Are results of bariatric surgery different in the Middle East? Early experience of an international bariatric surgery program and an ACS NSQIP outcomes comparison

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

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

Assessing the Feasibility and Effects of Introducing the USA National Surgical Quality Improvement Program on Clinical Outcomes and Cost in Saudi Arabia: An Observational Study

Introduction

This study aimed at introducing a systematic clinical registry to assess the outcomes of surgical performances and the associated costs of surgical complications in hospitals of Saudi Arabia.

Materials and Methods

This was an observational retrospective cohort study. Three large Saudi public hospitals from different regions participated in the study. A systematic sample consisting of 2077 medical records was retrospectively reviewed after being received from the hospitals' surgical wards. The inclusion criteria of the study were inpatients of the surgical cases, patients older than 18 years, and those who underwent major surgery under general anesthesia. The occurrence of adverse events in surgical wards and the direct costs associated with these surgical adverse events were estimated. Results were reported in terms of odds ratio and 95% confidence interval. A value of p < 0.05 was considered statistically significant.

Results

Introducing the systematic clinical registry to assess surgical outcomes and complications across multiple hospital sites is feasible. The findings of the study suggest that some areas are exemplary and others need improvement, such as sepsis cases, renal failure, ventilator use for more than 48 h, urinary tract infection, surgical site infection (SSI), length of stay after colorectal surgery, and rehospitalization. Additional costs from surgical complications in Riyadh only were approximately 0.5 million Saudi Arabian Riyal (127,764.40 USD) during that year. Most of the additional costs were due to sepsis and SSI.

Conclusion

Empirical evidence derived from the idea of introducing a National Surgical Quality Improvement Program might be generally applicable to other countries in the region and worldwide, and can be used to measure surgical adverse events and track interventions over time. As a result, quality improvement initiatives could be identified to be implemented immediately focusing on preventing several surgical adverse events. A future study is needed to explore the underlying factors that contribute to the occurrence of surgical adverse events to be prevented and/or mitigated.

Mandatory Risk Assessment Reduces Venous Thromboembolism in Bariatric Surgery Patients

INTRODUCTION

Bariatric surgery patients are at high risk for venous thromboembolism (VTE), and chemoprophylaxis is recommended.

METHODS

Sheikh Khalifa Medical City (SKMC) is an American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) member since 2009. We report the rates of VTE in bariatric surgery patients from 2010 to 2016 compared to ACS NSQIP bariatric surgery programs before and after switching from heparin to low molecular weight heparin (LMWH), initiating mandatory risk assessment using Caprini scoring for VTE and adopting an aggressive strategy for high-risk patients regarding dosage of LMWH and chemoprophylaxis after discharge.

RESULTS

During the study period, there were 1152 cases (laparoscopic Roux-en-Y gastric bypass (LRYGB) 625 and laparoscopic sleeve gastrectomy (LSG) 527) at Bariatric & Metabolic Institute (BMI) Abu Dhabi compared to 65,693 cases (LRYGB 32,130 and LSG 33,563) at ACS NSQIP bariatric surgery programs. VTE rates remained stable at ACS NSQIP bariatric surgery programs from 2010 to 2016 (0.45, 0.45, 0.45, 0.25, 0.35, 0.3, and 0.3%). In contrast, VTE rates at BMI Abu Dhabi decreased from 2.2% in 2011 to 0.35% after we adopted an aggressive strategy to VTE without an increase in bleeding complications. LRYGB patients with VTE had higher OR time, leak, collection, and mortality at ACS NSQIP hospitals compared to those at BMI Abu Dhabi. In contrast, rates were similar in LSG patients with VTE.

CONCLUSION

Changing our approach to VTE management led our VTE rates to decrease and become like those of ACS NSQIP bariatric surgery patients in LSG and LRYGB.

Health Care Institutions Volume Is Significantly Associated with Postoperative Outcomes in Bariatric Surgery

PURPOSE

The volume of bariatric surgery has significantly increased over the past decade with concomitant postoperative outcomes improvement. The goal of this nationwide study was to estimate the volume-outcome relationship in bariatric surgery at the hospital level.

