The role of socioeconomic status in resolution of type 2 diabetes mellitus following longitudinal sleeve gastrectomy

INTRODUCTION

The role socioeconomic status (SES) on outcomes following bariatric surgery has been heavily investigated in previous studies. The goal of this study is to determine the association between Area Deprivation Index (ADI), a multidimensional indicator of socioeconomic conditions, and remission of type 2 diabetes mellitus following longitudinal sleeve gastrectomy (SG).

METHODS

This is a retrospective analysis of 312 patients undergoing LSG at a single-center in a metropolitan hospital setting over two years. Socioeconomic disadvantage was assessed by ADI, a model that incorporates education, income, employment and housing stock to rank neighborhoods both on the state and the national level. Type 2 diabetes mellitus (T2DM) was defined as utilization of diabetes medication or HgA1C of greater than 6.5% within a 3 months period, and was assessed at three time points: pre-op, 6-month follow-up and 1-year follow-up.

RESULTS

In this cohort of individuals presenting for LSG, 72 (23.1%) had T2DM. The mean ADI of patients with T2DM (41.1 ± 17.1) was not statistically different from the group without T2DM (45.0 ± 16.4; p = 0.08631). By one year follow-up, 39 (60.0%) of individuals with T2DM had achieved remission. The ADI for individuals that achieved T2DM resolution was not different from the ADI of the group that did not (38.1 ± 15.4 vs 45.3 ± 17.7; p = 0.0958). In individuals with T2DM at baseline, 47 (65%) had A1C pre-op and A1C at 1 year follow-up; there was a significant reduction in Hgb-A1c (-0.71; -12.3%; p < 0.01). There was no correlation between change in A1C at 1 year and ADI national rank (p = 0.26).

DISCUSSION

We did not find a significant association between ADI and resolution of T2DM following sleeve gastrectomy. Resolution of T2DM following SG can be achieved by individuals regardless of SES. This supports the continued use of SG for socioeconomically deprived populations. In addition, we did not find an association between resolution of T2DM and weight loss, the most commonly used outcome metric following bariatric surgery.

Socioeconomic disparities and bariatric surgery outcomes: A qualitative analysis

BACKGROUND

Disparities in socioeconomic status (SES) have been associated with less weight loss after bariatric surgery. The objective of this study was to identify socioeconomic barriers to weight loss after bariatric surgery.

METHODS

We performed semi-structured interviews with bariatric surgery patients and providers from April-November 2020. Participants were asked to describe their post-operative experiences regarding dietary habits, physical activity, and follow-up care. Interview data were coded using Directed Content Analysis based on domains in Andersen's Behavioral Model of Health Services Use and Torain's Surgical Disparities Model.

RESULTS

24 patients (median of 4.1 years post-operatively; mean age 50.6 ± 10.7 years; 12 bypass and 12 sleeve; 83% female) and 21 providers (6 bariatric surgeons, 5 registered dietitians, 4 health psychologists, and 6 primary care providers) were interviewed. Barriers to weight loss included: 1) challenging employment situations; 2) limited income; 3) unreliable transportation; 4) unsafe/inconvenient neighborhoods; and 5) limited health literacy.

CONCLUSIONS

Interventions targeting socioeconomic barriers to weight loss are needed to support patients, particularly those who are socioeconomically disadvantaged.

[Socioeconomic impact of the current management of severe biliary acute pancreatitis: comparative study]

OBJETIVE

Acute pancreatitis of biliary origin is a common gastrointestinal pathology, in which timely management still is the most important. The aims of this research is establish the socioeconomic impact in the current management of severe acute pancreatitis of biliary origin comparing two centers of the third level, one of high socioeconomic population and another of low in Bogotá, Colombia.

MATERIALS AND METHODS

A retrospective, cross-sectional comparative study was conducted between January 2012 and December 2017, in two hospitals of Bogotá DC. We evaluated their socioeconomic characteristics, gender, time of evolution at the time of consultation, Marshall score, ICU stay, hospital stay, complications, surgical management and mortality.

RESULTS

101 patients from two different socioeconomic strata (high and low) were analyzed, where a 10 times higher risk of requiring a surgical procedure in the group of patients with low stratum was found, as well as a higher mortality compared with those of high stratum. (11.3% Vs 4.2%). There were also more complications in the low socioeconomic group with respect to the high, as in the exocrine failure (81.1% vs 31.3%) and the compartment syndrome (35.8% vs 4.2%).

CONCLUSION

There is greater morbidity and mortality in patients of low socioeconomic status in the context of this pathology. This study can guide new research that increases the clarity of the socioeconomic impact on the outcomes of severe acute pancreatitis.

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.

Male gender is an independent risk factor for patients undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass: an MBSAQIP® database analysis

BACKGROUND

Male patients undergoing bariatric surgery have (historically) been considered higher risk than females. The aim of this study was to examine the disparity between genders undergoing laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB) procedures and assess gender as an independent risk factor.

METHODS

The MBSAQIP® Data Registry Participant User Files for 2015-2017 was reviewed for patients having primary SG and RYGB. Patients were divided into groups based on gender and procedure. Variables for major complications were grouped together, including but not limited to PE, stroke, and MI. Univariate and propensity matching analyses were performed.

RESULTS

Of 429,664 cases, 20.58% were male. Univariate analysis demonstrated males were older (46.48 ± 11.96 vs. 43.71 ± 11.89 years, p < 0.0001), had higher BMI (46.58 ± 8.46 vs. 45.05 ± 7.75 kg/m², p < 0.0001), and had higher incidence of comorbidities. Males had higher rates of major complications (1.72 vs. 1.05%; p < 0.0001) and 30-day mortality (0.18 vs. 0.07%, p < 0.0001). Significance was maintained after subgroup analysis of SG and RYGB. Propensity matched analysis demonstrated male gender was an independent risk factor for RYGB and SG, major complications [2.21 vs. 1.7%, p < 0.0001 (RYGB), 1.12 vs. 0.89%, p < 0.0001 (SG)], and mortality [0.23 vs. 0.12%, p < 0.0001 (RYGB), 0.10 vs. 0.05%; p < 0.0001 (SG)].

CONCLUSION

Males continue to represent a disproportionately small percentage of bariatric surgery patients despite having no difference in obesity rates compared to females. Male gender is an independent risk factor for major post-operative complications and 30-day mortality, even after controlling for comorbidities.

Patients insured by Medicare and Medicaid undergo lower rates of bariatric surgery

BACKGROUND

Although the number of weight loss procedures is increasing, bariatric surgery is not used equitably in the United States. As obesity is more prevalent in minorities, higher priorities are placed toward improvement of access to care for these groups.

