Evaluation of the obesity surgery mortality risk score for the prediction of postoperative complications after primary and revisional laparoscopic Roux-en-Y gastric bypass

Preoperative risk factors for early postoperative bleeding after Roux-en-Y gastric bypass surgery: a systematic review and meta-analysis

PURPOSE

Although bariatric surgery is an effective intervention for obesity, it comes with risks such as early postoperative bleeding (EPB). Identifying preoperative risk factors for this complication can help patients' risk stratification and optimization. We performed a systematic review and meta-analysis to find predictors for early postoperative bleeding after Roux-en-Y gastric bypass (RYGB).

METHODS

We conducted a systematic review, searching PubMed, Cochrane Library, and Web of Science until November 2023. We performed a random-effects meta-analysis to explore preoperative risk factors associated with early postoperative bleeding after RYGB. Sources of heterogeneity were explored by leave-one-out analyses.

RESULTS

23 studies were included, comprising 232,488 patients. Male gender (meta-analytical RR = 1.42, 95%CI = 1.21-1.66, I2 = 18%, Q Cochran test p-value = 0.29) and revisional surgery (meta-analytical RR = 1.35, 95%CI = 1.12-1.62, I2 = 22%, Q Cochran test p = 0.21) were associated with higher risk of EPB. On average, patients with EPB were older than the remainder (MD for the mean age = 2.82 years, 95%CI = 0.97-4.67, I2 = 0.00%, Q Cochran test p = 0.46). Except for hypertension (meta-analytical RR = 1.33, 95%CI = 1.02-1.73, I2 = 66%, Q Cochran test p < 0.0001), comorbidities were not associated with a higher risk of EPB.

CONCLUSION

Preoperative risk factors, including age, gender, hypertension, and revisional bariatric surgery, are associated with early postoperative bleeding after RYGB. Further primary studies, with higher methodological quality, are required to detail more risk factors.

Effect of Preoperative Weight Loss and Baseline Comorbidity on Short-Term Complications and Reoperations After Laparoscopic Roux-en-Y Gastric Bypass in 2,067 Patients

PURPOSE

Decreasing popularity of Roux-en-Y gastric bypass (RYGB) in bariatric-metabolic surgery may be due to higher perceived peri-operative complications. There are few studies on whether preoperative weight loss can reduce complications or reoperations following RYGB. We investigated this using a standardised operative technique.

MATERIALS AND METHODS

Retrospective single-centre study of RYGB from 2004 to 2019 using a prospective database. Preoperative behavioural management included intentional weight loss. Maximum preoperative weight, weight on the day of operation, and Obesity-Surgery Mortality Risk Score (OS-MRS) class were recorded. Short-term outcomes (post-operative stay, 30-day complication and reoperation rates) were analysed.

RESULTS

In 2,067 RYGB patients (1,901 primary and 166 revisional), median preoperative total body weight loss (TWL) was 6.2% (IQR: 2.5-10.7%). The median age was 46 (interquartile range (IQR) 38-54) and 80.4% were female (n=1,661). For primary surgery, the median body mass index (BMI) was 47.6 kg/m² (IQR: 43.1-53.3). Excluding the 100-procedure learning curve, the complication rate for primary cases was 4.4% and reoperation rate of 2.8% and one peri-operative mortality (0.06%). OS-MRS ≥2 (class B or C) predicted higher risk of complications (6.1%) compared to those with a score <2 (class A) (3.8%, p=0.021), but not reoperations. Five percent preoperative TWL did not decrease complications compared to <5% TWL. Patients with ≥10% TWL had greater baseline risk and had an increased risk of complications (6.6% vs 3.7%, p=0.017) and reoperations (4.5% vs 2.7%, p<0.001).

CONCLUSIONS

RYGB performed using a standardised technique has low overall risk. The influence of preoperative weight loss on outcomes was inconsistent.

A Clinical Decision Support System for Predicting the Early Complications of One-Anastomosis Gastric Bypass Surgery

BACKGROUND/OBJECTIVE

One of the most effective treatments for patients with obesity, albeit with some complications, is obesity surgery. The aim of this study was to develop a clinical decision support system (CDSS) to predict the early complications of one-anastomosis gastric bypass (OAGB) surgery.

SUBJECTS/METHODS

This study was conducted in Tehran, Iran on patients who underwent OAGB surgery in 2011-2014 in five hospitals. Initially, variables affecting the OAGB early complications were identified using the literature review. Patients' data were extracted from an existing database of obesity surgery. Then, different artificial neural networks (ANNs) (multilayer perceptron (MLP) network) were developed and evaluated for prediction of 10-day, 1-month, and 3-month complications.

