Impact of age on morbidity and mortality following bariatric surgery

Patient and operative characteristics of readmission and poly-readmission following metabolic surgery: an MBSAQIP analysis (2015-2021)

BACKGROUND

Recently, same-day Metabolic Surgery (MS) has gained traction, especially to reduce costs and hospital resource utilization. While shorter hospital stays are desirable, accelerated discharge could increase postoperative burden for those patients at risk. This study evaluated whether specific patient characteristics are associated with increased 30-day readmission rates and number of readmissions as a potentially identifying those less suited for same-day discharge.

METHODS

Using the MBSAQIP (2015-2021), 960,757 cases of primary minimally invasive sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and duodenal switch (DS) were included. Readmission characteristics were extracted from ancillary Participant Use Files (PUF) and linked to the main MBSAQIP data. Zero-inflated Poisson (ZIP) models assessed associations between preoperative patient characteristics and readmission risk. The two-stage models analyzed odds of any 30-day readmission and calculated the relative risk (RR) of multiple readmissions.

RESULTS

Several key predictors of single as well as multiple readmissions in the first 30 days following intervention were noted. Black or Hispanic race, BMI, diabetes, COPD, GERD, and therapeutic anticoagulation were associated with increased odds of readmission likelihood after MS. Black race and GERD predicted increased readmission frequency (multiple readmissions) among all readmission cases, while those aged ≥ 40 years and Hispanic race were less likely to require multiple readmissions.

CONCLUSION

This large-scale MS analysis highlights patient characteristics that should be carefully considered by MS providers during patient counseling and consideration of same-day discharge. Readmission poses significant financial, physiological, and psychological burdens emphasizing the need for careful patient evaluation and counseling, particularly for those at higher risk, to optimize patient outcomes in the context of accelerated discharge protocols.

Demographic Factors Associated with Postoperative Complications in Primary Bariatric Surgery: A Rapid Review

BACKGROUND

Bariatric surgery is highly effective for the management of severe obesity, but its safety profile is not completely understood. This review aimed to synthesise evidence linking demographic factors to postoperative complications and mortality following primary bariatric surgery.

METHODS

We searched Medline for observational studies of adult patients linking demographic factors to postoperative complications of primary bariatric surgery published from 2017 to 2022. Risk ratios (RR) with 95% confidence intervals (95% CI) were calculated and pooled using random effect meta-analysis. Heterogeneity was quantified using the I2 statistic and tested for statistical significance using the Q-statistic. Sensitivity analyses were used to explore potential sources of heterogeneity.

RESULTS

A total of 71 observational studies (69 cohort, 2 case-control) were reviewed and appraised. Older age was consistently associated with increased risks of postoperative mortality (RR = 2.62, 95% CI 1.63-4.23, I2 = 42.04%), serious complications (RR = 1.76, 95% CI 1.09-2.82, I2 = 93.24%), anastomotic leak (RR = 1.64, 95% CI 1.04-2.58, I2 = 61.09%), and haemorrhage (RR = 1.44, 95% CI 1.07-1.94, I2 = 45.25%). Male sex was associated with increased anastomotic leak (RR = 1.39, 95% CI 1.04-1.87, I2 = 72.36%). Sensitivity analyses did not identify sources of bias. Socioeconomic factors, including Black/African American race, low financial status, and marital status (mixed results), were linked to higher complication risks in some studies.

CONCLUSIONS

Older age and certain demographic factors (male sex, Black/African American race, low financial status, marital status) were associated with increased risks of postoperative complications following primary bariatric surgery.

Causes of Death After Bariatric Surgery: Long-Term Study of 10 Years

BACKGROUND

There is a lack of up-to-date research addressing the causes of death and predictors of long-term mortality after bariatric surgery.

METHODS

This was a single-centre retrospective study. Trust records were used to identify deceased patients and their medical history. The demographic data, comorbidities, cause of death, and time since surgery were retrieved and tabulated. Data was recoded to allow for use in IBM SPSS.

RESULTS

There were 39 deaths amongst 891 patients who underwent bariatric surgery between 15th June 2010 to 18th September 2022. The main cause of death was pneumonia and respiratory causes with 15.4% of the cohort. A history of asthma/COPD had an association with the cause of death (p = 0.021). A history of hypertension, ischaemic heart disease (IHD), and smoking were all associated with a higher age at death, whilst a history of IHD was associated with a higher number of days from operation to death. Age at operation and number of comorbidities both correlated with age at death, and multiple linear regression of age at death with age at operation and number of comorbidities as predictors was significant (p < 0.001). A Cox regression found age at operation to have a significant effect on survival, with a hazard ratio of 1.063 (95% CI:1.027 to 1.100, p < 0.001).

CONCLUSION

Pneumonia and respiratory causes are the largest causes of long-term mortality after bariatric surgery. The only factor found to have a detrimental effect on all-cause mortality was age at operation which reduced survival. Hypertension, IHD, and smoking are indirect factors that are associated with mortality.

The combined risk predictive power of frailty and hypoalbuminemia in free tissue flap reconstruction: A cohort study of 34,571 patients from the NSQIP database

INTRODUCTION

Significant morbidity and mortality are hallmarks of the functional decline seen in physically frail patients. The modified frailty index 5 (mFI-5) represents a risk predictor score that has been validated as a comorbidity-based scale in surgery. Serum albumin levels of <3.5 g/dL (hypoalbuminemia) have also been implicated with poor postoperative outcomes. However, the association between these two parameters remains to be investigated. We aimed to elucidate the interdependence of preoperative albumin levels and frailty, as evaluated by the mFI-5 score, and its reliability to prognosticate postoperative results in free flap reconstruction (FFR).