OBJECTIVES

To evaluate whether patient insurance status has any effect on use of bariatric surgery for patients in New York State.

SETTING

Administrative statewide database.

METHODS

The Statewide Planning and Research Cooperative System administrative database was used to identify all patients undergoing primary bariatric procedures between 2005 and 2016. Revision procedures were excluded from analysis. Multivariable logistic regression models were used to compare outcomes among patients with different payor status after controlling for confounding factors.

RESULTS

After the application of inclusion and exclusion criteria, there were 125,666 bariatric records from 2005 to 2016. Most patients had commercial insurance (n = 106,148, 84.5%), followed by Medicare (n = 9355, 7.4%), Medicaid (n = 7939, 6.3%), and other/unknown (n = 2224, 1.8%). The percentage of Medicaid was estimated to be increase by 12%/yr and the percentage of Medicare was estimated to be increase by 5%/yr during 2005 to 2016. Univariate analysis showed that patients with different insurance types were significantly different in terms of age, sex, race, region, subtype of surgeries, most co-morbidities, overall complication, 30-day readmission/emergency department visits, and length of stay (P values < .0001). After adjusting for other confounding factors, patients with Medicare insurance had significantly higher risk of having overall complications, 30-day readmissions/emergency department visits, and longer length of stay.

CONCLUSIONS

The majority of patients undergoing bariatric surgery are insured by private insurance, whereas only 13.7% of bariatric surgeries are performed on patients with public insurance.

The effect of surrogate procedure volume on bariatric surgery outcomes: do common laparoscopic general surgery procedures matter?

BACKGROUND

A growing body of evidence shows that experience and acquired skills from surrogate surgical procedures may be transferrable to a specific index operation. It is unclear whether this applies to bariatric surgery. This study aims to determine whether there is a surrogate volume effect of common laparoscopic general surgery procedures on all-cause bariatric surgical morbidity.

METHODS

This was a population-based study of all patients aged ≥ 18 who received a bariatric procedure in Ontario from 2008 to 2015. The main outcome of interest was all-cause morbidity during the index admission. All-cause morbidity included any documented complication which extended length of stay by 24 h or required reoperation. Bariatric cases included laparoscopic Roux-en-Y gastric bypass, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch. Non-bariatric cases included three common laparoscopic general surgery procedures.

RESULTS

13,836 bariatric procedures were performed by 29 surgeons at nine centers of excellence. A reduction in all-cause morbidity was seen when bariatric surgeons exceeded 75 cases annually (OR 0.82, 95% CI 0.69-0.98, P = 0.023), with further reduction in increasing bariatric volume. However, the volume of non-bariatric surgeries did not significantly affect bariatric all-cause morbidity rates amongst bariatric surgeons, even when exceeding 100 cases (OR 0.84, 95% CI 0.61-1.12, P = 0.222).

CONCLUSIONS

The present study suggests that experience and skills acquired in performing non-bariatric laparoscopic general surgery does not appear to affect all-cause morbidity in bariatric surgery. Therefore, only a surgeon's bariatric procedure volume should considered be a quality marker for outcomes after bariatric surgery.

Bariatric Procedures in Older Adults in the United States: Analysis of a Multicenter Database

Background: Bariatric procedures help reduce obesity-related comorbidities and thus improve survival. Clinical characteristics and outcomes after bariatric procedures in older adults were investigated. Methods: A multi-institutional Nationwide Inpatient Sample (NIS) database was queried from years 2005 through 2012. Older adults >60 years of age with procedure codes for bariatric procedures and a diagnosis of obesity/morbid obesity were selected to compare clinical characteristics/outcomes between those undergoing closed versus open procedures and identify risk factors associated with in-hospital mortality and increased hospital length of stay (LOS). Results: Over the study period, 79,122 bariatric procedures were performed. Those undergoing open procedures compared to closed procedures had a higher in-hospital mortality (0.8% vs. 0.2%) and a longer hospital LOS (4.8 days vs. 2.2 days). Risk factors significantly associated with in-hospital mortality were open procedures, the Western region, and the Elixhauser comorbidity index. Risk factors associated with increased LOS were Medicaid insurance type, an open procedure, a higher Elixhauser comorbidity score, a required skilled nursing facility (SNF) discharge, and died in hospital. Conclusion: Closed bariatric procedures are increasingly being preferred in older adults, with a four-fold lower mortality compared to open procedures. Besides choice of procedure, the presence of specific comorbidities is associated with increased mortality in older adults.

Weighing in on Bariatric Surgery: Effectiveness Among Medicaid Beneficiaries-Limited Evidence and Future Research Needs

INTRODUCTION

In the general population, bariatric surgery is well documented as the most effective obesity treatment for sustained weight loss and remission of comorbidities. Characterization of the patient populations most likely to benefit from surgical intervention is needed, but the heterogeneity of treatment effects across payer groups has not been reviewed.

METHODS

A systematic review of published studies focusing on bariatric surgery outcomes among Medicaid beneficiaries was conducted. By using PubMed and Scopus, this study searched for studies that quantitatively compared clinical or social bariatric surgery outcomes for United States adult Medicaid recipients and commercially insured patients.

RESULTS

Of the 568 titles reviewed, 21 met inclusion criteria. Weight loss and the remission of comorbidities at 1 or 2 years postoperatively were similar between groups despite differences in baseline health status. Short-term health care utilization and mortality outcomes were worse in Medicaid recipients; for instance, Medicaid patients had an average length of stay that was 2 days longer and experienced three more deaths in the first postoperative year.

CONCLUSIONS

The critical research gaps in the evidence base needed to improve treatment guidelines for Medicaid patients undergoing bariatric surgery include an understanding of the causes of the baseline health differences and how these differences contribute to postoperative outcomes.

The effect of hospital teaching status on outcomes in bariatric surgery

BACKGROUND

Studies have shown conflicting effects of resident involvement on outcomes after laparoscopic bariatric surgery. Resident involvement may be a proxy for a teaching environment in which multiple factors affect patient outcomes. However, no study has examined outcomes of laparoscopic bariatric surgery based on hospital teaching status.

OBJECTIVE

To compare outcomes after laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) between teaching hospitals (THs) and nonteaching hospitals (NTHs).

SETTING

Retrospective review of a national database in the United States.

METHODS

The Nationwide Inpatient Sample database (2011-2013) was reviewed for obese patients who underwent LRYGB or LSG. Patient demographic characteristics and outcomes were analyzed according to hospital teaching status. Primary outcome measures included risk-adjusted inpatient mortality and serious morbidity.