RESULTS

Factors including age, BMI, smoking status, intra-operative complications, comorbidities, laboratory tests, sonography results, and endoscopy results were considered important factors for predicting early complications of OAGB. A CDSS was developed with these variables. The accuracy, specificity, and sensitivity of the 10-day prediction system in the test data were 98.4%, 98.6%, and 98.3%, respectively. These figures for 1-month system were 96%, 93%, and 98.4% and for the 3-month system were 89.3%, 86.6%, and 91.5%, respectively.

CONCLUSIONS

Using the CDSS designed, we could accurately predict the early complications of OAGB surgery.

Revisional Gastric Bypass Is Inferior to Primary Gastric Bypass in Terms of Short- and Long-term Outcomes-Systematic Review and Meta-Analysis

Purpose

Although Roux-en-Y gastric bypass (RYGB) is the main primary bariatric procedure, it has also been utilized as revisional bariatric surgery. Our aim is to compare revisionary gastric bypass with primary gastric bypass through systematic review with meta-analysis.

Methods

Available literature was searched for eligible studies up to December 2017. Inclusion criteria were reports on morbidity, %EWL, or diabetes remission. Secondary outcomes involved mortality, anastomotic leakage, operative time, and length of hospital stay. Random effect meta-analyses were undertaken.

Results

Initial search yielded 1164 references. Final meta-analysis involved 21 studies and revealed significant differences in terms of morbidity (RR1.54, p < 0.001) and EWL (WMD-19.9, p < 0.001). There were no differences in diabetes remission.

Conclusion

Revisionary RYGB has worse weight loss effect with greater morbidity rate than primary RYGB.

Electronic supplementary material

The online version of this article (10.1007/s11695-018-3300-2) contains supplementary material, which is available to authorized users.

Incidence, Indications, and Predictive Factors for ICU Admission in Elderly, High-Risk Patients Undergoing Laparoscopic Sleeve Gastrectomy

BACKGROUND

Obesity affects the elderly, leading to increased prevalence of age- and obesity-associated comorbidities. There are no guidelines for indications and risk assessment for the elderly undergoing bariatric surgery.

OBJECTIVES

To determine the incidence, indications, and outcomes of planned ICU admission in elderly, high-risk patients after laparoscopic sleeve gastrectomy (LSG) and to assess if preoperative risk factors for planned postoperative ICU admission in elderly patients undergoing LSG could be predicted preoperatively.

METHODS

Retrospective review of prospectively collected data for all patients aged ≥ 60 years who underwent LSG (2011-2016) at Hamad General Hospital in Qatar.

RESULTS

We followed up 58 patients aged 60-75 years for 28 ± 17 months. About 77.6% of patients were in the intermediate-risk group of the Obesity Surgery Mortality Risk Score (OS-MRS). Fourteen patients (24%) required ICU admission for 2 ± 1.2 days; all patients belonged to the American Society of Anesthesiologists (ASA) III class and intermediate to high risk on OS-MRS. There were no reported mortalities. The mean body mass index (BMI) decreased from 49 ± 10.6 to 37.6 ± 10.1 kg/m². The number of patient comorbidities (OR, 1.43; 95% CI, 1.03-1.99) and the diagnosis of obstructive sleep apnea (OSA; OR, 7.8; 95% CI, 1.92-31.68) were associated with planned ICU admission.

CONCLUSION

Elderly patients undergoing LSG usually have excellent postoperative course despite the associated high risk and the required ICU admission. The number of comorbidities, diagnosis of OSA, and ASA score are possible clinically significant predictive factors for the need of post-LSG ICU admission.

Influence of Patient Choice on Outcome of Bariatric Surgery

BACKGROUND

The "perfect" bariatric procedure remains the topic of debate. The aim of this study is to compare the safety and outcome of laparoscopic Roux-en-Y gastric bypass (LRYGB) to those of laparoscopic sleeve gastrectomy (LSG) and adjustable gastric band (AGB) in a single centre, amongst those patients who made their own choice of which procedure they prefer.

METHODS

After the multi-disciplinary team's assessment, the patients could make their own choice of procedures (self-selected, SS), unless medical/surgical conditions limited this (medically restricted, MR). All consecutive primary bariatric procedures were involved and reviewed between June 2010 and September 2014. The primary outcomes included 30-day complication and readmission rates, excess weight loss (%EWL) and co-morbidity resolution at 24 months postoperatively.

