Learning Curves of Laparoscopic Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in Bariatric Surgery: a Systematic Review and Introduction of a Standardization

BACKGROUND

The most commonly performed bariatric procedures are laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (LSG). Impact of learning curves on operative outcome has been well shown, but the necessary learning curves have not been clearly defined. This study provides a systematic review of the literature and proposes a standardization of phases of learning curves for RYGB and LSG.

METHODS

A systematic literature search was performed using PubMed, Web of Science, and CENTRAL databases. All studies specifying a number or range of approaches to characterize the learning curve for RYGB and LSG were selected.

RESULTS

A total of 28 publications related to learning curves for 27,770 performed bariatric surgeries were included. Parameters used to determine the learning curve were operative time, complications, conversions, length of stay, and blood loss. Learning curve range was 30-500 (RYGB) and 30-200 operations (LSG) according to different definitions and respective phases of learning curves. Learning phases described the number of procedures necessary to achieve predefined skill levels, such as competency, proficiency, and mastery.

CONCLUSIONS

Definitions of learning curves for bariatric surgery are heterogeneous. Introduction of the three skill phases competency, proficiency, and mastery is proposed to provide a standardized definition using multiple outcome variables to enable better comparison in the future. These levels are reached after 30-70, 70-150, and up to 500 RYGB, and after 30-50, 60-100, and 100-200 LSG. Training curricula, previous laparoscopic experience, and high procedure volume are hallmarks for successful outcomes during the learning curve.

Hypoglycemia after Bariatric Surgery in Mice and Optimal Dosage and Efficacy of Glucose Supplementation

The Roux-en-Y Gastric Bypass (RYGB) mouse model is a vital tool for studying the pathophysiology of bariatric surgery and contributes greatly to research on obesity and diabetes. However, complications including postsurgical hypoglycemia can have profoundly negative effects. Unlike in humans, blood glucose (BG) is not typically managed in postoperative rodents, despite their critical role as translational models; without this management, rodents can experience hypoglycemia, potentially impairing wound healing, decreasing survivability, complicating interpretation of research data, and limiting translational utility. In this project, we sought to identify an optimal method for minimally invasive administration of dextrose in C57BL/6N (n = 16; 8 male, 8 female) mice. To do so, we characterized BG pharmacokinetic profiles after subcutaneous and oral-transmucosal (OTM) administration of dextrose. Compared with OTM dosage, the subcutaneous route provided more consistent and reliable delivery of glucose and did not cause significant adverse reactions. We then evaluated the frequency of hypoglycemic events after RYGB in C57BL/6N mice (n = 16; 8 male, 8 female) and the effects of subcutaneous dextrose supplementation on morbidity and mortality. BG measurement and behavioral pain assessment (grimace test) were performed for 3 d after surgery. Hypoglycemic (BG ≤ 60 mg/dL) animals were assigned to dose (5% dextrose SC) or no-dose treatment groups. Nearly all (87%) mice became hypoglycemic; 2 of these mice died. No significant intergroup difference in grimace score or mortality was detected. Overall, our results demonstrate that hypoglycemia is a frequent adverse event after RYGB in mice and that subcutaneous injection of dextrose is a safe and effective way to manage hypoglycemia. Further studies are necessary to optimize the intervention threshold and optimal dosage; regardless, we recommend glycemic management after RYGB surgery in mice.

Laparoscopic Sleeve Gastrectomy or Laparoscopic Gastric Bypass for Patients with Metabolic Syndrome: An MBSAQIP Analysis

In patients undergoing bariatric surgery, the presence of metabolic syndrome (MetS) contributes to perioperative morbidity. We aimed to evaluate the utilization and outcome of severely obese patients with MetS who underwent laparoscopic sleeve gastrectomy (LSG) versus laparoscopic Roux-en-Y gastric bypass (LRYGB). Using the 2015 and 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, data were obtained for patients with MetS undergoing LSG or LRYGB. There were 29,588 MetS patients (LSG: 58.7% vs LRYGB: 41.3%). There was no significant difference in 30-day mortality (0.1% for LSG vs 0.2% for LRYGB, adjusted odds ratio (AOR) 0.58, confidence interval (CI) 0.32-1.05, P = 0.07) or length of stay between groups (2 ± 2 for LSG vs 2.2 ± 2 days for LRYGB, P = 0.40). Compared with LRYGB, LSG was associated with significantly shorter operative time (78 ± 39 vs 122 ± 54 minutes, P < 0.01), lower overall morbidity (2.3% vs 4.4%, AOR 0.53, CI 0.46-0.60, P < 0.01), lower serious morbidity (1.5% vs 2.3%, AOR 0.64, CI 0.53-0.76, P < 0.01), lower 30-day reoperation (1.2% vs 2.3%, AOR 0.52, CI 0.43-0.63, P < 0.01), and lower 30-day readmission (4.2% vs 6.6%, AOR 0.62, CI 0.55-0.69, P < 0.01). In conclusion, LSG is the predominant operation being performed for severely obese patients with MetS, and its popularity may in part be related to its improved perioperative safety profile.

Bariatric surgery in the elderly: outcomes analysis of patients over 70 using the ACS-NSQIP database

BACKGROUND

Bariatric surgery offers patients with morbid obesity and related diseases short- and long-term benefits to their health and quality of life. Evidence-based medicine is integral in the evaluation of risk versus benefit; however, data are lacking for several high-risk patient populations, including the elderly.

OBJECTIVES

This study assessed morbidity and mortality data for patients age ≥70 undergoing laparoscopic sleeve gastrectomy (SG) or laparoscopic Roux-en-Y gastric bypass (RYGB).

SETTING

University Hospital, Bronx, New York, United States using national database.

METHODS

We used the American College of Surgeons-National Surgical Quality Improvement Project database for years 2005-2016 and identified patients who underwent primary SG or RYGB. Patients age ≥70 were assigned to the over age 70 (AGE70+) cohort and younger patients were assigned to the under age 70 (U70) cohort. Postoperative length of stay and 30-day morbidity and mortality were assessed.

RESULTS

A total of 1498 patients age ≥70 underwent nonrevisional bariatric surgery, including 751 (50.1%) SG and 747 (49.9%) RYGB. AGE70+ was associated with increased mortality and increased rates of cardiac, pulmonary, renal, and cerebrovascular morbidity. AGE70+ patients had longer mean length of stay, and were more likely to require transfusion and return to operative room. When stratified by procedure, rates of organ-space surgical site infection, acute renal failure, urinary tract infection, myocardial infarction, deep vein thrombosis/thrombophlebitis, and septic shock were significantly increased in AGE70+ patients undergoing RYGB but not SG. Impaired functional status was associated with increased rates of morbidity and mortality for AGE70+ patients and for U70 patients, although the small number of patients within each category limited statistical analysis.

CONCLUSIONS

Evaluation of risk versus benefit is performed on a case-by-case basis, but evidence-based medicine is critical in empowering surgeons and patients to make informed decisions. The overall rate of morbidity and mortality for AGE70+ patients undergoing bariatric surgery was increased relative to U70 patients. Rates of several adverse events, including acute renal failure and myocardial infarction, were increased in AGE70+ patients undergoing RYGB but not SG, suggesting that SG may be the preferred procedure for elderly patients with organ-specific risk factors. The increased rates of morbidity and mortality observed for patients with impaired functional status supports consideration of functional status when evaluating preoperative risk.

Five-Year Outcomes of Gastric Bypass in Adolescents as Compared with Adults

BACKGROUND

Bariatric surgery results in weight loss and health improvements in adults and adolescents. However, whether outcomes differ according to the age of the patient at the time of surgery is unclear.

METHODS

We evaluated the health effects of Roux-en-Y gastric bypass in a cohort of adolescents (161 patients enrolled from 2006 through 2012) and a cohort of adults (396 patients enrolled from 2006 through 2009). The two cohorts were participants in two related but independent studies. Linear mixed and Poisson mixed models were used to compare outcomes with regard to weight and coexisting conditions between the cohorts 5 years after surgery. The rates of death and subsequent abdominal operations and selected micronutrient levels (up to 2 years after surgery) were also compared between the cohorts.

RESULTS

There was no significant difference in percent weight change between adolescents (-26%; 95% confidence interval [CI], -29 to -23) and adults (-29%; 95% CI, -31 to -27) 5 years after surgery (P = 0.08). After surgery, adolescents were significantly more likely than adults to have remission of type 2 diabetes (86% vs. 53%; risk ratio, 1.27; 95% CI, 1.03 to 1.57) and of hypertension (68% vs. 41%; risk ratio, 1.51; 95% CI, 1.21 to 1.88). Three adolescents (1.9%) and seven adults (1.8%) died in the 5 years after surgery. The rate of abdominal reoperations was significantly higher among adolescents than among adults (19 vs. 10 reoperations per 500 person-years, P = 0.003). More adolescents than adults had low ferritin levels (72 of 132 patients [48%] vs. 54 of 179 patients [29%], P = 0.004).

CONCLUSIONS

Adolescents and adults who underwent gastric bypass had marked weight loss that was similar in magnitude 5 years after surgery. Adolescents had remission of diabetes and hypertension more often than adults. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases; ClinicalTrials.gov number, NCT00474318.).

Pros and cons of gastric bypass surgery in individuals with obesity and type 2 diabetes: nationwide, matched, observational cohort study

OBJECTIVES

Long-term effects of gastric bypass (GBP) surgery have been presented in observational and randomised studies, but there are only limited data for persons with obesity and type 2 diabetes mellitus (T2DM) regarding postoperative complications.