RESULTS

We analyzed 32,449 LRYGBs and 26,075 LSGs. There were 35,160 (60.1%) cases performed at THs and 23,364 (39.9%) cases performed at NTHs. At THs, the distribution of LRYGB versus LSG cases was 20,461 (58.2%) versus 14,699 (41.8%), respectively; at NTHs, the distribution was 11,988 (51.3%) versus 11,376 (48.7%), respectively. For LRYGB, there were no significant differences between THs versus NTHs in mortality (AOR 1.14; P = 0.99), but there was an increase in odds of serious morbidity at THs (AOR 1.36; P<0.001). For LSG, there were no significant differences between THs versus NTHs for mortality (AOR 1.15; P = 0.99) or serious morbidity (AOR 1.03; P = 0.99).

CONCLUSIONS

There is an association between THs and increased serious morbidity for LRYGB, but hospital teaching status has no effect on morbidity or mortality after LSG. Further research is warranted to elucidate the reasons for these associations.

Patient Safety and Quality Improvement Initiatives in Contemporary Metabolic and Bariatric Surgical Practice

Patient safety and quality improvement have been part of bariatric surgery since its inception, and there have been significant improvements in outcomes of bariatric surgery over the past 2 decades. A strong accreditation program exists. This program defines 2 tiers of accredited centers: low-acuity and comprehensive centers similar to the trauma systems. Accreditation has been shown to have a favorable impact on outcomes of bariatric surgery. Bariatric surgery lends itself well to improvements in processes and use of perioperative protocols, such as ulcer and thromboembolic prophylaxis prevention or gallstone prevention and management.

Disparities in Mangement of Patients with Benign Colorectal Disease: Impact of Urbanization and Specialized Care

Disparities in the management of patients with various medical conditions are well established. Colorectal diseases continue to remain one of the most common causes for surgical intervention. The aim of this study was to assess disparities (rural versus urban) in the surgical management of patients with noncancerous benign colorectal diseases. We hypothesized that there is no difference among rural versus urban centers (UC) in the surgical management for noncancerous benign colorectal diseases. The national estimates of surgical procedures for benign colorectal diseases from the National Inpatient Sample database 2011 representing 20 per cent of all in-patient admissions were abstracted. Patients undergoing procedures (abscess drainage, hemmoroidectomy, fistulectomy, and bowel resections) were included. Patients with colon cancer and those who underwent emergency surgery were excluded. The population was divided into two groups: urban and rural, based on the location of treatment. Outcome measures were in-hospital complications, mortality, and hospital costs. Subanalysis of UC was preformed: centers with colorectal surgeons and centers without colorectal surgeons. Regression analysis was performed. A total of 20,617 patients who underwent surgical intervention for benign colorectal diseases across 496 (urban: 342, rural: 154) centers, were included. Of the UC, 38.3 per cent centers had colorectal surgeons. Patients managed in UC had lower complication rate (7.6% vs 10.2%, P < 0.001), shorter hospital length of stay (4.7 ± 3.1 vs 5.9 ± 3.6 days, P < 0.001), and higher hospital costs ($56,820 ± $27,691 vs $49,341 ± $2,598, P < 0.001) compared with rural centers. On subanalysis, patients managed in UC with colorectal surgeons had 11 per cent lower incidence of in-hospital complications [odds ratio: 0.89 (95% confidence interval: 0.76–0.94)] and a shorter hospital length of stay [Beta: -0.72 (95% confidence interval: —0.81 to —0.65)] when compared with patients managed in UC without colorectal specialization. Disparities exit in outcomes of the patients with noncancerous benign colorectal diseases managed surgically in urban versus rural centers. Specialized care with colorectal surgeons at UC helps reduce adverse patient outcomes. Steps to provide effective and safe surgical care in a cost-effective manner across rural as well as UC are warranted. Level of evidence: Level III, retrospective cohort analysis.

Trends of bariatric surgery in France during the last 10 years: analysis of 267,466 procedures from 2005-2014

BACKGROUND

During the past decade, the field of bariatric surgery has changed dramatically.

OBJECTIVES

The study aims to summarize and perform a periodic assessment of the current trends in the use of bariatric surgery in France and review findings on the long-term progression of bariatric surgery. The data were extracted from the national registry Programme de Médicalisation des Systèmes d׳Information from 2005 to 2014.

SETTING

National health system and private practice in France.

METHODS

We identified all hospitalizations during which a bariatric procedure was performed for the treatment of morbid obesity from 2005 to 2014 in France. Data were reviewed for patient characteristics and the number and types of bariatric procedures. We also analyzed the setting and the characteristics of the centers and the difference of the activity between the public and private sector.

RESULTS

Between 2005 and 2014, the number of bariatric operations increased fourfold. Sleeve gastrectomy became the most performed bariatric intervention, representing 60.7% of bariatric activity in 2014. There was a concomitant steep increase in sleeve gastrectomy, with Roux-en-Y gastric bypass increasing slightly overall and a substantial decrease in adjustable gastric banding. In 2014, 481 centers performed bariatric surgery. Among them, one third performed<30 operations/yr. We observed an overall in-hospital mortality ranging from .038% to .05% during the last 3 years.

CONCLUSION

Bariatric surgery is increasing in France, with a fourfold augmentation of interventions in the last 10 years. The number of sleeve gastrectomies has increased considerably. This activity is performed in numerous centers, one third of them performing<30 interventions/yr.

One-year Surgical Outcomes and Costs for Medicaid Versus Non-Medicaid Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass: A Single-Center Study

PURPOSE

To compare 1-year outcomes and costs between severely obese Medicaid and non-Medicaid patients who underwent laparoscopic Roux-en-Y gastric bypass surgery.

METHODS

This is a single-institution retrospective review comparing 33 Medicaid patients to 99 randomly selected non-Medicaid patients (1:3 case-control). Ninety-day and 1-year outcomes were extracted from the electronic health record. Costs were obtained from the UW information technology division. Bivariate analyses were used to compare study variables.

RESULTS

Emergency department visits (48.2% vs. 27.4%; P=0.06) and readmissions (37.0% vs. 14.7%; P=0.01) were more common for Medicaid patients. Medicaid patients had less excess body weight loss (50.7% vs. 65.6%; P=0.001) but similar comorbidity resolution and complication rates. One-year median costs were similar between Medicaid and non-Medicaid patients ($21,160 vs. $24,215; P=0.92).