METHODS

We conducted a multicenter, retrospective cohort study and accessed the ACS National Surgical Quality Improvement Program (ACS-NSQIP) from 2008 to 2021. We identified all adult patients (≥18 years of age) who underwent a FFR. We extracted perioperative data and lab values including albumin. Multivariable linear and logistic regression analyses were performed to identify independent risk predictors. Main outcomes involved mortality, length of hospital stay, reoperation, medical and surgical complications, and discharge destination within the 30-day postoperative period.

RESULTS

A total of 34,571 patients were included in the study, with an average age of 53.9 years (standard deviation [SD] 12.2) and an average body mass index (BMI) of 28.8 (SD 6.1). Of these patients, 7484 were male (21.6%), whereas 22,363 (64.7%) had no frailty (mFI = 0). Additionally, 9466 patients had a frailty score of 1 (27.4%), 2505 had a score of 2 (7.2%), 226 had a score of 3 (0.7%), and 11 had a score of 4 or higher (0.0%). Albumin levels were available for 16,250 patients (47.0%), and among them, 1334 (8.2%) had hypoalbuminemia. Regression analyses showed that higher mFI scores were independent predictors of any, surgical, and medical complications, as well as increased rates of reoperations, unplanned readmissions, and prolonged hospital stays. Hypoalbuminemia independently predicted any, surgical, and medical complications, and higher mortality, reoperation, and longer hospital stay. When both frailty and albumin levels (mFI-5 and albumin) were considered together, this combined assessment was found to be a more accurate predictor of all major outcomes (any, medical and surgical complications, mortality, and reoperation). Further, our analysis identified a weak negative correlation between serum albumin levels and mFI scores (Spearman R: -.1; p < .0001).

CONCLUSION

In conclusion, this cohort study highlights the association of hypoalbuminemia with adverse postoperative outcomes, including those not directly related to frailty. Simultaneously, higher mFI scores independently predicted outcomes not associated with hypoalbuminemia. Stemming from these findings, we recommend considering both serum albumin levels and frailty in patients receiving FFR. This perioperative algorithm may help provide more individualized planning including multidisciplinary care and pre and posthabilitation.

The surgical patient of yesterday, today, and tomorrow-a time-trend analysis based on a cohort of 8.7 million surgical patients

BACKGROUND

Global healthcare delivery is challenged by the aging population and the increase in obesity and type 2 diabetes. The extent to which such trends affect the cohort of patients the authors surgically operate on remains to be elucidated. Comprising of 8.7 million surgical patients, the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database can be analyzed to investigate the echo of general population dynamics and forecast future trends.

MATERIAL AND METHODS

The authors reviewed the ACS-NSQIP database (2008-2020) in its entirety, extracting patient age, BMI, and diabetes prevalence. Based on these data, the authors forecasted future trends up to 2030 using a drift model.

RESULTS

During the review period, median age increased by 3 years, and median BMI by 0.9 kg/m2. The proportion of patients with overweight, obesity class I, and class II rates increased. The prevalence of diabetes rose between 2008 (14.9%) and 2020 (15.3%). The authors forecast the median age in 2030 to reach 61.5 years and median BMI to climb to 29.8 kg/m2. Concerningly, in 2030, eight of ten surgical patients are projected to have a BMI above normal. Diabetes prevalence is projected to rise to 15.6% over the next decade.

CONCLUSION

General population trends echo in the field of surgery, with the surgical cohort aging at an alarmingly rapid rate and increasingly suffering from obesity and diabetes. These trends show no sign of abating without dedicated efforts and call for urgent measures and fundamental re-structuring for improved future surgical care.

Racial disparities in reasons for mortality following bariatric surgery

BACKGROUND

Metabolic and bariatric surgery (MBS) remains a safe and effective treatment for patients with severe obesity. Recent studies have highlighted racial disparities in perioperative outcomes, including up to a twofold higher mortality rate in non-Hispanic black (NHB) (vs. non-Hispanic white (NHW)) patients. Causality for these disparate outcomes remains unclear and largely unexplored.

OBJECTIVE

Our study aim was to determine reasons for mortality among racial and ethnic cohorts and MBS patients.

SETTING

Academic Hospital.

METHODS

Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) cases were identified using the 2015 to 2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project (MBSAQIP) database using current procedural (CPT) codes 43,664, 43,645, and 43,775. Multivariate regression analyses were performed to determine independent predictors of overall and bariatric-related mortality. Reasons for mortality were identified and compared between racial and ethnic cohorts.

RESULTS

Of 650,903 RYGB and SG cases, 512,041 were included in our analysis (73% SG). For the entire cohort, all-cause and bariatric-related mortality rates were 0.095% and 0.05%, respectively. Age, male gender, ASA 4, functional status, therapeutic anticoagulation, smoking, COPD, and RYGB were independently associated with both overall and bariatric-related mortality. NHB had increased odds (2.13, p < 0.001) of bariatric-related mortality. Compared to NHW patients (13.3%), venous thromboembolic (VTE) complication was the most common reason for overall mortality in NHB (27.8%) and Hispanic (25%) patients (p < 0.001). VTE-related mortality directly associated with the bariatric procedure was also higher in NHB (34.6%) and Hispanic (33.3%) (vs. NHW 21.0%) patients (p 0.05). When stratified by procedure, mortality causes in RYGB cases were similar between racial and ethnic cohorts. In the SG cohort, the proportion of VTE-related mortality varied significantly (p 0.043) between NHB (39.2%), Hispanic 40.0%, and NHW (20.5%) patients.

CONCLUSION

There are racial and ethnic differences in causes of mortality following bariatric surgery. The predominant cause of overall and bariatric-related mortality in NHB bariatric surgery patients is postoperative venous thromboembolism. More granular MBSAQIP data capture is needed to determine the role of patient risk versus practice patterns in these disparate outcomes.