DESIGN

This is a nationwide observational study based on two quality registers in Sweden (National Diabetes Register, NDR and Scandinavian Obesity Surgery Register, SOReg) and other national databases.

SETTING

After merging the data, we matched individuals with T2DM who had undergone GBP with those not surgically treated for obesity on propensity score, based on sex, age, body mass index (BMI) and calendar time. The risks of postoperative outcomes (rehospitalisations) were assessed using Cox regression models.

PARTICIPANTS

We identified 5321 patients with T2DM in the SOReg and 5321 matched controls in the NDR, aged 18-65 years, with BMI >27.5 kg/m² and followed for up to 9 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

We assessed risks for all-cause mortality and hospitalisations for cardiovascular disease, severe kidney disease, along with surgical and other medical conditions.

RESULTS

The results agree with the previously suggested lower risks of all-cause mortality (49%) and cardiovascular disease (34%), and we also found positive effects for severe kidney disease but significantly increased risks (twofold to ninefold) of several short-term complications after GBP, such as abdominal pain and gastrointestinal conditions, frequently requiring surgical procedures, apart from reconstructive plastic surgery. Long-term, the risk of anaemia was 92% higher, malnutrition developed approximately three times as often, psychiatric diagnoses were 33% more frequent and alcohol abuse was three times as great as in the control group.

CONCLUSIONS

This nationwide study confirms the benefits and describes the panorama of adverse events after bariatric surgery in persons with obesity and T2DM. Long-term postoperative monitoring and support, as better selection of patients by appropriate specialists in interdisciplinary settings, should be provided to optimise the outcomes.

Banded vs. non-banded Roux-en-Y gastric bypass for morbid obesity: a systematic review and meta-analysis

We aim to review the available literature on patients with morbid obesity treated with banded (BRYGB) or non-banded Roux-en-Y gastric bypass (NBRYGB), in order to compare the clinical outcomes and intraoperative parameters of the two methods. A systematic literature search was performed in PubMed, Cochrane library and Scopus databases, in accordance with the PRISMA guidelines. Eight studies met the inclusion criteria incorporating 3899 patients. This study reveals similar rates of complications, mortality, remission of type 2 diabetes, hypertension, dyslipidaemia, gastroesophageal reflux and obstructive sleep apnoea, along with similar % excess weight loss (%EWL) at 1 and 2 years postoperatively. In contrast, according to an analysis of two eligible studies the BRYGB procedure was associated with increased %EWL at 5 years postoperatively. These results should be interpreted with caution due to the small number of statistical arms and randomized controlled studies. However, the present article represents the best available evidence in the field. Well-designed, randomized controlled studies, comparing BRYGB to NBRYGB, are necessary to further assess their clinical outcomes.

Outcomes of Laparoscopic Bariatric Surgery in the Elderly Population

There have been limited data on the safety of laparoscopic bariatric surgery in the elderly. To compare outcomes of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) between elderly (≥65 years) and nonelderly (18-64 years) patients. Using the 2011 to 2015 NSQIP database, we analyzed severely obese patients who underwent LRYGB or LSG. Univariate and multivariate analyses were performed to assess primary outcomes including 30-day mortality, serious morbidity, length of stay, and readmission. There were 41,475 LRYGB cases performed, including 2,010 (4.8%) cases in elderly patients. Compared with the nonelderly, elderly patients who underwent LRYGB had higher serious morbidity [odds ratio (OR) = 1.43, confidence interval (CI) = 1.16-1.76, P = 0.001], but similar 30-day mortality (OR = 0.8, CI = 0.28-2.34, P = 0.688). There were 44,550 LSG cases performed, including 2,055 (4.6%) cases in elderly patients. Compared with the nonelderly, elderly patients who underwent LSG had significantly higher serious morbidity (OR = 1.44, CI = 1.12-1.84, P = 0.005) and higher 30-day mortality (OR = 3.62, CI = 1.34-9.83, P = 0.011). Laparoscopic bariatric surgery is safe in the elderly population, and is similar between bariatric procedures. However, elderly patients have higher serious morbidity; therefore, they should be counseled regarding their higher risk, but should not be denied bariatric surgery based solely on their age.

Is laparoscopic sleeve gastrectomy safer than laparoscopic gastric bypass? a comparison of 30-day complications using the MBSAQIP data registry

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become popular due to its technical ease and excellent short-term results. Understanding the risk profile of LSG compared with the gold standard laparoscopic Roux-en-Y gastric bypass (LRYGB) is critical for patient selection.

OBJECTIVES

To use traditional regression techniques and random forest classification algorithms to compare LSG with LRYGB using the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Data Registry.

SETTING

United States.

METHODS

Outcomes were leak, morbidity, and mortality within 30 days. Variable importance was assessed using random forest algorithms. Multivariate models were created in a training set and evaluated on the testing set with receiver operating characteristic curves. The adjusted odds of each outcome were compared.

RESULTS

Of 134,142 patients, 93,062 (69%) underwent LSG and 41,080 (31%) underwent LRYGB. One hundred seventy-eight deaths occurred in 96 (.1%) of LSG patients compared with 82 (.2%) of LRYGB patients (P<.001). Morbidity occurred in 8% (5.8% in LSG versus 11.7% in LRYGB, P<.001). Leaks occurred in 1% (.8% in LSG versus 1.6% in LRYGB, P<.001). The most important predictors of all outcomes were body mass index, albumin, and age. In the adjusted multivariate models, LRYGB had higher odds of all complications (leak: odds ratio 2.10, P<.001; morbidity: odds ratio 2.02, P<.001; death: odds ratio 1.64, P<.01).

CONCLUSION

In the Metabolic and Bariatric Surgery Accreditation and Quality Improvements data registry for 2015, LSG had half the risk-adjusted odds of death, serious morbidity, and leak in the first 30 days compared with LRYGB.

Association of Bariatric Surgery Using Laparoscopic Banding, Roux-en-Y Gastric Bypass, or Laparoscopic Sleeve Gastrectomy vs Usual Care Obesity Management With All-Cause Mortality

IMPORTANCE

Bariatric surgery is an effective and safe approach for weight loss and short-term improvement in metabolic disorders such as diabetes. However, studies have been limited in most settings by lack of a nonsurgical group, losses to follow-up, missing data, and small sample sizes in clinical trials and observational studies.

OBJECTIVE

To assess the association of 3 common types of bariatric surgery compared with nonsurgical treatment with mortality and other clinical outcomes among obese patients.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study in a large Israeli integrated health fund covering 54% of Israeli citizens with less than 1% turnover of members annually. Obese adult patients who underwent bariatric surgery between January 1, 2005, and December 31, 2014, were selected and compared with obese nonsurgical patients matched on age, sex, body mass index (BMI), and diabetes, with a final follow-up date of December 31, 2015. A total of 33 540 patients were included in this study.

EXPOSURES

Bariatric surgery (laparoscopic banding, Roux-en-Y gastric bypass, or laparoscopic sleeve gastrectomy) or usual care obesity management only (provided by a primary care physician and which may include dietary counseling and behavior modification).

MAIN OUTCOMES AND MEASURES

The primary outcome, all-cause mortality, matched and adjusted for BMI prior to surgery, age, sex, socioeconomic status, diabetes, hyperlipidemia, hypertension, cardiovascular disease, and smoking.

RESULTS

The study population included 8385 patients who underwent bariatric surgery (median age, 46 [IQR, 37-54] years; 5490 [65.5%] women; baseline median BMI, 40.6 [IQR, 38.5-43.7]; laparoscopic banding [n = 3635], gastric bypass [n = 1388], laparoscopic sleeve gastrectomy [n = 3362], and 25 155 nonsurgical matched patients (median age, 46 [IQR, 37-54] years; 16 470 [65.5%] women; baseline median BMI, 40.5 [IQR, 37.0-43.5]). The availability of follow-up data was 100% for all-cause mortality. There were 105 deaths (1.3%) among surgical patients during a median follow-up of 4.3 (IQR, 2.8-6.6) years (including 61 [1.7%] who underwent laparoscopic banding, 18 [1.3%] gastric bypass, and 26 [0.8%] sleeve gastrectomy), and 583 deaths (2.3%) among nonsurgical patients during a median follow-up of 4.0 (IQR, 2.6-6.2) years. The absolute difference was 2.51 (95% CI, 1.86-3.15) fewer deaths/1000 person-years in the surgical vs nonsurgical group. Adjusted hazard ratios (HRs) for mortality among nonsurgical vs surgical patients were 2.02 (95% CI, 1.63-2.52) for the entire study population; by surgical type, HRs were 2.01 (95% CI, 1.50-2.69) for laparoscopic banding, 2.65 (95% CI, 1.55-4.52) for gastric bypass, and 1.60 (95% CI, 1.02-2.51) for laparoscopic sleeve gastrectomy.

CONCLUSIONS AND RELEVANCE

Among obese patients in a large integrated health fund in Israel, bariatric surgery using laparoscopic banding, gastric bypass, or laparoscopic sleeve gastrectomy, compared with usual care nonsurgical obesity management, was associated with lower all-cause mortality over a median follow-up of approximately 4.5 years. The evidence of this association adds to the limited literature describing beneficial outcomes of these 3 types of bariatric surgery compared with usual care obesity management alone.

Laparoscopic One-Anastomosis Gastric Bypass: Technique, Results, and Long-Term Follow-Up in 1200 Patients

BACKGROUND

Excellent results have been reported with mini-gastric bypass. We adopted and modified the one-anastomosis gastric bypass (OAGB) concept. Herein is our approach, results, and long-term follow-up (FU).