CONCLUSIONS

One-year comorbidity resolution, complications, and costs following laparoscopic Roux-en-Y gastric bypass were similar between Medicaid and non-Medicaid patients. Focusing on reducing emergency department presentations and readmissions would be a high-impact area for future quality improvement initiatives.

Relative contribution of modifiable versus non-modifiable factors as predictors of racial variance in roux-en-Y gastric bypass weight loss outcomes

African-Americans have been shown to have poorer weight loss outcomes after bariatric surgery, and many reasons for such outcomes have been postulated, including metabolic and genetic differences, socioeconomic factors, and differences in culture. African-Americans have also been noted to have differences from the majority population in other psychosocial correlates to weight loss outcomes. However, the relative contribution of targetable factors in relation to non-modifiable factors to such outcomes remains unclear. African-American and Caucasian patients who had received a Roux-en-Y gastric bypass and returned for a 12-month follow up appointment (n = 415) were selected for retrospective analysis. A stepwise hierarchical regression of 12 month percent excess weight loss (% EWL) was conducted that included race after controlling for psychosocial and demographic factors previously linked to postsurgical outcomes. These variables were then compared between racial groups using independent t tests and chi-square analyses. Race remained a significant predictor of % EWL after controlling for pertinent psychosocial and demographic variables. Age and preoperative BMI were significant negative predictors, whereas presurgical BMI loss and Caucasian race were positive (p < 0.05). Percentage of follow-up appointment attendance was borderline significant. No significant racial differences were noted in these variables. Non-modifiable factors inherent to race such as metabolism play small but significant roles in the postoperative weight loss in African-American patients. Further research is needed to better elucidate the roles of targetable factors in outcomes, particularly adherence and pay status as their evaluation in this study was limited.

Are there gender-specific aspects of gastric banding? Data analysis from the quality assurance study of the surgical treatment of obesity in Germany

BACKGROUND

Since 1 January 2005, the situation of bariatric surgery has been examined in Germany. All data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University Magdeburg.

METHODS

Data collection on the results of gastric banding procedures was started in 2005, and the data are registered in an online database. Follow-up data were collected once a year. Participation in the quality assurance study is voluntary.

RESULTS

Since 2005, 3,453 gastric banding procedures have been performed at 88 hospitals. The mean age of patients was 40.7 years, and the mean body mass index (BMI) was 45.2 kg/m2. BMI and comorbidities are significantly higher in male patients. Regarding gender-specific aspects, there are no significant differences in the perioperative complication rates. The amelioration rate of comorbidities in male patients is lower than in female patients.

CONCLUSION

Gastric banding in Germany is generally performed in patients with a BMI below 45 kg/m2. The perioperative complication rate is low. Data from the nationwide survey of the German Bariatric Surgery Registry show significant differences in preoperative comorbidities and their amelioration between male and female patients. There is a need for further evaluation of gender-specific aspects of gastric banding procedures to optimize patient selection, reduce specific postoperative complications, and achieve long-term effects on weight loss and remission of comorbidities.

The application of comorbidity indices to predict early postoperative outcomes after laparoscopic Roux-en-Y gastric bypass: a nationwide comparative analysis of over 70,000 cases

BACKGROUND

Patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) often have substantial comorbidities, which must be taken into account to appropriately assess expected postoperative outcomes. The Charlson/Deyo and Elixhauser indices are widely used comorbidity measures, both of which also have revised algorithms based on enhanced ICD-9-CM coding. It is currently unclear which of the existing comorbidity measures best predicts early postoperative outcomes following LRYGB.

METHODS

Using the Nationwide Inpatient Sample, patients 18 years or older undergoing LRYGB for obesity between 2001 and 2008 were identified. Comorbidities were assessed according to the original and enhanced Charlson/Deyo and Elixhauser indices. Using multivariate logistic regression, the following early postoperative outcomes were assessed: overall postoperative complications, length of hospital stay, and conversion to open surgery. Model performance for the four comorbidity indices was assessed and compared using C-statistics and the Akaike's information criterion (AIC).

RESULTS

A total of 70,287 patients were included. Mean age was 43.1 years (SD, 10.8), 81.6 % were female and 60.3 % were White. Both the original and enhanced Elixhauser indices modestly outperformed the Charlson/Deyo in predicting the surgical outcomes. All four models had similar C-statistics, but the original Elixhauser index was associated with the smallest AIC for all of the surgical outcomes.

CONCLUSIONS

The original Elixhauser index is the best predictor of early postoperative outcomes in our cohort of patients undergoing LRYGB. However, differences between the Charlson/Deyo and Elixhauser indices are modest, and each of these indices provides clinically relevant insight for predicting early postoperative outcomes in this high-risk patient population.

Racial differences among patients undergoing laparoscopic gastric bypass surgery: a population-based trend analysis from 2002 to 2008

BACKGROUND

Laparoscopic gastric bypass surgery (LGBS) has become the most widely used bariatric procedure due to its beneficial long-term outcomes for patients with morbid obesity. However, it is unclear whether racial differences in admission for LGBS have changed over time compared to racial differences in all other admissions. We aimed to investigate the trends and differences in the use of LGBS among white, African-American, and Hispanic patients from 2002 to 2008.

METHODS

We performed a secondary analysis of data on obese adult patients operated between 2002 and 2008, using the Nationwide Inpatient Sample (NIS) database. The probability of being admitted for LGBS was estimated using logistic regression with race, year, and year by race interaction as predictors, controlling for numerous patient and hospital characteristics.

RESULTS

Among 1,704,972 obese hospitalized patients captured through NIS from 2002 to 2008, 2.6 % underwent LGBS (2.8 % Whites, 1.7 % African-Americans, and 2.6 % Hispanics). In adjusted analysis, obese African-American (OR 0.48, p < 0.001) and Hispanic patients (OR 0.59, p < 0.001) were less likely to be admitted for LGBS than white patients in 2002. Race-year interactions showed that the odds of African-Americans undergoing LGBS significantly increased from 2002 to 2008 compared with Whites (annual OR 1.03, p < 0.001) while no such increase was detected for Hispanics (annual OR 1.02, p = 0.11). In 2008, African-American (OR 0.58, p < 0.001) and Hispanic patients (OR 0.65, p < 0.001) still had lower odds than white patients.

CONCLUSIONS

This is the first study showing that the difference in the use of LGBS between obese African-American and white patients declined between 2002 and 2008. However, LGBS use still remained significantly lower for both African-American and Hispanic patients in 2008 compared with white patients.

