Large databases offer useful complementary information that could be considered external validation when strong evidence-based medicine data are lacking. They also allow us to evaluate infrequent situations for which randomized control trials are not feasible and add specific information that can complement the quality of surgical knowledge.

Effect of Incentive Spirometry on Postoperative Hypoxemia and Pulmonary Complications After Bariatric Surgery: A Randomized Clinical Trial

Importance

The combination of obesity and foregut surgery puts patients undergoing bariatric surgery at high risk for postoperative pulmonary complications. Postoperative incentive spirometry (IS) is a ubiquitous practice; however, little evidence exists on its effectiveness.

Objective

To determine the effect of postoperative IS on hypoxemia, arterial oxygen saturation (Sao2) level, and pulmonary complications after bariatric surgery.

Design, Setting, and Participants

A randomized noninferiority clinical trial enrolled patients undergoing bariatric surgery from May 1, 2015, to June 30, 2016. Patients were randomized to postoperative IS (control group) or clinical observation (test group) at a single-center tertiary referral teaching hospital. Analysis was based on the evaluable population.

Interventions

The controls received the standard of care with IS use 10 times every hour while awake. The test group did not receive an IS device or these orders.

Main Outcomes and Measures

The primary outcome was frequency of hypoxemia, defined as an Sao2 level of less than 92% without supplementation at 6, 12, and 24 postoperative hours. Secondary outcomes were Sao2 levels at these times and the rate of 30-day postoperative pulmonary complications.

Results

A total of 224 patients (50 men [22.3%] and 174 women [77.7%]; mean [SD] age, 45.6 [11.8] years) were enrolled, and 112 were randomized for each group. Baseline characteristics of the groups were similar. No significant differences in frequency of postoperative hypoxemia between the control and test groups were found at 6 (11.9% vs 10.4%; P = .72), 12 (5.4% vs 8.2%; P = .40), or 24 (3.7% vs 4.6%; P = .73) postoperative hours. No significant differences were observed in mean (SD) Sao2 level between the control and test groups at 6 (94.9% [3.2%] vs 94.9% [2.9%]; P = .99), 12 (95.4% [2.2%] vs 95.1% [2.5%]; P = .40), or 24 (95.7% [2.4%] vs 95.6% [2.4%]; P = .69) postoperative hours. Rates of 30-day postoperative pulmonary complications did not differ between groups (8 patients [7.1%] in the control group vs 4 [3.6%] in the test group; P = .24).

Conclusions and Relevance

Postoperative IS did not demonstrate any effect on postoperative hypoxemia, Sao2 level, or postoperative pulmonary complications. Based on these findings, the routine use of IS is not recommended after bariatric surgery in its current implementation.

Trial Registration

clinicaltrials.gov Identifier: NCT02431455.