METHODS

Initial 1200 patients submitted to laparoscopic OAGB between 2002 and 2008 were analyzed after a 6-12-year FU. Mean age was 43 years (12-74) and body mass index (BMI) 46 kg/m2 (33-86). There were 697 (58 %) without previous or simultaneous abdominal operations, 273 (23 %) with previous, 203 (17 %) with simultaneous, and 27 (2 %) performed as revisions.

RESULTS

Mean operating time (min) was as follows: (a) primary procedure, 86 (45-180); (b) with other operations, 112 (95-230); and (c) revisions, 180 (130-240). Intraoperative complications led to 4 (0.3 %) conversions. Complications prompted operations in 16 (1.3 %) and were solved conservatively in 12 (1 %). Long-term complications occurred in 12 (1 %). There were 2 (0.16 %) deaths. Thirty-day and late readmission rates were 0.8 and 1 %. Cumulative FU was 87 and 70 % at 6 and 12 years. The highest mean percent excess weight loss was 88 % (at 2 years), then 77 and 70 %, 6 and 12 years postoperatively. Mean BMI (kg/m2) decreased from 46 to 26.6 and was 28.5 and 29.9 at those time frames. Remission or improvement of comorbidities was achieved in most patients. The quality of life index was satisfactory in all parameters from 6 months onwards.

CONCLUSIONS

Laparoscopic OAGB is safe and effective. It reduces difficulty, operating time, and early and late complications of Roux-en-Y gastric bypass. Long-term weight loss, resolution of comorbidities, and degree of satisfaction are similar to results obtained with more aggressive and complex techniques. It is currently a robust and powerful alternative in bariatric surgery.

Body mass index is predictive of higher in-hospital mortality in patients undergoing laparoscopic gastric bypass but not laparoscopic sleeve gastrectomy or gastric banding

High body mass index (BMI) has been shown to be a factor predictive of increased morbidity and mortality in several single-institution studies. Using the University HealthSystem Consortium clinical database, we examined the impact of BMI on in-hospital mortality for patients who underwent laparoscopic gastric bypass, sleeve gastrectomy, and gastric banding between October 2011 and February 2014. Outcomes were examined within each procedure according to BMI groups of 35 to 49.9, 50.0 to 59.9, and 60.0 kg/m(2) or greater. Outcome measures included in-hospital mortality, major complications, length of hospital stay, 30-day readmission, and cost. A total of 40,102 bariatric procedures were performed during this time period. For gastric bypass, there was an increase of in-hospital mortality (0.01 and 0.02 vs 0.34%; P < 0.01) and major complications (0.93 and 0.99 vs 2.62%; P < 0.01) in the BMI 60 kg/m(2) or greater group. In contrast, sleeve gastrectomy and gastric banding had no association between BMI and rates of mortality and major complications. Cost increased with increasing BMI groups for all procedures. A strong association was found between BMI 60 kg/m(2) or greater and higher in-hospital mortality and major complication rates for patients who underwent laparoscopic gastric bypass but not in patients who underwent sleeve gastrectomy or gastric banding.

Safety and survival benefit of surgical management for elderly gastric cancer patients

OBJECTIVE

To study the safety and survival outcome of surgical management for elderly gastric cancer patients. Methods: Patients proven of gastric cancer who aged ≥80 years during November 2002 to July 2011 were retrospectively analyzed. The detailed information of patients’ characteristics and surgical management was retrieved. Follow-up of overall survival status was performed to analyze the surgical effectiveness.

RESULTS

Totally, 92 (48 in surgery and 44 in non-surgery group) out of 187 eligible patients recorded adequate information and analyzed finally. There were 34 patients undergone radical gastrectomy, 6 palliative gastrectomy, 1 gastrojejunostomy and 7 exploratory laparotomy. Median follow-up durations were 25 (9-111) and 28 (8-114) months in surgery and non-surgery groups, respectively (p=0.797). Clinical-pathological T stage and node status were comparable. Clinical-pathological distal metastasis status was 15 and 26 M1 cases for surgery and nonsurgery, respectively (p=0.006). Incidence of postoperative complications and hospital mortality were 25.0% and 2.1%, respectively. The 2-year survival rates of M0 subgroups were 35.7% and 0% for surgery and nonesurgery, respectively (HR=3.98, p=0.022).

CONCLUSIONS

The safety of surgery for well-selected ≥ 80-year elderly gastric cancer patients was potentially acceptable and the patients of early or locally advanced diseases could obtain survival benefits by surgery.

Bariatric surgery

Essential facts: Type 2 diabetes is linked closely to obesity. Bariatric surgery can lead to dramatic improvements in the management of the condition, according to the National Institute for Health and Care Excellence (NICE). There are two main types of bariatric surgery. A gastric band procedure uses a band to reduce the size of the stomach so a smaller amount of food is required to make the patient feel full. A gastric bypass is where the digestive system is re-routed past most of the stomach so less food is digested.

Early morbidity and mortality of laparoscopic sleeve gastrectomy and gastric bypass in the elderly: a NSQIP analysis

BACKGROUND

Even though the U.S. population is aging, outcomes of bariatric surgery in the elderly are not well defined. Current literature mostly evaluates the effects of gastric bypass (RYGB), with paucity of data on sleeve gastrectomy (SG). The objective of this study was to assess 30-day morbidity and mortality associated with laparoscopic SG in patients aged 65 years and over, in comparison to RYGB.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was queried for all patients aged 65 and over who underwent laparoscopic RYGB and SG between 2010 and 2011. Baseline characteristics and outcomes were compared. P value<.05 was considered significant. Odds ratios (OR) with 95% confidence interval (CI) were reported when applicable.

RESULTS

We identified 1005 patients. Mean body mass index was 44 ± 7. SG was performed in 155 patients (15.4%). The American Society of Anesthesiology physical classification of 3 or 4 was similar between the 2 groups (82.6% versus 86.7%, P = .173). Diabetes was more frequent in the RYGB group (43.2% versus 55.6%, P = .004). 30-day mortality (0.6% versus 0.6%, OR 1.1, 95% CI .11-9.49), serious morbidity (5.2% versus 5.6%, OR .91, 95% CI .42-0.96), and overall morbidity (9% versus 9.1%, OR 1.0, 95% CI .55-1.81) were similar.

CONCLUSION

In elderly patients undergoing laparoscopic bariatric surgery, SG is not associated with significantly different 30-day outcomes compared to RYGB. Both procedures are followed by acceptably low morbidity and mortality.

Prophylactic gastrojejunostomy for unresectable periampullary carcinoma

BACKGROUND

The role of prophylactic gastrojejunostomy in patients with unresectable periampullary cancer is controversial.

OBJECTIVES

To determine whether prophylactic gastrojejunostomy should be performed routinely in patients with unresectable periampullary cancer.

SEARCH METHODS

For the initial version of this review, we searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, issue 3), MEDLINE, EMBASE and Science Citation Index Expanded until April 2010. Literature searches were re-run in August 2012.

SELECTION CRITERIA

We included randomised controlled trials comparing prophylactic gastrojejunostomy versus no gastrojejunostomy in patients with unresectable periampullary cancer (irrespective of language or publication status).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and independently extracted data. We analysed data with both the fixed-effect and the random-effects models using Review Manager (RevMan). We calculated the hazard ratio (HR), risk ratio (RR), and mean difference (MD) with 95% confidence intervals (CI) based on an intention-to-treat or available case analysis.

MAIN RESULTS

We identified two trials (of high risk of bias) involving 152 patients randomised to gastrojejunostomy (80 patients) and no gastrojejunostomy (72 patients). In both trials, patients were found to be unresectable during exploratory laparotomy. Most of the patients also underwent biliary-enteric drainage. There was no evidence of difference in the overall survival (HR 1.02; 95% CI 0.84 to 1.25), peri-operative mortality or morbidity, quality of life, or hospital stay (MD 0.97 days; 95%CI -0.18 to 2.12) between the two groups. The proportion of patients who developed long-term gastric outlet obstruction was significantly lower in the prophylactic gastrojejunostomy group (2/80; 2.5%) compared with no gastrojejunostomy group (20/72; 27.8%) (RR 0.10; 95%CI 0.03 to 0.37). The operating time was significantly longer in the gastrojejunostomy group compared with no gastrojejunostomy group (MD 45.00 minutes; 95%CI 21.39 to 68.61).

AUTHORS' CONCLUSIONS

Routine prophylactic gastrojejunostomy is indicated in patients with unresectable periampullary cancer undergoing exploratory laparotomy (with or without hepaticojejunostomy).

Short- and midterm results between laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy for the treatment of morbid obesity

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most widely used bariatric procedures today, and laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure for the treatment of morbid obesity is becoming increasingly popular in Europe. The aim of this study was to compare short- and midterm results between LRYGB and LSG.

METHODS

An observational retrospective study from a database of patients undergoing LRYGB and LSG between January 2008 and June 2011. Seventy patients (mean age 39 years) were included. Patients were followed at 6, 12, and 18 months. Operative time, length of stay, weight loss, comorbidity improvement or resolution, postoperative complications, reinterventions and mortality were evaluated.

RESULTS

Thirty-six LRYGB and 34 LSG were included. Mean operative time of LSG was 106 min while LRYGB was 196 min (P < 0.001). Differences in length of stay, early and late complications, and improvement or resolution in comorbidities were not significant (P > 0.05). Eighteen months after surgery, average excess weight loss was 77.6% in LRYGB and 57.1% in LSG (P = 0.003). There was no surgery-related mortality.