Roux-en-Y gastric bypass for morbid obesity: what are the preoperative predictors of weight loss?

Obesity has become an increasingly important health problem over the past 30 years. Presently around a quarter of the UK adult population are obese and this figure is set to increase further in the coming decades. The health consequences of obesity on multiple body systems have been well established as has the financial cost of the condition to both the individuals affected as well as to society as a whole. Bariatric surgery has been shown to be the only long term effective solution in terms of sustained weight loss and comorbidity resolution. The commonest bariatric procedure in the UK is the Roux-en-y gastric bypass which consistently results in the loss of 70%-80% of excess bodyweight. Results however are variable and in order to optimise resource allocation and avoid exposing patients unlikely to benefit from surgery to its inherent risks, much research has been done to try to identify those patients most likely to obtain a good result. The only factor which has been subjected to meta-analysis is that of preoperative weight loss which shows a positive association with postoperative weight loss following bypass surgery. Although the remaining data are not based on level 1 evidence those other preoperatively identifiable factors which are associated with an improved outcome include Caucasian or Hispanic ethnicity, higher educational status, non-shift-work working patterns, female gender and divorced or single marital status. Similarly increased levels of preoperative physical activity and an absence of binge eating behaviour are consistent with a favourable result whereas increased age, smoking and other socioeconomic factors have not been shown to have a significant impact. Conversely diabetes mellitus seems to have a slight negative correlation with postoperative weight loss; however, a history of sexual abuse or psychiatric illness has not been shown to have a lasting influence.

3-year real-world outcomes with the Swedish adjustable gastric band™ in France

The study objective was to ascertain outcomes with the Swedish adjustable gastric band (SAGB) on an intention-to-treat basis in multiple centers across the French social health insurance system. SAGB results at 3-year follow-up are reported. The noncomparative, observational, prospective, consecutive cohort study design sought a 500-patient minimum recruitment geographically representative of continental France. Safety (adverse events [AEs], device-related morbidity, and mortality) and effectiveness (change in body mass index [BMI, kilograms per square meter], percentage excess weight loss, comorbidities, quality of life [QoL]) were assessed. Adjustable gastric band survival was calculated. Thirty-one surgeons in 28 multidisciplinary teams/sites enrolled patients between September 2, 2007 and April 30, 2008. SAGB was successfully implanted in 517 patients: 88.0 % female; mean age, 37.5 years; obesity duration, 15.3 years (baseline: mean BMI, 41.0; comorbidities, 773 in 74.3 % of patients; Bariatric Analysis and Reporting Outcome System (BAROS), 1.4; EuroQoL 5-Dimensions (EQ-5D), 0.61; EuroQoL-visual analog scale (EQ-VAS), 52.3). At 3 years: BMI, 32.2 (mean change, -9.0; p < 0.0001); excess weight loss, 47.4 %; comorbidities, 161 in 27.2 %; BAROS, 3.6 (+2.2, p < 0.0001); EQ-5D, 0.84 (+0.22, p < 0.0001); EQ-VAS, 73.4 (+21.4, p < 0.0001). SAGB-induced weight loss was associated with substantially improved QoL. One death occurred and was unrelated to the treatment. No AE was reported in 68.3 % of patients, and no confirmed device-related AE in 77.0 %. Overall AE rate was 0.19 per patient year. Device retention was 87.0 %. Analysis of patients lost to follow-up showed a nonsignificant effect on overall study results. In a prospective, consecutive cohort, "real-world", nationwide study, the Swedish Adjustable Gastric Band was found safe and effective at 3-year follow-up.

The impact of hospital and surgeon volume on clinical outcome following bariatric surgery

The dramatic rise in the prevalence of obesity worldwide has led to the rapid growth of bariatric surgery. The aim of this pooled analysis is to evaluate the relationship between institutional and surgeon volume and outcomes following bariatric surgery. Medical, Embase, trial registries, conference proceedings and reference lists were searched for trials comparing clinical outcome following bariatric surgery at high and low volume hospitals and by high and low volume surgeons. Outcomes analysed were mortality, morbidity and length of hospital stay. Fifteen publications were included in this analysis. In total, 289,732 bariatric procedures were included in the institutional volume analysis, and 32,920 bariatric operations were included in the surgeon volume analysis. Mortality was reduced following surgery at high volume institutions (0.24 vs. 2.18 %; pooled odds ratio = 0.26; P = 0.004) and by high volume surgeons (0.41 vs. 2.77 %; pooled odds ratio = 0.21; P < 0.001). Similarly, morbidity was reduced in high volume institutions (7.84 vs. 8.85 %; pooled odds ratio = 0.52; P < 0.001) and with high volume surgeons (6.92 vs. 7.29 %; pooled odds ratio = 0.47; P < 0.001). There were insufficient data for conclusive statistical analysis of length of hospital stay. This pooled analysis does suggest a benefit in the centralisation of bariatric surgery to high volume institutions and surgeons with respect to mortality and morbidity. Future high-powered studies with adjustment for procedural and patient case mix are required to further define the volume-outcome relationship in bariatric surgery.

Are there gender-specific aspects of sleeve gastrectomy-data analysis from the quality assurance study of surgical treatment of obesity in Germany

Since 1 January 2005, the situation of bariatric surgery has been examined in Germany. All data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University Magdeburg. Data are registered in an internet online database. Data collection on the results of sleeve gastrectomy was started in 2006. Follow-up data were collected once a year. Participation in the quality assurance study is voluntary. Since 2005, 3,125 sleeve gastrectomies have been performed in 80 hospitals. The number of procedures has increased from 1 in 2005 to 1,564 in 2010. Initially, the leakage rate was 7 % in 2007. The leakage rate dropped to 1.7 in 2010. The mean age of patients was 43.5 years and mean body mass index (BMI) was 52.03 kg/m(2). BMI and comorbidities are significantly higher in male than in female patients. The leakage rate in female patients was, at 1.60 %, significantly lower than in male patients, at 3.28 %. Sleeve gastrectomy is becoming more and more popular in Germany. But the postoperative complication rate is still high. Data from the nationwide survey of bariatric surgery in Germany show significant differences in preoperative comorbidities and complication rates between male and female patients. There is a need for further evaluation of gender-specific aspects to optimize patient selection and reduce specific postoperative complications.

Volume-outcome association in bariatric surgery: a systematic review

OBJECTIVE

To systematically examine the association between annual hospital and surgeon case volume and patient outcomes in bariatric surgery.