RESULTS

A total of 303 patients were included and 271 of them made their own choice (SS 90%). One hundred eighty-three chose LRYGB (60.4%), and 57 underwent LSG (SS 45 and MR 12; overall 18.8%), with the initial BMI of 50.7 and 52.5 kg/m², respectively. Sixty-two patients (SS 43, MR 19, overall 20%) underwent AGB, with a BMI of 52.1 kg/m². Thirty-day complication rates for LRYGB and LSG were 10.2 and 2.9% (p < 0.05), and the readmission rates were 4.7 and 2.9%, respectively. %EWL for LRYGB was significantly higher than that of other procedures at 24 months (67.8 vs SS-sleeve 43.9%, MR-sleeve 47%, SS-band 33.8% and MR-band 36%; FU rate 94%). Diabetes remission was achieved in 31/50 patients in the LRYGB group (62%) and 2/9 patients (22%) in the LSG group.

CONCLUSIONS

Self-selected bariatric procedures yield excellent weight loss and metabolic outcome. Providing an information-dense environment augments the choice of the right operation and could improve patients' compliance with weight loss surgery programmes.

Outcome of bariatric surgery in older patients

BACKGROUND

People are living longer than they were expected to 2 decades ago. Increased life expectancy and reduced mortality encompasses a simultaneous increase in the number of older adults with obesity that entails an increase of co-morbidities, such as diabetes, hypertension, cancer, and many other diseases. The aim of our study was to compare the outcomes of bariatric surgery in patients age ≥65 in comparison with younger patients.

METHODS

This retrospective study compares bariatric surgeries performed in a private institution between the years 2013 and 2015. The study included 9044 patients divided into an older group (451 patients) and the younger group (8593 patients).

RESULTS

In the younger group, bariatric surgery is distributed as follows: 77.68% sleeve gastrectomy, 12.72% gastric banding, 9.27% gastric bypass, and .33% duodenal switch or biliopancreatic diversion; in the older group: 70.51% sleeve gastrectomy, 15.08% gastric bypass, 13.97% gastric band, and .44% biliopancreatic diversion. In the control group 550 cases (6.4%) underwent revisional surgery; 64 cases (14.10%) underwent revision in the older group. Older patients lost less excess weight than younger patients (72.44% versus 86.11%, respectively). Older patients presented higher rates of complications (8.42% versus 5.59%), co-morbidities (77.60% versus 55.45%), and revisions (1.33% versus .77%). There was no statistical difference in hospital stay between older group and control group (2.27 versus 2.23, respectively). When performing a Clavien-Dindo classification, we demonstrated significant differences in class 3B and 4A and no differences in other classes. Two deaths occurred in the control group. Diabetes, fatty liver, and sleep apnea have been improved or remitted in >90% of patients in both groups, hypertension and hyperlipidemia by >80%, and hyperuricemia and ischemic heart disease were improved or resolved in >70% of the patients CONCLUSIONS: Bariatric surgery in the elderly has more complications, but it can still be considered safe.

Risk factors for early postoperative complications after bariatric surgery

Purpose

Vertical sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are currently the most common bariatric procedures. Although the safety of these operations has markedly improved, there continues to be a certain rate of complications. Such adverse events can have a significant deleterious effect on the outcome of these procedures and represent a costly burden on patients and society at large. A better understanding of these complications and their predictive factors may help ameliorate and optimize outcomes.

Methods

Seven hundred seventy-two consecutive patients who underwent SG or RYGB for morbid obesity between January 2011 and October 2015, in the Division of Bariatric Surgery at a tertiary institution, were included through retrospective review of the medical database. The complications were categorized and evaluated according to severity using the Clavien-Dindo classification system. Significant risk factors were evaluated by binary logistic regression to identify independent predictors and analyzed to identify their relationship with the type of complication.

Results

Independent predictors of severe complication after these procedures included male gender, open and revisional surgery, hypertension, and hypoalbuminemia. Hypoalbuminemia had significant associations with occurrence of deep surgical site infection and leak. Open surgery had significant associations with occurrence of superficial and deep surgical site infection and respiratory complications. Independent predictors of severe complication after laparoscopic primary RYGB included previous abdominal surgery. Previous abdominal surgery had significant associations with deep surgical site infection and leak.

Conclusion

Recognition and optimization of these risk factors would be valuable in operative risk prediction before bariatric surgery.