CONCLUSIONS

Both LRYGB and LSG are safe procedures that provide good results in weight loss and resolution of comorbidities at 18 months.

Overview of outcomes of laparoscopic and open Roux-en-Y gastric bypass in the United States

INTRODUCTION

Roux-en-Y Gastric Bypass is the gold standard procedure for weight loss surgery and is the most commonly performed bariatric operation in the United States. Laparoscopic gastric bypass (LGBP) has become the predominantly used technique for weight loss surgery since 2004. The aim of this study was to compare surgical outcomes of LGBP versus open gastric bypass (OGBP) for the treatment of morbid obesity.

METHODS

Using the Nationwide Inpatient Sample database, clinical data of morbidly obese patients who underwent LGBP or OGBP from 2006 to 2008 were analyzed. Outcome measures included patient characteristics, comorbidities, postoperative complications, length of hospital stay (LOS), hospital charges, and in-hospital mortality.

RESULTS

A total of 226,043 morbidly obese patients underwent gastric bypass during the three-year period (LGBP: 183,452 [81.16%], OGBP: 42,591[18.84%]). The majority of patients in both groups were female (LGBP: 81.0% vs. OGBP: 78.5%, p < 0.01) and Caucasian (LGBP: 73.9% vs. OGBP: 72.6%, p < 0.01). Most comorbidities were significantly higher in the OGBP group. All specific postoperative complications were significantly higher in the OGBP group (urinary tract infection [UTI], pneumonia, acute renal failure, respiratory failure, myocardial infarction, venous thromboembolism, ileus, gastrointestinal leak, wound infection, and bowel obstruction). LGBP was associated with lower overall postoperative complications (3.5% vs. 10.8%; p < 0.01), shorter LOS (2.4 days vs. 4.2 days; p < 0.01), lower mortality (0.06 vs. 0.52; p < 0.01), and lower hospital costs ($39,570 vs. $45,629; p < 0.01) compared with the OGBP.

CONCLUSION

LGBP was associated with shorter LOS, lower morbidity, lower mortality, and lower hospital costs compared with those of OGBP. The laparoscopic approach to gastric bypass should be considered the gold standard approach for the treatment of morbid obesity.

Challenges and pitfalls of experimental bariatric procedures in rats

INTRODUCTION

The impact of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) on obesity and obesity-related diseases is unquestionable. Up to now, the technical descriptions of these techniques in animals/rats have not been very comprehensive.

METHODS

For SG and RYGB, operating time, learning curve, and intraoperative mortality in relation to weight of the rat and type of anesthesia were recorded. Furthermore, a review of the literature on experimental approaches towards SG and RYGB in rats was carried out, merging in a detailed technical description for both procedures.

RESULTS

The data presented here revealed that the mean operating time for SG (69.4 ± 22.2 min (SD)) was shorter than for RYGB (123.0 ± 20.7 min). There is a learning curve for both procedures, resulting in a reduced operating time of up to 60% in SG and 35% in RYGB (p < 0.05; t-test). However, with increased weight, operating time increases to about 80 min for SG and about 120 min for RYGB. Obese rats have an increased intraoperative mortality rate of up to 50%. After gaseous anesthesia the mortality can be even higher. The literature search revealed 40 papers dealing with SG and RYGB in rats. 18 articles (45%) contained neither photographs nor illustrations; 14 articles (35%) did not mention the applied type of anesthesia. The mortality rate was described in 15 papers (37.5%).

CONCLUSION

Experimental obesity surgery in rats is challenging. Because of the high mortality in obese rats operated under gaseous anesthesia, exercises to establish the techniques should be performed in small rats using intraperitoneal anesthesia.

Robotic-assisted Roux-en-Y Gastric bypass: minimizing morbidity and mortality

BACKGROUND

Despite the rapid acceptance of laparoscopic Roux-en-Y gastric bypass (RYGB) by the community and increase in the number of these procedures being done, there is still significant morbidity and mortality.

METHODS

At the University of Texas Medical School at Houston, we have performed 320 RYGB with robotic assistance (RARYGB). Surgical times, length of stay, morbidity, and mortality have been recorded since the beginning of our robotic experience and represent the world's largest single institution series of RARYGB. Outcome data were examined in a postoperative cohort.

RESULTS

The average starting BMI was 49.1 kg/m(2), and it declined by 66% to 32.5 kg/m(2) by the end of 1 year. The average operative time was 192 min, and the average length of stay was 2.7 days. Within the first year, there were a total of 77 (24.1%) complications. The foremost complications noted in the literature to be 3% to 11% were all <1% in our series, and we have no mortalities. Compared to our 356 laparoscopic RYGB, there was a significantly lower gastrointestinal leak rate in the robotic arm. A cohort of 79 postoperative patients was analyzed with respect to weight loss, resolution of co-morbidity, and quality of life. While there was no variation in quality of life over time, weight loss, resolution of co-morbidities, and overall outcome score were significantly improved.

CONCLUSIONS

We effectively perform robotic-assisted RYGB that lowers the morbidity and mortality of this procedure compared to today's standard while maintaining thriving outcomes.

[Postoperative complications after laparoscopic Roux-en-Y gastric bypass in bariatric surgery]

Der laparoskopische Roux-Y-Magenbypass weist eine Reihe charakteristischer chirurgischer KomplikationsmÖglichkeiten neben den in der bariatrischen Chirurgie generell vorhandenen Risiken auf. Durch die minimal-invasive Technik konnte das Risiko insgesamt vermindert werden. Die MortalitÄt betrÄgt 0–0,5%, das MorbiditÄtsrisiko betrÄgt zwischen 6 und 30%. Dabei erschweren die speziellen UmstÄnde des morbid adipÖsen Patienten hÄufig die Diagnosestellung, und insbesondere septische Komplikationen mit einem hohen MortalitÄtsrisiko stellen eine große Gefahr dar. GrÖßt mÖgliche Sicherheit und PrÄvention sind daher besonders wichtig. Die hÄufigsten Todesursachen sind Lungenembolie und Anastomoseninsuffizienz. Die hÄufigsten Komplikationen haben pulmonale und kardiale Ursachen. Wundkomplikationen werden als Folge des laparoskopischen Zugangssehrselten beobachtet. Chirurgische Komplikationen resultieren im Wesentlichen aus Blutungen, Problemen an den Anastomosen und NÄhten sowie dem DÜnndarm in Form von PassagestÖrungen unterschiedlicher Genese. Die chirurgischen wie bariatrischen Ergebnisse zeigen, dass das Ausmaß der FrÜh- und SpÄtkomplikationen im Vergleich zu den Folgeneiner fehlenden operativen Behandlung akzeptabel ist. Postoperative Complications after Laparoscopic Roux-en-Y Gastric Bypass in Bariatric Surgery The laparoscopic Roux-en-Y gastric bypass surgery involves some characteristic surgical complications besides the general risks associated with bariatric surgery. The overall risk could be effectively decreased due to the minimal invasive technique, though. The mortality is 0–0.5% and the risk ofmorbidity varies between 6 and 30%. However, the specific circumstances of morbidly obese patients make diagnostics difficult. Especially septic complications of any kind represent a high risk ofmortality. Therefore, maximal safety und prevention are very important issues to consider. The most common causes of death are pulmonary embolismand insufficiency of anastomosis. Due to the laparoscopic approach complications of wound healing are scarcely observed. The most frequent complications result from pulmonary and cardiac dysfunctions. Surgical complications mainly result from bleedings, problems with the anastomoses and sutures as well as from the small intestine showing any kind of passage malfunction. Overall, the surgical and bariatric results reveal that early postoperative and long-term complications remain within tolerable limits when compared toconsequences of a lack of surgery.

Validation of the Obesity Surgery Mortality Risk Score in a Multicenter Study Proves It Stratifies Mortality Risk in Patients Undergoing Gastric Bypass for Morbid Obesity

BACKGROUND

A scoring system for clinical assessment of mortality risk has been previously proposed for bariatric surgery (Demaria EJ, Portenier D, Wolfe L, Surg Obes Relat Dis. 2007;3:34-40.). The Obesity Surgery Mortality Risk Score (OS-MRS) was developed from a single institution experience of 2075 patients. The current study provides multicenter validation of the value of the OS-MRS. The OS-MRS assigns 1 point to each of 5 preoperative variables, including body mass index>or=50 kg/m2, male gender, hypertension, known risk factors for pulmonary embolism (previous thromboembolism, preoperative vena cava filter, hypoventilation, pulmonary hypertension), and age>or=45 years. Patients with total score of 0 to 1 are classified as 'A' (lowest) risk group, score 2 to 3 as 'B' (intermediate) risk group, and score 4 to 5 as 'C' (high) risk group.

METHODS

Prospectively-collected data from 4431 consecutive patients undergoing a primary gastric bypass at 4 bariatric programs recruited to validate the proposed system were analyzed to assess OS-MRS as a means of stratifying surgical mortality risk.

RESULTS

There were 33 total deaths for an overall mortality for the validation cohort of 0.7% consistent with published standards. Mortality for 2164 class A patients was 0.2%, for 2142 class B patients was 1.1%, and for 125 class C patients was 2.4%. Mortality was significantly different between each of the class A, B, and C groupings (P<0.05, chi2). Mortality was 5-fold greater in the class B group than in class A. Only 6 patients with all 5 risk factors were identified. Class C patients (n=125, 3% of total cohort) were characterized by a 12-fold greater mortality than the lowest risk group (A) and a disproportionate 9% of all mortalities.