BACKGROUND

Bariatric surgery remains a technically demanding field with significant risk for morbidity and mortality. To mitigate this risk, minimum annual hospital and surgeon case volume requirements are being set and certain hospitals are being designated as "Bariatric Surgery Centers of Excellence." The effects of these interventions on patient outcomes remain unclear.

METHODS

A comprehensive systematic review on volume-outcome association in bariatric surgery was conducted by searching MEDLINE, Cochrane Database of Systematic Reviews, and Evidence Based Medicine Reviews databases. Abstracts of identified articles were reviewed and pertinent full-text versions were retrieved. Manual search of bibliographies was performed and relevant studies were retrieved. Methodological quality assessment and data extraction were completed in a systematic fashion. Pooling of results was not feasible due to the heterogeneity of the studies. A qualitative summary of results is presented.

RESULTS

From a total of 2928 unique citations, 24 studies involving a total of 458,032 patients were selected for review. Two studies were prospective cohorts (level of evidence [LOE] 1), 3 were retrospective cohorts (LOE 3), 2 were retrospective case controls (LOE 3), and 17 were retrospective case series (LOE 4). The overall methodological quality of the reviewed studies was fair. A positive association between annual surgeon volume and patient outcomes was reported in 11 of 13 studies. A positive association between annual hospital volume and patient outcomes was reported in 14 of 17 studies.

CONCLUSIONS

There is strong evidence of improved patient outcomes in the hands of high-volume surgeons and high-volume centers. This study supports the concept of "Bariatric Surgery Center of Excellence" accreditation; however, future research into the quality of care characteristics of successful bariatric programs is recommended. Understanding the characteristics of high-volume surgeons, which lead to improved patient outcomes, also requires further investigation.

Bariatric surgery: a systematic review of the clinical and economic evidence

CONTEXT

Use of bariatric surgery for severe obesity has increased dramatically.

OBJECTIVE

To systematically review 1. the clinical efficacy and safety, 2. cost-effectiveness of bariatric surgery, and 3. the association between number of surgeries performed (surgical volume) and outcomes.

DATA SOURCES

MEDLINE (from 1950), EMBASE (from 1980), CENTRAL, EconLit, EURON EED, Harvard Center for Risk Analysis, trial registries and HTA websites were searched to January 2011.

STUDY SELECTION

1. Randomized controlled trials (RCTs) and 2. cost-utility and cost-minimisation studies comparing a contemporary bariatric surgery (i.e., adjustable gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy) to another contemporary surgical comparator or a non-surgical treatment or 3. Any study reporting the association between surgical volume and outcome.

DATA EXTRACTION

Outcomes included changes in weight and obesity-related comorbidity, quality of life and mortality, surgical complications, resource utilization, and incremental cost-utility.

RESULTS

RCT data evaluating mortality and obesity-related comorbidity endpoints were lacking. A small RCT of 16 patients reported that adjustable gastric banding reduced weight by 27% (p < 0.01) compared to diet-treated controls over 40 weeks. Six small RCTs reported comparisons of commonly used, contemporary procedures. Gastric banding reduced weight to a lower extent than gastric bypass and sleeve gastrectomy and resulted in shorter operating times, fewer serious complications, lower weight loss efficacy, and more frequent reoperations compared to gastric bypass. Sleeve gastrectomy and gastric bypass reduced weight to a similar extent. A 2-year RCT in 50 adolescents reported that gastric banding substantially reduced weight compared to lifestyle modification (35 kg vs. 3 kg; p <0.001). Based on findings of 14 observational studies, higher volume centers and surgeons had lower mortality and complication rates. Surgery resulted in long-term incremental cost-utility ratios of $ <1.000-$40,000 (2009 USD) per quality-adjusted-life-year compared with non-surgical treatment.

CONCLUSIONS

Contemporary bariatric surgery appears to result in sustained weight reduction with acceptable costs but rigorous, longer-term (≥5 year) data are needed and a paucity of RCT data on mortality and obesity related comorbidity is evident. Procedure-specific variations in efficacy and risks exist and require further study to clarify the specific indications for and advantages of different procedures.

Predictive factors of mortality in bariatric surgery: data from the Nationwide Inpatient Sample

BACKGROUND

Understanding predictors of mortality in bariatric surgery enables surgeons to use these factors for analysis of risk-adjusted mortality and aids in the surgical decision making and informed consent process.

OBJECTIVES

To evaluate the effect of patient characteristics (age, gender, race, and payer type), preoperative comorbidities, and operative technique (laparoscopic versus open, gastric bypass versus gastric band) on mortality in patients who underwent bariatric operations.

METHODS

Using the National Inpatient Sample database, clinical data of patients with morbid obesity who underwent bariatric surgery from 2006 to 2008 were examined. Multivariate logistic regression analyses were performed to identify independent predictors of in-hospital mortality.

RESULTS

A total 304,515 patients underwent bariatric surgery over the 3-year period. The majority of patients were female (80%) and Caucasian (74%). Their mean age was 44 years and 31.6% were >50 years old. The most common payer type was private (73.5%). Laparoscopic approach was utilized in 86.2% of cases. The overall in-hospital mortality was 0.12%. Using multivariate regression analysis, male gender (adjusted odds ratio [AOR], 1.7), age >50 years (AOR, 3.8), congestive heart failure (AOR, 9.5), peripheral vascular disease (AOR, 7.4), chronic renal failure (AOR, 2.7), open procedure (AOR, 5.5), and gastric bypass operation (AOR, 1.6) were factors associated with greater mortality. Ethnicity, hypertension, diabetes, liver disease, chronic lung disease, sleep apnea, alcohol abuse, and payer type had no association with mortality in this study.

CONCLUSION

Modifiable risk factors predictive of mortality include open surgery and gastric bypass procedure; nonmodifiable risk factors include older age, male gender, and a history of congestive heart failure, peripheral vascular disease, and chronic renal failure. Surgeons should consider these factors in selection of patients to undergo bariatric operations, providing informed consent, and selection of the procedural type.

Relationship between surgeon volume and adverse outcomes after RYGB in Longitudinal Assessment of Bariatric Surgery (LABS) study

BACKGROUND

Bariatric surgery is technically demanding surgery performed on high-risk patients. Previous studies using administrative databases have shown a relationship between surgeon volume and patient outcome after Roux-en-Y gastric bypass (RYGB). We examined the relationship between surgeons' annual RYGB volumes and 30-day patient outcomes at 10 centers within the United States.