MATERIALS AND METHODS

A cross-sectional analysis of all patients who underwent bariatric surgery procedure in France from January 2011 to December 2014 was designed. Volume-outcome relationship was analyzed using generalized estimating equations.

RESULTS

We identified 184,332 inpatient stays for bariatric surgical procedures performed in 606 hospitals. Health care institutions performing more than 200 bariatric cases per year were significantly associated with shorter average length of stay (p < 0.001) and less frequent need for intensive or critical care unit (p = 0.003) during the index stay in comparison with lower volume institutions. Reoperations rate increased from 3.1% [95% CI, 2.8-3.3] (n = 5627) at 1 month to 4.9% [4.6-5.2] at 3 months and 8.2% [7.8-8.7] at 6 months. The risk of reoperation after gastric bypass was 1.37 times less frequent in higher volume institutions (≥ 200 inpatient stays per year, p = 0.003), while it was 1.26 times more frequent after gastric banding in higher volume institutions (p = 0.057) and was unaltered regarding sleeve gastrectomy (p = 0.819).

CONCLUSION

This study showed for the first time in bariatric surgery that reoperation rate after gastric bypass or sleeve significantly increased at 3 and 6 months postoperatively. Health care institutions performing more than 200 bariatric cases per year were significantly associated with improved postoperative outcomes and less frequent need for reoperation.

Efficacy of bariatric surgery in improving metabolic outcomes in patients with diabetes. A 24-month follow-up study from a single center in the UAE

BACKGROUND

Owing to its impact on weight loss, remission of diabetes mellitus and metabolic syndrome, bariatric surgery has offered hope for grossly obese individuals. In recent years, obesity has increased in the UAE and the use of bariatric surgery has increased in-line with this trend. However, data regarding bariatric surgery outcomes in diabetic Emirati people is scarce.

OBJECTIVE

To evaluate the effect of bariatric surgery in patients with diabetes mellitus.

METHODS

This is a retrospective analysis of diabetic patients treated with bariatric surgery with a minimal follow-up of 1 year and extended for some patients (21) to 2 years follow up. A total of 80 patients underwent bariatric surgery. Two surgical procedures were used; laparoscopic sleeve gastrectomy (n=53) or mini-gastric bypass between January 1, 2015, and July 20, 2017.

RESULTS

Mean baseline weight was 119.2±31.2 kg, this has significantly dropped to 100.1±23.1, 91.2±22.3, 82.3±17.5, and 81.3±15.3 kg at 3, 6, 12, and 24 months respectively, and this change was statistically significant P<0.001 at each time point. Mean baseline HbA1c was 8.6% ± 2.3% and this dropped significantly to 6.5±1.7, 5.9±1.2, 5.6±0.8, and 5.4±0.7 at 3, 6, 12, and 24 months respectively (P<0.000). In 49 (61.3%) we considered fatty liver based on ultrasound features either with or without elevation in alanine aminotransferase (ALT). We noticed a significant decrease in ALT at 3, 6, and 12 months after surgery. Furthermore, 11 patients (22.4%) showed sonographic features of improvement in fatty liver in addition to normalization of ALT.

CONCLUSIONS

Bariatric surgery was effective over a follow-up period of 2 years in achieving significant weight loss as well as resulting in improvements in glycemic control, blood pressure, and fatty liver.

Management Algorithm for Leaks Following Laparoscopic Sleeve Gastrectomy

BACKGROUND

Leak after laparoscopic sleeve gastrectomy (LSG) is a serious complication. No clear algorithm has been described for management.

METHODS

We reviewed our prospective database for all leaks after LSG treated at the Bariatric and Metabolic Institute (BMI) Abu Dhabi from 2010 to 2014. Our management algorithm is based on the timing of the LSG leak, nutritional status of the patient, and the presence of stenosis or peritonitis. Acute leaks with or without peritonitis are treated by operatively or utilizing endoscopic stenting, respectively. LSG leaks with stenosis not amenable to endoscopic stenting are treated with laparoscopic Roux en Y esophagojejunostomy (LRYEJ).