CONCLUSION

The OS-MRS was found to stratify mortality risk in 4431 patients from 4 validation centers that were nonparticipants in the original defining cohort study. The score represents the first validated scoring system for risk stratification in bariatric surgery and is anticipated to aid informed consent discussions, guide surgical decision-making, and allow standardization of outcome comparisons between treatment centers.

Comparative long-term mortality after laparoscopic adjustable gastric banding versus nonsurgical controls

BACKGROUND

To compare the mortality rate of obese patients treated by laparoscopic gastric banding (LAGB) with the mortality rate of matched obese patients observed at medical centers. The net effect of bariatric surgery on total mortality is still controversial. Gastric bypass has been shown to reduce the relative risk of death, but similar data with LABG are still lacking.

METHODS

The surgical series was composed of 821 patients with a body mass index (BMI) >40 kg/m(2) consecutively treated with LAGB at Padova University, Italy. The reference group was composed of 821 gender-, age-, and BMI-matched patients selected from a sample of 4681 adults with a BMI >40 kg/m(2) observed at 6 Italian medical centers not using surgical therapy.

RESULTS

The mean follow-up was 5.6 +/- 1.9 and 7.2 +/- 1.2 years in the surgical and reference group, respectively. The vital status was known in 97.6% of the surgical group (8 deaths) and in 97.4% of the reference group (36 deaths). In the surgical group, the percentage of excess weight loss was 39.8% +/- 17.9% 1 year after LAGB and 37.2% +/- 23.8% 5 years after LAGB. The rate of late revisional surgery was 12.2%. Survival was estimated using the Kaplan-Meier method, and the differences between the 2 groups were evaluated using the log-rank test. The survival rate was significantly greater in the surgical group (P = 0.0004). On multivariate Cox analysis, the 5-year relative risk of death in the surgical group, adjusted for gender, age, and baseline BMI, was 0.36 (95% confidence interval 0.16-0.80).

CONCLUSION

LAGB was associated with a 0% operative mortality rate and 40% stable excess weight loss. LAGB patients had a 5-year 60% lower risk of death than comparable morbidly obese patients.

Perioperative outcomes of bariatric surgery in adolescents compared with adults at academic medical centers

BACKGROUND

To compare the perioperative outcomes of bariatric surgery between adolescent (12-18 years) and adult (>18 years) patients for the treatment of morbid obesity using an administrative database.

METHODS

Using the International Classification of Diseases, 9th Revision, Clinical Modification diagnosis and procedural codes, we obtained data from the University HealthSystem Consortium for 55,501 morbidly obese patients (309 adolescents and 55,192 adults) who had undergone laparoscopic or open gastric bypass, laparoscopic gastric banding, or laparoscopic gastroplasty from 2002 to 2006. The outcome measures included demographics, length of hospital stay, intensive care unit stay, 30-day readmission, morbidity, and observed and expected (risk-adjusted) mortality.

RESULTS

The overall 30-day complication rate was significantly lower in the adolescent group (5.5% adolescents and 9.8% adults). The in-hospital and observed/expected mortality ratios were similar between groups. The greatest morbidity was associated with open gastric bypass procedures (7.6% for adolescents and 11.1% for adults) followed by laparoscopic gastric bypass (4.3% and 7.5%, respectively). Open gastric bypass in adults had the greatest observed/expected mortality ratio (1.0). In adolescents, the 30-day morbidity and mortality rate was 0% for restrictive procedures (laparoscopic adjustable gastric banding and gastroplasty).

CONCLUSION

Bariatric surgery in adolescents represents a small subset of all bariatric operations performed at academic centers, although the number has increased threefold since 2002. Gastric bypass is the most commonly performed bariatric procedure in adolescents. The outcomes of bariatric surgery in adolescents appear to be as safe as those in adults, with lower 30-day morbidity.

Avoidance of complications in older patients and Medicare recipients undergoing gastric bypass

HYPOTHESIS

Perioperative morbidity and mortality do not increase in carefully evaluated and managed Medicare and elderly patients undergoing gastric bypass.

DESIGN

Retrospective review of a prospectively maintained bariatric database.

SETTING

Academic tertiary care medical center.

PATIENTS

We reviewed our database of 928 consecutive patients who underwent gastric bypass from March 24, 1998, through May 31, 2006. Of these patients, 36 underwent revision surgery and were excluded. The remaining 892 patients were separated into 4 groups by age and Medicare status. Group 1 consisted of 46 patients 60 years or older at the time of gastric bypass (range, 60-66 years). Group 2 consisted of 846 patients 59 years or younger at the time of gastric bypass (range, 18-59 years). Group 3 consisted of 31 Medicare recipients (age range, 31-66 years). Group 4 consisted of 861 non-Medicare recipients (age range, 18-64 years).

MAIN OUTCOME MEASURES

Groups were compared in terms of demographics, morbidity, and mortality.

RESULTS

No differences were found in outcomes between older vs younger and Medicare vs non-Medicare patients for any postoperative complication or mortality.

CONCLUSIONS

Bariatric surgery can be performed in carefully selected Medicare recipients and patients 60 years or older with acceptable morbidity and mortality. No difference was found in the occurrence of complications in Medicare patients, patients younger than 60 years, or patients 60 years and older. We believe that these results reflect careful patient selection, intensive preoperative education, and expert operative and perioperative management. Our results indicate that bariatric surgery should not be denied solely based on age or Medicare status.

A state-wide review of contemporary outcomes of gastric bypass in Florida: does provider volume impact outcomes?

OBJECTIVES

To report contemporary outcomes of gastric bypass for obesity and to assess the relationship between provider volume and outcomes.

BACKGROUND

Certain Florida-based insurers are denying patients access to bariatric surgery because of alleged high morbidity and mortality.

SETTINGS AND PATIENTS

The prospectively collected and mandatory-reported Florida-wide hospital discharge database was analyzed. Restrictive procedures such as adjustable gastric banding and gastroplasty were excluded.

RESULTS

The overall complication and in-hospital mortality rates in 19,174 patients who underwent gastric bypass from 1999 to 2003 were 9.3% (8.9-9.7) and 0.28% (0.21-0.36), respectively. Age and male gender were associated with increased duration of hospital stay (P < 0.001), increased in-hospital complications [age: odds ratio (OR) = 1.11, CI: 1.08-1.13; male: OR = 1.53, CI: 0.36-1.72] and increased in-hospital mortality (age: OR = 1.51, CI: 1.32-1.73; male: CI = 2.66, CI: 1.53-4.63), all P < 0.001. The odds of in-hospital complications significantly increased with diminishing surgeon or hospital procedure volume (surgeon: OR = 2.0, CI: 1.3-3.1; P < 0.001, 1-5 procedures relative to >500 procedures; hospital volume: OR = 2.1, CI: 1.2-3.5; P < 0.001, 1-9 procedures relative to >500 procedures). The percent change of in-hospital mortality in later years of the study was lowest, indicating higher mortality rates, for surgeons or hospitals with fewer (< or =100) compared with higher (> or =500) procedures.

CONCLUSION

Increased utilization of bariatric surgery in Florida is associated with overall favorable short-term outcomes. Older age and male gender were associated with increased morbidity and mortality. Surgeon and hospital procedure volume have an inverse relationship with in-hospital complications and mortality.

Effect of location and speed of diagnosis on anastomotic leak outcomes in 3828 gastric bypass cases

INTRODUCTION

Leaks after Roux-en-Y gastric bypass are a major cause of mortality. This study attempts to define the relationship between the leak site, time from surgery to detection, and outcome.

METHODS

Retrospective review of 3,828 gastric bypass procedures.

RESULTS

Of the leaks (3.9% overall), 60/2,337 (2.6%) occurred after open gastric bypass, 57/1,080 (5.2%) after laparoscopic gastric bypass, and 33/411 (8.0%) after revisions. Overall leak-related mortality after Roux-en-Y gastric bypass was 0.6% (22/3,828). Mortality rate from gastrojejunostomy leaks (38 in the open gastric bypass, and 43 in the laparoscopic) was higher in the open group than the laparoscopic group (18.4 vs 2.3%, p = 0.015). Median time of detection for a gastrojejunostomy leak in the open group was longer than in the laparoscopic group (3 vs 1 days, Wilcoxon score p < 0.001). Jejunojejunostomy (JJ) leak was associated with a 40% mortality rate. Initial upper gastrointestinal series did not detect 9/10 jejunojejunostomy leaks. Median detection time was longer in the jejunojejunostomy leak group than the gastrojejunostomy leak group (4 vs 2 days, p = 0.037).

DISCUSSION

Leak mortality and time of detection was higher after open gastric bypass than laparoscopic gastric bypass. GBP patients with normal upper gastrointestinal (UGI) studies may harbor leaks, especially at the JJ or excluded stomach. Normal UGI findings should not delay therapy if clinical signs suggest a leak.

Factors affecting morbidity and mortality of Roux-en-Y gastric bypass for clinically severe obesity: an analysis of 1,000 consecutive open cases by a single surgeon

INTRODUCTION

Determinants of perioperative risk for RYGB are not well defined.

METHODS

Retrospective analysis of comorbidities was used to evaluate predictors of perioperative risk in 1,000 consecutive patients having open RYGB by univariate analyses and logistic regression.