METHODS

The Longitudinal Assessment of Bariatric Surgery (LABS)-1 is a prospective study examining the 30-day adverse outcomes after bariatric surgery. The outcomes after RYGB were adjusted by procedure type (open versus laparoscopic), functional status, body mass index, history of deep vein thrombosis, pulmonary embolism, and obstructive sleep apnea. The data were examined to determine the nature and strength of the association between surgeon volume and patients' short-term (30-day) adverse outcomes after RYGB.

RESULTS

The analysis included 3410 initial RYGB operations performed by 31 surgeons, 15 of whom averaged <50 cases annually. The crude composite adverse outcome (i.e., death, deep vein thrombosis, pulmonary embolism, reintervention or nondischarge at day 30) incidence was 5.2%. After risk adjustment, a greater surgeon RYGB volume was associated with lower composite event rates, with a continuous relationship (i.e., varying cutpoints differentiated the composite event rates), such that for each 10-case/yr increase in volume, the risk of a composite event decreased by 10%.

CONCLUSION

In the LABS, the patient's risk of an adverse outcome after RYGB decreased significantly with the increase in surgeon RYGB volume (cases performed annually).

The impact of socioeconomic factors on patient preparation for bariatric surgery

BACKGROUND

Socioeconomic factors (SEF) influence bariatric surgery access and outcomes perhaps because of variations in patient knowledge and behaviors. This study examines the associations between income, formal education, race, health insurance, employment status, and patient self-educational and behavioral activities prior to bariatric surgery.

METHODS

From March 2005 through January 2006, we surveyed 127 individuals who contacted our office seeking bariatric surgery. Study participants were asked to report their income, formal education, health insurance, employment status, height, weight, and standard demographic data. The type and number of self-educational resources utilized were elicited; a description of current eating and exercise behaviors was obtained; and an objective assessment (OA) of knowledge of the risks of both obesity and bariatric procedures was completed.

RESULTS

The most valuable self-educational resource cited by respondents was the internet (41.2%) and was unaffected by SEF. Individuals who were employed, privately insured, white, and earning>or=$20,000/year reported using a greater number of self-educational resources than their peers, while subjects who were privately insured, had higher formal educational levels, and earned>or=$20,000/year demonstrated greater proficiency on the OA instrument. Engagement in healthy eating and exercise behaviors was unaffected by any SEF. On multivariate analysis, higher income was the sole significant factor directly related to the number of educational resources utilized and proficiency on OA.

CONCLUSION

Obese patients from lower-income households may benefit from additional preoperative education. All individuals, regardless of socioeconomic factors, must be encouraged to implement healthy eating and exercise behaviors preoperatively.

Weight-loss maintenance in successful weight losers: surgical vs non-surgical methods

OBJECTIVE

As large weight losses are rarely achieved through any method except bariatric surgery, there have been no studies comparing individuals who initially lost large amounts of weight through bariatric surgery or non-surgical means. The National Weight Control Registry (NWCR) provides a resource for making such unique comparisons. This study compared the amount of weight regain, behaviors and psychological characteristics in NWCR participants who were equally successful in losing and maintaining large amounts of weight through either bariatric surgery or non-surgical methods.

DESIGN

Surgical participants (n=105) were matched with two non-surgical participants (n=210) on gender, entry weight, maximum weight loss and weight-maintenance duration, and compared prospectively over 1 year.

RESULTS

Participants in the surgical and non-surgical groups reported having lost approximately 56 kg and keeping > or =13.6 kg off for 5.5+/-7.1 years. Both groups gained small but significant amounts of weight from registry entry to 1 year (P=0.034), but did not significantly differ in magnitude of weight regain (1.8+/-7.5 and 1.7+/-7.0 kg for surgical and non-surgical groups, respectively; P=0.369). Surgical participants reported less physical activity, more fast food and fat consumption, less dietary restraint, and higher depression and stress at entry and 1 year. Higher levels of disinhibition at entry and increased disinhibition over 1 year were related to weight regain in both groups.

CONCLUSIONS

Despite marked behavioral differences between the groups, significant differences in weight regain were not observed. The findings suggest that weight-loss maintenance comparable with that after bariatric surgery can be accomplished through non-surgical methods with more intensive behavioral efforts. Increased susceptibility to cues that trigger overeating may increase risk of weight regain regardless of initial weight-loss method.

Relationship of body mass index with demographic and clinical characteristics in the Longitudinal Assessment of Bariatric Surgery (LABS)

BACKGROUND

The relationship between body mass index (BMI) and demographic/clinical characteristics of patients undergoing bariatric surgery is poorly characterized. BMI is often used to characterize patient risk in bariatric surgery. However, its relationship with other risk factors has not been well characterized.

METHODS

The Longitudinal Assessment of Bariatric Surgery-1 was a study of the 30-day outcomes in patients undergoing bariatric procedures at 10 clinical centers in the United States. The sample for this study included participants with a BMI > or =40 kg/m(2) and no history of undergoing a bariatric procedure from March 1, 2005 to March 26, 2007. This analysis examined the relationships between BMI strata and several demographic/clinical characteristics.

RESULTS

Of 2559 patients (23% male, 10% black, 9% age > or =60 yr) with a BMI of > or =40 kg/m(2), 29% had a BMI of 50 to <60 kg/m(2) and 12% a BMI of > or =60 kg/m(2). The percentage of men and blacks increased with greater BMI category and the percentage of older patients (age > or =60 yr) decreased. Patients with a greater BMI were more likely to have a history of several co-morbid conditions (hypertension, diabetes, congestive heart failure, asthma, poor functional status, sleep apnea, pulmonary hypertension, venous thromboembolism, or venous edema with ulcerations) than were patients with a BMI of 40-50 kg/m(2) after adjusting for age, race, sex, and ethnicity.

CONCLUSION

A greater BMI was associated with several patient characteristics that have been linked to less weight loss, more adverse outcomes, and increased healthcare use in previous studies. Outcomes analyses should consider the potential for the confounding of BMI with demographic and clinical characteristics.

Bariatric surgery: low mortality at a high-volume center

BACKGROUND

The American Society of Bariatric Surgery has initiated a Bariatric Surgery Center of Excellence Program and the American College of Surgeons has followed with their Bariatric Surgery Center Network Accreditation Program. These programs postulate that concentration of weight loss operations in high-volume centers will decrease surgical mortality and improve outcomes.

METHODS

The purpose of this study was to calculate the in-hospital mortality for bariatric operations accomplished at the highest volume bariatric surgery center in the state of New Jersey. After receiving Institutional Revew Board approval, the revised surgical schedule was used to identify all patients undergoing weight loss surgery (WLS) at Hackensack University Medical Center from 1998 through June, 2006. Data for these patients were then harvested from the hospital's electronic medical record. Step-wise and univariate logistic regression analysis tested the impact of various factors on hospital length of stay and in-hospital mortality.