RESULTS

We performed 236 LSG without a leak, and 14 LSG leaks were referred to our unit. Mean age was 35.6 years, and 50 % of patients were males. Mean BMI was 37 kg/m(2). The patients presented on average 13.9 weeks after LSG. Enteral feeding was used as the primary nutrition route in 85.5 % of patients. Our management strategy was operative in 78.4 % of patients (jejunostomy feeding in 57 % and LRYEJ in 21.4 % of patients) and conservative with or without stents in 21.6 % of patients. Mean in hospital length of stay (LOS) was 5.6 weeks. Our reoperation rate was 7 %. There were no mortalities and one patient 7 % developed pulmonary embolism. None of the patients treated returned with a leak or collection after a mean follow up of 23.6 months.

CONCLUSION

Treating leaks following LSG based on the timing of presentation, presence of stricture, and malnutrition is safe and effective.

Bariatric surgery outcomes: a single-center study in the United Arab Emirates

BACKGROUND

Bariatric surgery has become an attractive treatment for severe obesity over the last decade, due to its impacts on weight loss and remission of type 2 diabetes and metabolic syndrome. In the United Arab Emirates, a country where the rate of obesity is dramatically increasing bariatric surgery has gained popularity in recent years; however, published data on its outcomes in the Emirati population are lacking.

METHODS

We retrospectively reviewed the medical records of 95 patients who underwent bariatric surgery (ie, laparoscopic Roux-en-Y gastric bypass [RYGB] or laparoscopic sleeve gastrectomy) at the Rashid Center for Diabetes and Research in Ajman, United Arab Emirates. Weight outcomes and metabolic marker data were abstracted at baseline and at 3, 6, and 12 months postoperatively.

RESULTS

Laparoscopic RYGB was the main procedure performed by our bariatric unit. All variables demonstrated postoperative improvement. An average excess weight loss of 68% was observed at 12 months. Fat mass was the body component that decreased the most, with an average reduction of 46%. Additionally, lipid profiles were significantly different (P<0.01) at 12 months, with triglyceride levels improving by 27% and low-density lipoprotein levels improving by 21%. Similarly, glycated hemoglobin (HbA1c) levels decreased significantly (P<0.001) in patients with type 2 diabetes, with an average reduction of 73%.

CONCLUSION

Our results show that a substantial short-term reduction in weight and significant improvements in metabolic markers followed bariatric surgery in severely obese Emirati patients. Our results are consistent with the outcomes of other internationally published studies. Additional studies are warranted to determine whether the favorable impacts of bariatric surgery can be sustained over the long term.

Screening colonoscopy in the initial workup of bariatric surgery patients: guidelines are needed

BACKGROUND

Cancer is one of the most common causes of death among morbidly obese individuals. Obese individuals have a well-documented increased risk of colon cancer. No guidelines are available for the workup of bariatric surgery patients in relation to colon cancer.

METHODS

The indications for screening colonoscopy at the Bariatric and Metabolic Institute Abu Dhabi (BMI Abu Dhabi) include all patients older than 50 years [40 years if patients are United Arab Emirates (UAE) nationals] with unexplained abdominal symptoms, anemia of unknown cause, or a family or personal history of colonic pathology. This study retrospectively reviewed the charts of all the patients who had colonoscopy during the period January 2009 to January 2013. The patients were divided into two groups: group A [patients with a body mass index (BMI) > 30 kg/m(2)] and group B (patients with a BMI < 30 kg/m(2)). The demographics and the prevalence of polyps and cancer in the two groups were compared.

RESULTS

During the study period, 341 colonoscopies were performed: 137 for patients with a BMI higher than 30 kg/m(2) (mean age, 44 years) and 204 for patients with a BMI lower than 30 kg/m(2) (mean age, 46 years) (P > 0.05). The overall prevalence of adenomatous polyps was 6.74 % and that of cancer was 1.75 %. Further analysis showed that the prevalences of adenomatous polyps and cancer were respectively 12.4 and 2.1 % for the patients with a BMI higher than 30 kg/m(2), whereas the prevalences were respectively 2.9 and 0.9 % for the patients with BMI lower than 30 kg/m(2) (P < 0.001).

CONCLUSION

The risk for the development of colonic adenomatous polyps and cancer is high among young obese individuals in the Middle East. Guidelines are needed to establish criteria for screening in this group of individuals.