RESULTS

One hundred forty-six men, 854 women; average age 38.3+/-11.2 years; mean BMI 51.8+/-10.5 (range 24-116) were evaluated. Average hospital stay (LOS) was 3.8 days; 87%<3 days. 91.3% of procedures were without major complication. The most common complications were incisional hernia 3.5%, intestinal obstruction 1.9%, and leak 1.6%. 31 patients required reoperation within 30 days (3.1%). A 30-day mortality was 1.2%. Logistic regression evaluating predictors of operative mortality correlated strongly with coronary artery disease (CAD) (p<0.01), sleep apnea (p=0.03), and age (p=0.042). BMI>50 (0.6 vs 2.3%, p=0.03) and male sex were associated with increased mortality (1.3 vs. 4.0%, p=0.02). Sex-specific logistic regression demonstrated males with angiographically proven CAD were more likely to die (p=0.028) than matched cohorts. Age (p=0.033) and sleep apnea (p=0.040) were significant predictors of death for women.

CONCLUSION

Perioperative mortality after RYGB appears to be affected by sex, BMI, age, CAD, and sleep apnea. Strategies employing risk stratification should be developed for bariatric surgery.

Causes of 30-day Bariatric Surgery Mortality: With Emphasis on Bypass Obstruction

BACKGROUND

This is a study of the causes of 30-day postoperative death following surgical treatment for obesity and a search for ways to decrease an already low mortality rate.

METHODS

Data were contributed from 1986-2004 to the International Bariatric Surgery Registry by 85 sites, representing 137 surgeons. A spread-sheet was prepared with rows for causes and columns for patients. The 251 causes contributing to 93 deaths were then marked in cells wherever a patient was noted to have one of the causes. Rows and columns were then moved into positions that provided patterns of best fit.

RESULTS

11 patterns were found. 10 had well known initiating causes of death. Overall operative 30-day mortality was 0.24% (93 / 38,501). The most common cause of death was pulmonary embolism (32%, 30/93). 14 deaths were caused by leaks (15%, 14/93), and were equally prevalent after simple (15%, 2/14) or complex (15%, 12/79) operations. Small bowel obstruction caused 8 deaths, exclusively after complex operations. 5 of these involved the bypassed biliopancreatic limb and were defined as "bypass obstruction".

CONCLUSIONS

A spread-sheet study of cause of 30-day postoperative death revealed a rapidly lethal initiating complication of Roux-en-Y gastric bypass obstruction that requires the earliest possible recognition and treatment. Bypass obstruction needs a name and code to facilitate recognition, study, prevention and early treatment. Spread-sheet pattern analysis of all available data helped identify the initiating cause of death for individual patients when multiple data elements were present.

Outcomes among elderly bariatric patients at a high-volume center

BACKGROUND

Bariatric surgery in elderly patients remains controversial. With a growing morbidly obese elderly population, management strategies and treatment outcomes need to be evaluated.

METHODS

We reviewed all bariatric cases from 2001 to 2005 at a single institution. The preoperative factors (body mass index, smoking status, co-morbid conditions, number of medications) and surgical information (operation and length of stay) were recorded. Patients >60 years old who had undergone Roux-en-Y gastric bypass (RYGB) were followed up, and their surgical outcomes were analyzed (reduction in medications, resolution of diabetes mellitus and hypertension, percentage of excess body weight loss, complications, and mortality).

RESULTS

Of 1065 patients, 76 (7.1%) were aged > or =60 years. Of these 76 patients, 61 (5.7%) underwent RYGB. The other 989 patients (92.9%) were <60 years old, and 952 of these underwent RYGB. In the older group, the mean number of co-morbid conditions was 10 +/- 3.3, 70.5% had diabetes, and 83.6% had hypertension. In the younger group, the mean number of co-morbidities was 4.7 +/- 2.3. The mean number of preoperative medications was 10 +/- 4.5 in the older group compared with 6.0 +/- 4.3 in the younger group. The mean length of stay was 2.9 days in both groups. Postoperatively, medications were reduced by nearly 50% in both groups. Diabetes and hypertension resolved or improved significantly in both groups. The mean percentage of excess body weight loss was lower in the older patients (54.9% versus 60.1%; P = .09). The 90-day operative mortality rate was 1.64% in the older group versus 0.53% for the younger group (P = NS).

CONCLUSION

Our data support the use of RYGB in older patients in programs prepared to comprehensively manage the medical co-morbidities. Although the percentage of excess body weight loss was less, the mortality was acceptable despite the greater number of co-morbidities. Both diabetes and hypertension were more common in this population, with trends toward better improvement after RYGB than in younger patients.

[Factors associated with morbidity and mortality after gastric bypass. Alternatives for risk reduction: sleeve gastrectomy]

INTRODUCTION

The aim of this study was to analyze factors related to morbidity and mortality after gastric bypass and to evaluate lower-risk alternatives in selected patients.

PATIENTS AND METHODS

A prospective cohort of 761 patients who underwent gastric bypass was included. Prognostic factors were studied using a logistic regression model with SPSS 11.0. Independent variables were age, sex, body mass index (BMI), comorbidities, and the laparoscopic approach. Dependent variables consisted of medical complications, surgical complications, and mortality. We performed a preliminary descriptive study of morbidity and weight loss at 3 months after sleeve gastrectomy.

RESULTS

In the postoperative period, 2.8% of patients presented medical complications and 5.4% presented surgical complications. Mortality was 0.52%. Surgical complications were significantly associated with age > 45 years (P = .04; OR = 2.00 [1.03-3.8]) and male sex (P = .041; OR = 2.40 [1.12-5.14]). Medical complications were significantly associated with a BMI of > 50 kg/m2 (P = .012; OR = 3.32 [1.23-8.98]), and mortality was significantly associated with a BMI of > 50 kg/m2 (P = .006) and male sex (P = .006). Sleeve gastrectomy was performed in eight patients with a BMI of > 60 kg/m2, in three patients with a BMI of > 50 kg/m2, cardiopulmonary disease and android fat distribution, and in four patients with a BMI of between 35 and 40 kg/m2 and major comorbidity. Morbidity consisted of self-limited febrile syndrome in one patient. There was no mortality. Weight loss at 3 months was 39.8 +/- 5.36% of excess BMI in superobese patients (n = 4) and was 50.2 +/- 11.05% of excess BMI in morbidly obese patients (n = 4).

CONCLUSIONS

Postoperative morbidity and mortality was significantly higher in male patients, in patients aged more than 45 years, and in those with a BMI of > 50 kg/m2. Sleeve gastrectomy in selected patients could be a lower-risk alternative.

Postmortem findings in morbidly obese individuals dying after gastric bypass procedures

Mortality has been reported to complicate gastric bypass, with common causes of death attributable to anastomotic leaks, sepsis, hemorrhage, and bowel obstruction. We evaluated autopsy reports from 10 patients having undergone gastric bypass. Medical records were reviewed to identify comorbidities. Data of interest included preoperative electrocardiogram (EKG) abnormalities, cause of death, body weight, anastamosis appearance, heart weight, extent of coronary artery disease, ventricular size, liver weight, and gall bladder status. A total of 7 men and 3 women were autopsied. Average age was 40 years (range, 30-49 years), and mean body mass index at autopsy was 60.3 kg/m(2) (range, 33.2-80.9 kg/m(2)). Evidence of anastomotic leaks was present in 7 cases, resulting in 4 deaths. Death was attributed to pulmonary embolism in one case. There were 5 cardiac-related deaths, all attributed to arrhythmias. Microscopic evidence of coronary artery disease was observed in 6. Cardiomegaly was seen in all patients, left ventricular hypertrophy in 8, right ventricular hypertrophy in 3, and hepatomegaly in all 10. Nine patients were status post cholecystectomy. Of the 8 preoperative EKG available, abnormalities were identified in 5. After gastric bypass, death was attributed to cardiac-related causes, pulmonary embolism, and operative complications. A significant proportion of cardiac-related deaths occured in the absence of atherosclerosis. Most patients had preoperative EKG abnormalities. As a high incidence of cardiomegaly was observed, operative stress associated with the procedure may increase the risk of arrhythmia in morbid obesity. Consequently, in morbidly obese patients, a detailed preoperative cardiovascular evaluation is warranted to reduce postoperative mortality.

A comparison of open and laparoscopic Roux-en-Y gastric bypass surgery for morbid and super obesity: a decision-analysis model

BACKGROUND

The aim of this study was to compare laparoscopic Roux-en-Y gastric bypass (LGBP) with open Roux-en-Y gastric bypass (OGBP) to determine which approach resulted in better clinical outcomes and cost effectiveness in patients with morbid obesity.

METHODS

A decision-analysis model was constructed to evaluate outcomes of LGBP versus OGBP in patients with body mass index (BMI) ranges of 35 to 49, 50 to 60, and greater than 60. Baseline assumptions for the model were derived from published reports. Sensitivity and cost-effectiveness analyses were performed to determine the optimal strategy. Success was defined as no major procedure-related complications and no long-term complications over a 1-year period after surgery. Failure of therapy was defined as either recurrent symptoms or death attributed to a surgical complication.

RESULTS

In patients with a BMI of 35 to 49, LGBP failed in 14% and OGBP failed in 18% of patients, favoring LGBP alone as the dominant strategy. Mortality in the OGBP group was 1.3 times that of the LGBP group. For a BMI of 50 to 60, LGBP was dominant with an overall success rate of 82% as compared with OGBP (77%). Mortality in the OGBP group was 1.3 times that of the LGBP group. For a BMI of greater than 60, LGBP was the dominant strategy with an overall success rate of 67% compared with OGBP (63%). Sensitivity and cost-effective analysis showed that LGBP was the dominant strategy in terms of greater success and less overall morbidity and mortality for all 3 groups.