RESULTS

Between 1998 and June, 2006, 5,365 patients underwent WLS surgery: 2,099 open vertical banded gastroplasty-Roux en Y gastric bypass (VBG-RYGB); 2,177 laparoscopic Roux en Y gastric bypass (LRYGB); and 1,089 laparoscopic adjustable gastric banding (LAGB). 75.5% of patients were women. Median age was 41 years old (13-79), median weight 128 kg (81.2-290.3), and median body mass index 46.1 kg/m2 (35.0-92.6). Median total operating room time for VBG-RYGB was 115 min (33-328); LRYGB 155 min (53-493), and LAGB 92 min (33-274). Median length of stay for VBG-RYGB was 3 days (1-39 days), LRYGB 2 days (1-46 days), and LAGB 1 day (1-20). Seven patients died in hospital after the 5,365 WLS operations (0.13%): four after VBG-RYGB (0.19%); three after LRYGB (0.14%); and none after LAGB (0%). The characteristics of the patients who died did not significantly differ from the group as a whole.

CONCLUSION

Surgeons at Hackensack University Medical Center, a high volume, accredited 1A American College of Surgeons Bariatric Surgery Center, achieved a 0.13% mortality among 5,365 patients undergoing weight loss operations between 1998 and June, 2006. This study supports the concept that high-volume centers perform bariatric operations with low mortalities.

Predictors of weight loss and effectiveness of Roux-en-Y gastric bypass in the morbidly obese Hispano-American population

BACKGROUND

Co-morbidities and the metabolic response to intervention in morbid obesity have been reported to vary among different ethnic groups. We compared the rate of weight loss, effectiveness of gastric bypass surgery, and variables influencing success after gastric bypass in Hispanics compared to Caucasians.

METHODS

Morbidly obese adult (>18 years old) patients (body mass index [BMI] 40 or above) evaluated by our bariatric group from 2005 to 2006 who underwent Roux-en-Y gastric bypass (RYGBP) were studied. Every patient was evaluated for height, weight, BMI, percent body fat, fat mass, serum metabolic analysis (SMA) 12, lipid profile, complete blood count (CBC), iron, ferritin, Vitamins A, D, and B1, complete urinalysis and Fibrospect score II. Weight loss was evaluated at 1, 3, 6, and 12 months.

RESULTS

Seventy-five patients underwent successful open RYGBP with no mortality. Regardless of the significant difference in age and co-morbidities, the mean percentage of total weight loss after 1 year of follow-up was 32% for Hispanics and 30% for Caucasians with no significant difference (p > .5). When comparing the percentage of excess weight lost (% EWL) at 1, 3, 6, and 12 months, there was no significant difference between both groups. Using multiple regression analysis, we found that high-density lipoprotein (HDL) and systolic blood pressure (SBP) significantly predicted EWL at 12 months in Caucasians and Fibrospect predicted significantly EWL at 1 year.

CONCLUSION

At 1 year after RYGBP, both ethnic groups lost approximately 77-80% of their EWL and BMI. All Caucasians and 95.7% of Hispanics achieved successful weight loss (>50% EWL).

Short-term outcomes for super-super obese (BMI > or =60 kg/m2) patients undergoing weight loss surgery at a high-volume bariatric surgery center: laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and open tubular gastric bypass

BACKGROUND

We previously reported significantly longer operating room times and a trend toward increased complications and mortality in the super-super obese (body mass index [BMI] > or =60 kg/m(2)) early in our experience with laparoscopic Roux-en-Y gastric bypass. The goal of this study was to re-examine the short-term outcomes for super-super obese patients undergoing weight loss surgery at our high-volume bariatric surgery center well beyond our learning curve.

METHODS

The records for all patients who had undergone weight loss surgery at Hackensack University Medical Center from 2002 to June 2006 were harvested from the hospital's electronic medical database. This population was analyzed as 2 groups (those with a BMI <60 kg/m(2) and those with a BMI > or =60 kg/m(2)), as well as by type of operation. Step-wise and univariate logistic regression analyses assessed the effect of BMI on the outcome variables, including mortality, length of surgery, length of hospital stay, and disposition at discharge.

RESULTS

A total of 3692 patients were studied. Of these patients, 3401 had a BMI <60 kg/m(2) and 291 had a BMI > or =60 kg/m(2). Of the 291 super-super obese patients, 130 underwent vertical banded gastroplasty-Roux-en-Y gastric bypass, 116 laparoscopic Roux-en-Y gastric bypass, and 45 laparoscopic adjustable gastric banding. The proportion of male patients, black patients, and patients with sleep apnea was increased in the BMI > or =60 kg/m(2) group. The number of co-morbid diseases per patient correlated with age but not BMI. The BMI > or =60 kg/m(2) group required a significantly longer total operating room time (136 versus 120 min). Hospital length of stay was significantly longer only in the laparoscopic Roux-en-Y gastric bypass patients (3 d for the BMI > or =60 kg/m(2) group versus 2 d for the BMI <60 kg/m(2) group). A significantly greater percentage of patients in the super-super obese group were discharged to chronic care facilities. The overall in-hospital mortality rate was 0.15% (5 of 3692) but did not significantly differ between the 2 groups: BMI <60 kg/m(2), rate of 0.12% (4 of 3401 patients), and BMI > or =60 kg/m(2), rate of 0.34% (1 of 291 patients). The type of operation did not significantly affect the disposition at discharge or in-hospital mortality.

CONCLUSION

Super-super obese patients required longer total operating room times, a longer hospital length of stay, and were more likely to be discharged to chronic care facilities than were patients with a BMI <60 kg/m(2); however, the in-hospital mortality was similar for both groups.

Bariatric surgery in Australia: who, why and how?

A review of published reports was conducted to identify gaps in the research regarding bariatric surgery. Much of the research that has been conducted is clinical outcome based; however, little research has been conducted in many key areas. Data on the demographics of the bariatric surgery group are patchy at best. The role of best practice and evidence-based medicine in bariatric surgery seems to be poorly understood, and equity issues and the role of clinical pathways in bariatric surgery need to be clarified. Significant gaps were identified in the published reports regarding pathways to bariatric surgery and multidisciplinary team use. Additionally, much of the published report and research data were from US studies, as few Australian studies have been conducted. Further research and policy and practice developments in bariatric surgery are needed, especially with regard to the Australian context.