The evaluation of risk prediction models in predicting outcomes after bariatric surgery: a prospective observational cohort pilot study

Background

As the prevalence of obesity is increasing, the number of patients requiring surgical intervention for obesity-related illness is also rising. The aim of this pilot study was to explore predictors of short-term morbidity and longer-term poor weight loss after bariatric surgery.

Methods

This was a single-centre prospective observational cohort pilot study in patients undergoing bariatric surgery. We assessed the accuracy (discrimination and calibration) of two previously validated risk prediction models (the Physiological and Operative Severity Score for the enumeration of Morbidity and Mortality, POSSUM score, and the Obesity Surgical Mortality Risk Score, OS-MS) for postoperative outcome (postoperative morbidity defined using the Post Operative Morbidity Survey). We then tested the relationship between postoperative morbidity and longer-term weight loss outcome adjusting for known patient risk factors.

Results

Complete data were collected on 197 patients who underwent surgery for obesity or obesity-related illnesses between March 2010 and September 2013. Results showed POSSUM and OS-MRS were less accurate at predicting Post Operative Morbidity Survey (POMS)-defined morbidity on day 3 than defining prolonged length of stay due to poor mobility and/or POMS-defined morbidity. Having fewer than 28 days alive and out of hospital within 30 days of surgery was predictive of poor weight loss at 1 year, independent of POSSUM-defined risk (odds ratio 2.6; 95% confidence interval 1.28-5.24).

Conclusions

POSSUM may be used to predict patients who will have prolonged postoperative LOS after bariatric surgery due to morbidity or poor mobility. However, independent of POSSUM score, having less than 28 days alive and out of hospital predicted poor weight loss outcome at 1 year. This adds to the literature that postoperative complications are independently associated with poor longer-term surgical outcomes.

Patients' preferences for information in bariatric surgery

BACKGROUND

The decision to undergo bariatric surgery is multifactorial and made both by patient and doctor. Information is of the utmost importance for this decision.

OBJECTIVE

To investigate the bariatric surgery patient's preferences regarding information provision in bariatric surgery.

SETTING

A teaching hospital, bariatric center of excellence in Amsterdam, the Netherlands.

METHODS

All patients who underwent a primary laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy between September 2013 and September 2014 were approached by mail to participate. A questionnaire was used to elicit patient preferences for the content and format of information. Sociodemographic characteristics, clinicopathologic factors, and psychologic factors were explored as predictors for specific preferences.

RESULTS

Of the 356 eligible patients, 112 (31.5%) participated. The mean age was 49.2 (±10.7) years, and 91 (81.3%) patients were female. Patients deemed the opportunity to ask questions (96.4%) the most important feature of the consult, followed by a realistic view on expectations-for example, results of the procedure (95.5%) and information concerning the consequences of surgery for daily life (89.1%). Information about the risk of complications on the order of 10% was desired by 93% of patients; 48% desired information about lower risks (.1%). Only 25 patients (22.3%) desired detailed information concerning their weight loss after surgery.

CONCLUSION

Bariatric patients wished for information about the consequences of surgery on daily life, whereas the importance of information concerning complications decreased when their incidence lessened.

Failure of the Obesity Surgery Mortality Risk Score (OS-MRS) to Predict Postoperative Complications After Bariatric Surgery. A Single-Center Series and Systematic Review

BACKGROUND

The obesity surgery mortality risk score (OS-MRS) was developed to determine the risk of postoperative mortality in patients undergoing bariatric surgery. The aim of the present study is to assess the utility of this score for preventing the risk of postoperative complications from bariatric surgery.

METHODS

Prospective study of 321 patients undergoing bariatric surgery to whom the OS-MRS was applied. Postoperative complications were classified according to the Clavien-Dindo system. The relation between the OS-MRS and the appearance of complications and mortality was analyzed. A Medline/Embase search was conducted using bariatric surgery, mortality, and complications as key words. Studies using the OS-MRS to predict morbidity and mortality were included.

RESULTS

Of the 321 patients, 303 (94.3%) underwent gastric bypass and the remaining 18 (5.6%) a sleeve gastrectomy. The OS-MRS classified 178 patients as class A (55.5%), 129 as class B (40.2%), and 14 as class C (4.4%). According to the Clavien-Dindo system, 10.4% of the complications were ≥III. There was one death (class B). No significant association was found between the OS-MRS and the rate of complications.

CONCLUSIONS

In our study, the OS-MRS is not correlated with the appearance of early complications or mortality. Future studies must focus on systems for predicting the appearance and severity of postoperative complications classified according to the Clavien-Dindo system, and not only on mortality.