CONCLUSIONS

This analysis suggests that for all BMI ranges evaluated, LGBP is preferable to OGBP. These conclusions are limited by potential selection and publication bias in the trials assessed for this analysis. These limitations can be resolved only by randomized control trials.

The malabsorptive very, very long limb Roux-en-Y gastric bypass for super obesity: results in 257 patients

BACKGROUND

For the past 11 years, we have used a malabsorptive form of Roux-en-Y gastric bypass (RYGB), the "very, very long limb" RYGB, for selected patients with BMIs >50 kg/m(2) and in highly selected patients with BMI <50 kg/m(2). This modified distal gastric bypass establishes a 100-cm common channel (for digestion and absorption) and a "very, very" long Roux limb of 400 to 500 cm.

METHODS

To determine long-term efficacy and complications, we followed prospectively 257 consecutive patients; 188 (73%) participated in a postoperative survey.

RESULTS

Of the patients, 60% were female; overall age (x +/- SD) was 45 +/- 11 years, and BMI was 61 +/- 11 kg/m(2). Operative mortality was 1% with substantive postoperative morbidity occurring in 13%. Eighty-two percent of patients returning the survey an average of 48 months postoperatively (range, 12 to 148 months) lost >50% of excess body weight; BMI at follow-up was 37 +/- 9 kg/m(2). Resolution of comorbidities included diabetes mellitus (94%), hypertension (65%), sleep apnea (48%), and asthma (30%). Side effects included mild food intolerance (82%), occasional loose or watery stools (71%), nephrolithiasis (16%), and symptomatic steatorrhea (5%). Nine patients (4%) who developed or were developing impending protein/calorie malnutrition required proximal relocation of the enteroenterostomy with symptom resolution.

CONCLUSIONS

Overall, 90% were satisfied with the operation, and 93% would recommend it to a friend. The very, very long limb RYGB is relatively safe and effective and has acceptable side effects in the treatment of selected patients with super obesity (BMI >50). Because of the possibility of malabsorptive sequelae, patients should be selected based on degree of medical sophistication, insight, and compliance.

[Perioperative risk among morbid obese patients subjected to gastric bypass]

BACKGROUND

Bariatric surgery is a complex procedure not exempt of complications.

AIM

To assess mortality and complications of excisional gastric bypass among morbidly obese subjects.

MATERIAL AND METHODS

Prospective analysis of 684 morbid obese patients (age range 14-70 years, 525 females) subjected to an excisional gastric bypass. Major postoperative complications and mortality were registered.

RESULTS

Mean body mass index (BMI) of the subjects was 43.7 kg/m2. One hundred sixty two patients had a BMI between 35 and 39.9 kg/m2, 419 had a BMI between 40 and 49.9 kg/m2 and 103 had a BMI over 50 kg/m2. Two patients with a BMI of 52 and 56 kg/m2 respectively, died in the postoperative period (0.3%). Thirty six patients had major complications. Anastomotic fistula was the most common complication in 12 patients (1.7%). Fourteen patients required a new operation due to complications. None of these died. The mean operative volume of the surgical team was 124 patients per year.

CONCLUSIONS

Excisional gastric bypass has a low rate of mortality and complications, if the surgical team operates a large volume of patients.

Is Roux-en-Y gastric bypass adequate in the super-obese?

BACKGROUND

The outcome after Roux-en-Y gastric bypass (RYGBP) in morbidly obese (MO) (body mass index [BMI] 40-50) was compared with super-obese (SO) (BMI >50) and super-super-obese (SSO) (BMI >60) patients.

METHODS

A prospective study was conducted in 738 consecutive patients who underwent RYGBP. 483 MO were compared with 184 SO and 70 SSO. Study endpoints included: effect on co-morbid conditions, postoperative morbidity and mortality, and long-term results. Statistical analysis utilized SPSS 11.0.

RESULTS

Percentage of males was significantly greater in the SO groups (16.5% vs 13%, P=0.01). Obesity-related conditions were significantly more frequent in the SO groups: sleep apnea (38% vs 17%, P<0.0005), gallstones (23% vs 14%, P=0.013); diabetes (29% vs 17%, P=0.002). Hospital stay was longer in the SO groups (5.7+/-6.1 days vs 4.6+/-2.6 days, P=0.024). Wound infection was more frequent in the SO groups (4.7% vs 1.4%, P=0.019). Postoperative mortality was greater in the SSO and SO groups (1.6% and 1.4%) than MO (0%) (P=0.019). Incisional hernia was more frequent in the SO groups (14.1% vs 8.6%; P=0.041). There was no significant difference in percent of excess weight loss (%EWL) between the three groups. EWL >50% at 5 years was: MO 81.5%, SO 87.5%, SSO 80%. The surgery was effective in treating the co-morbid conditions.

CONCLUSION

RYGBP achieved significant durable weight loss and effectively treated co-morbid conditions in SO and SSO patients with acceptable postoperative morbidity and slightly greater mortality than in MO patients.

Laparoscopic adjustable gastric band versus laparoscopic Roux-en-Y gastric bypass: ends justify the means?

BACKGROUND

In the United States, the most frequently performed bariatric procedure is the Roux-en-Y gastric bypass (RYGB). Worldwide, the most common operation performed is the laparoscopic adjustable gastric band (LAGB). The expanding use of LAGB is probably driven by the encouraging data on its safety and effectiveness, in contrast to the disappointing morbidity and mortality rates reported for RYGB. The aim of this study was to evaluate the results of LAGB versus RYGB at a single institution.

METHODS

Between November 2000 and July 2004, 590 bariatric procedures were performed. Of these, 120 patients (20%) had laparoscopic RYGB and 470 patients (80%) had LAGB. A retrospective review was performed.

RESULTS

In the LAGB group, 376 patients (80%) were female, and the mean age was 41 years (range, 17-65). In the RYGB group, 110 patients (91%) were female, and the mean age was 41 years (range, 20-61). Preoperative body mass index was 47 +/- 8 and 46 +/- 5, respectively (p = not significant). Operative time and hospitalization were significantly shorter in LAGB patients (p < 0.001). Complications and the need for reoperation were comparable in both groups. Weight loss at 12, 18, 24, and 36 months for LAGB and RYGB was 39 +/- 21 versus 65 +/- 13, 39 +/- 20 versus 62 +/- 17, 45 +/- 25 versus 67 +/- 8, and 55 +/- 20 versus 63 +/- 9, respectively.

CONCLUSIONS

The current study demonstrates that LAGB is a simpler, less invasive, and safer procedure than RYGB. Although mean percentage excess body weight loss (%EBWL) in RYGB patients increased rapidly during the first postoperative year, it remained nearly unchanged at 3 years. In contrast, in LAGB patients weight loss was slower but steady, achieving satisfactory %EBWL at 3 years. Therefore, we believe that LAGB should be considered the initial approach since it is safer than RYGB and is very effective at achieving weight loss.

Impact of major co-morbidities on mortality and complications after gastric bypass

BACKGROUND

We hypothesized that major co-morbidities affect survival and complications after gastric bypass.

METHODS

A total of 1465 patients undergoing laparoscopic and open gastric bypass between 1995 and 2002 were studied. Patients with a body mass index >or= 35 kg/m(2) and major co-morbidities (group 1, n = 1045) were compared with patients with a body mass index >or= 40 kg/m(2) with minor/no co-morbidities (group 2, n = 420).

RESULTS

Group 1 patients were older (43 versus 36 years, P < 0.001) and had a greater BMI (53 versus 50 kg/m(2), P < 0.001). Early postoperative complications were greater in group 1 than in group 2 and included leaks (4.1% versus 1.2%, P < 0.0032) and wound infections (3.9% versus 1.4%, P < 0.0133). Procedure-related mortality in the series was 1.7%. Mortality was 10-fold greater in group 1 (2.3% versus 0.2%, P < 0.0032). The incidence of small bowel obstruction, incisional hernia, and pulmonary embolism was similar in the two groups. Excess weight loss was significantly greater in group 2 (68% versus 62%, P < 0.001) at 1 year. Resolution of group 1 co-morbidities was great, including hypertension in 62%, diabetes in 75%, venous stasis disease in 96%, and pseudotumor cerebri in 98%.

CONCLUSION

Outcomes analysis of obesity surgery requires risk stratification. The very low mortality rates in published studies are likely explained by surgical treatment of low-risk patients with minor co-morbidities, such as those seen in group 2. However, despite the increased perioperative risk, the group 1 patients (with major co-morbidities) demonstrated dramatic resolution of their co-morbid conditions, justifying the decision to go forward with surgery. The data support a radical change in treatment philosophy in which morbidly obese individuals should be offered bariatric surgery before major co-morbid conditions develop as a strategy to decrease the operative risk.

Laparoscopic adjustable gastric banding: an attractive option

Bariatric surgery is the only effective treatment producing sustained weight loss and reduction in comorbidities in the morbidly obese. Laparoscopic adjustable gastric banding (LAGB) has evolved considerably in techniques of insertion and band management since the initial descriptions in the early 1990s. Major advantages of LAGB include lower perioperative morbidity and mortality, adjust-ability, and reversibility. Although weight loss occurs more slowly than after gastric bypass, end results are comparable.

Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures

CONTEXT

Case series demonstrate that bariatric surgery can be performed with a low rate of perioperative mortality (0.5%), but the rate among high-risk patients and the community at large is unknown.

OBJECTIVES

To evaluate the risk of early mortality among Medicare beneficiaries and to determine the relative risk of death among older patients.

DESIGN

Retrospective cohort study.

SETTING AND PATIENTS

All fee-for-service Medicare beneficiaries, 1997-2002.

MAIN OUTCOME MEASURES

Thirty-day, 90-day, and 1-year postsurgical all-cause mortality among patients undergoing bariatric procedures.

RESULTS

A total of 16 155 patients underwent bariatric procedures (mean age, 47.7 years [SD, 11.3 years]; 75.8% women). The rates of 30-day, 90-day, and 1-year mortality were 2.0%, 2.8%, and 4.6%, respectively. Men had higher rates of early death than women (3.7% vs 1.5%, 4.8% vs 2.1%, and 7.5% vs 3.7% at 30 days, 90 days, and 1 year, respectively; P<.001). Mortality rates were greater for those aged 65 years or older compared with younger patients (4.8% vs 1.7% at 30 days, 6.9% vs 2.3% at 90 days, and 11.1% vs 3.9% at 1 year; P<.001). After adjustment for sex and comorbidity index, the odds of death within 90 days were 5-fold greater for older Medicare beneficiaries (aged > or =75 years; n = 136) than for those aged 65 to 74 years (n = 1381; odds ratio, 5.0; 95% confidence interval, 3.1-8.0). The odds of death at 90 days were 1.6 times higher (95% confidence interval, 1.3-2.0) for patients of surgeons with less than the median surgical volume of bariatric procedures (among Medicare beneficiaries during the study period) after adjusting for age, sex, and comorbidity index.

CONCLUSIONS

Among Medicare beneficiaries, the risk of early death after bariatric surgery is considerably higher than previously suggested and associated with advancing age, male sex, and lower surgeon volume of bariatric procedures. Patients aged 65 years or older had a substantially higher risk of death within the early postoperative period than younger patients.

Laparoscopic Adjustable Gastric Banding: Evolving Clinical Experience

Laparoscopic adjustable gastric banding (LAGB) was first introduced in the early 1990s as a potentially safe, controllable, and reversible method for achieving significant weight loss in the severely obese. It is timely to review the existing data on this procedure derived from European, Australian, and American studies and compare and contrast their results. Special emphasis is placed on clinical outcomes and reported complications of LAGB. In general, international studies support use of the LAGB procedure,while American studies are generally better designed but more equivocal in their results.

Laparoscopic Roux-en-Y gastric bypass: results and learning curve of a high-volume academic program

HYPOTHESIS

Laparoscopic Roux-en-Y gastric bypass is a complex procedure performed on a high-risk patient population. Good results can be attained with experience and volume.

DESIGN

Retrospective study.

SETTING

Tertiary care academic hospital.

PATIENTS

Seven hundred fifty consecutive morbidly obese patients undergoing surgery from March 1998 to April 2004.

INTERVENTIONS

All patients underwent laparoscopic Roux-en-Y gastric bypass.

MAIN OUTCOME MEASURES

Perioperative deaths and complications.

RESULTS

The patient population was 85% women and had a mean body mass index of 47 kg/m2 (range, 32-86 kg/m2). The overall complication rate was 15% and the mortality was 0.3%. For the first 100 cases, the overall complication rate was 26% with a mortality of 1%. This complication rate decreased to approximately 13% and was stable for the next 650 patients. The incidence of major complications has also decreased since the first 100 cases. Leak decreased from 3% to 1.1%. Small-bowel obstruction decreased from 5% to 1.1%. Overall mean operating time was 138 minutes (range, 65-310 minutes). It decreased from 212 minutes for the first 100 cases to 132 minutes for the next 650 and 105 minutes (range, 65-200 minutes) for the last 100 cases.

CONCLUSIONS

Laparoscopic Roux-en-Y gastric bypass is a technically difficult operation. This review of a large series in a high-volume program demonstrated that the morbidity and mortality could be reduced by 50% with experience. The results are similar to those reported from other major centers. In addition, as reported elsewhere, the learning curve for this procedure may be 100 cases.

The cost effectiveness of laparoscopic versus open gastric bypass surgery

BACKGROUND

Over the last decade, laparoscopic gastric bypass (LGBP) has been proven to be a safe and well-tolerated approach to the Roux-en-Y gastric bypass, despite its increased cost when compared to the open approach (OGBP). This increased expense has led many to question whether LGBP is a cost effective alternative to OGBP. The aim of this study is to determine which approach is most cost effective, considering costs associated with the operation itself, perioperative complications, and income lost during convalescence.

METHODS

A PubMed search of the National Library of Medicine online journal database was conducted. Studies that met predetermined criteria for selection were included in the analyses of patient demographics, perioperative complications, length of hospital stay, excess weight loss, and time to recovery. Data on 6,425 OGBP and 5,867 LGBP patients were used to compare the outcomes associated with each approach.

RESULTS

Significant differences were found in the perioperative complication profiles, time to recovery, and overall expense of the two approaches. OGBP was associated with an increased incidence of major perioperative complications, especially extraintestinal complications, and greater perioperative mortality. LGBP was associated with shorter hospital stays, increased incidence of intestinal complications, and a 2.25% incidence of conversion to OGBP. Patient demographics and percent excess weight loss (%EWL) at 3 years follow-up were found to be similar with both OGBP and LGBP.

CONCLUSION

LGBP is a cost effective alternative to OGBP for surgical weight loss. Despite the increased cost of LGBP, patients suffer fewer expensive and lifethreatening perioperative complications.

Learning curve for laparoscopic Roux-en-Y gastric bypass with totally hand-sewn anastomosis: analysis of first 600 consecutive patients

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a challenging operation for the treatment of morbid obesity with well-demonstrated effectiveness in weight lost. There are several variations to the technique.

METHODS

From September 2000 to July 2004, 600 consecutive patients underwent surgery for morbid obesity at our institution. The surgical technique employed was LRYGB with totally hand-sewn gastrojejunal anastomosis (GJA). All patients were considered candidates for laparoscopic approach regardless of age, gender, body mass index (BMI), or previous bariatric or digestive surgery.

RESULTS

Mean BMI was 44.4 +/- 7.6 kg/m2. Thirty-two patients had undergone previous failed bariatric procedures. Conversion to an open procedure was necessary in three patients. Seventy-two patients (12%) developed early complications, including 23 (3.8%) leaks at the GJA (eight in the first 18 patients). Mortality rate was 1.1% (one death was related to GJA leakage). Early and late reoperation rates were 5.3 and 1.8%, respectively. Rate plateau of morbidity and mortality was reached after the first 18 patients when the surgical technique was fully standardized.

CONCLUSIONS

LRYGB is a technically demanding procedure for the surgical treatment of morbid obesity with significant morbidity during the learning curve. The learning curve can be soon overcome, reaching a rate plateau of complications after adequate training. Morbidly obese patients should be operated on in expert bariatric surgical laparoscopic units to obtain the best results.

Factors Influencing Survival following Surgical Treatment of Obesity

BACKGROUND

The prevalence of obesity in the United States and the surgical treatment of obesity have increased since 1999. An important measure of outcome following surgical treatment is survival.

METHODS

This study began with data prospectively collected from Jan 1, 1986 to Dec 31, 1999 by 55 data collection sites, representing 77 surgeons who used standardized data collection software developed by the International Bariatric Surgery Registry (IBSR). A subset of 18,972 subjects was submitted to the National Death Index (NDI) for search of death occurring from Jan 1, 1986 to Dec 31, 2001. The univariate survival analysis included Kaplan-Meier plots and log-rank tests. Cox proportional-hazards (PH) frailty model was used to identify risk factors and estimate hazard ratios in a multi-factor survival analysis. Covariates included gender, operative age, body mass index, operation category (simple and complex), operation year, diabetes, smoking and hypertension as recorded prior to operation.

RESULTS

Deaths were found for 3.45% of the patients (654/18,972). Average follow-up was 8.3 years. Age, gender, BMI, history of smoking, diabetes, and hypertension were significant predictors of survival. Operation category (P=0.13) and operation year (P=0.89) were not significant predictors of survival.

CONCLUSION

Simple and complex operations were equally effective in keeping patients alive in this cohort of patients operated on for severe obesity from 1986 to 1999. Young, female, non-smoking patients with low BMI at operation and no history of diabetes or hypertension had the longest survival. Longer follow-up for death is needed before any recommendations can be made for operation category based on survival.

Advanced age and sex as predictors of adverse outcomes following gastric bypass surgery

OBJECTIVES

This study aimed to determine whether advanced age or sex was predictive of adverse outcomes after Roux-en-Y gastric bypass.

METHODS

The Pennsylvania State Discharge Database was searched for records of morbidly obese patients who underwent Roux-en-Y gastric bypass. The SASs MIXED Procedure was used to test whether mortality alone or adverse outcomes (postoperative complications, nonroutine hospital transfer and mortality) were significantly related to sex or advanced age (>50 years). The presence of comorbidities was used as a blocking variable.

RESULTS

Between 1999 and 2001, 4,685 patients underwent Roux-en-Y gastric bypass in Pennsylvania, of which 82% were female and 20% were older than 50 years of age. Comorbidities were present in 71% of patients. Twenty-eight deaths (0.6%) and 813 adverse outcomes (17.4%) occurred. Mortality was greater in males than in females (1.2% vs. 0.47%, P<0.05) without comorbid interaction. Mortality did not increase with age. Adverse outcomes were related to both sexes (24% male, 16% female, P<0.05) and age (< or = 50, 16% vs. > 50, 23%, P<0.05) with a small comorbid interaction.

CONCLUSION

Adverse outcomes are more frequent among males and older patients and are influenced by comorbidities. Male patients have a higher mortality that was not affected by the presence of comorbidities.