Congestive heart failure is a risk factor for venous thromboembolism in bariatric surgery

Comparison between low molecular weight heparin and apixaban (direct oral anticoagulant) in the prophylaxis against venous thromboembolism after laparoscopic sleeve gastrectomy

BACKGROUND

Like any major operation, sleeve gastrectomy (SG) has its reported postoperative complications. Among them are venous thromboembolic complications (VTE) that may predispose to mortality. Despite the proven efficacy of the traditional anticoagulants, such as low molecular weight heparins (LMWHs) for VTE management, they have their limitations. Direct oral anticoagulants (DOACs) have been currently adopted for the management of VTE. We conducted this study to evaluate the efficacy and safety of apixaban against VTE after laparoscopic sleeve gastrectomy in comparison with LMWH.

METHODS

This was a randomized controlled trial that included 100 adult patients who underwent SG and received LMWH (Group A) or apixaban (Group B) for VTE prophylaxis. We recorded and analyzed the postoperative events up to the 30th day after surgery.

RESULTS

This study included Group A (n = 50) and Group B (n = 50). No VTE occurred in either group (0%). Postoperative bleeding was encountered in one patient of each group (2%). The follow-up venous Doppler study was unremarkable in the two groups.

CONCLUSION

Apixaban was shown to be comparable to LMWH for the prevention of VTE after LSG with similar efficacy and safety making it a promising alternative to LMWH in patients undergoing bariatric surgery.

New world of big data-new challenges for evidence synthesis: impact of data duplication on estimates generated by meta-analyses and the development of a framework for its identification and management

OBJECTIVES

The aim of this study was to highlight the effects of entering duplicated or overlapping data from published studies using the same data registries into a meta-analysis, including its identification and management using a novel structured framework.

STUDY DESIGN AND SETTING

Secondary analysis of data from a proportional meta-analysis of 30-day cumulative incidence of venous thromboembolic events (VTE) after metabolic and bariatric surgery was performed. Sensitivity analysis was conducted a) including all studies regardless of duplication (uncorrected sample) and b) comparing it to a corrected sample of studies. We developed a decision tree framework to identify duplicated data from prospective studies and data registries.

RESULTS

We demonstrated that biasing from duplicated data, primarily from data registries, underestimated the incidence of VTE in the literature by 0.15% of the patient population (an erroneous difference equivalent to 22.06% of total VTE). This error persisted at 8.16% of total VTE when limiting to studies using a primarily laparoscopic approach. The decision tree framework used a comparison of the data source (country and hospital or registry), sampling time frame (dates/years of included data) and inclusion characteristics (included procedures/diagnoses or inclusion criteria) to identify potentially duplicated data. Inter-rater reliability was excellent (κ = 1.00, P < .001), although only 17.86% of studies coded as containing data duplication were verified by the authors while the remaining studies could not be verified. Lastly, we identified a strong lack of diversity in the geographical origins of the data from the included studies.

CONCLUSION

We demonstrated that inadvertently including duplicated data in a meta-analysis can result in substantially inaccurate pooled estimates. We outlined a comprehensive decision tree framework that future researchers can apply to assist with decision making when identifying and managing duplicated data, including that from prospective trials and data registries or other publicly accessible datasets.

PLAIN LANGUAGE SUMMARY

We explored the effects of entering duplicated or overlapping data from published studies using the same data registries into a meta-analysis; and developed a decision tree framework to identify such duplicated data from prospective studies and data registries. We analyzed data of 30-day incidence of venous thromboembolic events after metabolic and bariatric surgery. We demonstrated that including duplicated data, mainly from data registries, in a meta-analysis can result in substantially inaccurate pooled estimates, underestimating the incidence of total venous thromboembolic events by 22.06%. We also found a lack of diversity in the geographical origins of the data. The decision tree compared data source (country and hospital/registry), sampling time frame (dates/years of included data) and inclusion characteristics (inclusion criteria/procedures/diagnoses) to identify potentially duplicated data. Future researchers can apply the framework to make decisions when identifying and managing duplicated data from data registries or other publicly accessible datasets.

Venous Thromboembolic Events Following Revisional Gastric Bypass: An Analysis of the MBSAQIP Database from 2015 to 2019 Using Propensity Matching

BACKGROUND

Primary bariatric surgery is associated with moderate-to-high risk of venous thromboembolic events (VTE); however, the risk for revisional surgery lacks granularity. Our primary objective was to define the risk of VTE following revisional Roux-en-Y gastric bypass (RYGB) compared to primary RYGB.

METHODS

Adults who underwent primary or revision/conversion RYGB between January 1, 2015, and December 31, 2019, with a BMI ≥ 35 kg/m2 were identified in a bariatric specific database. VTE was defined as pulmonary embolus and/or deep venous thrombosis. Thirty-day VTE and transfusion rates were compared between the two groups using propensity score matching of 3:1.

RESULTS

Primary RYGB was performed in 197,186 (92.4%) patients compared to 16,144 (7.6%) in the revisional group. Patients in the revisional group had fewer comorbidities than those undergoing primary RYGB. In the matched cohort of 64,258 procedures, there were 48,116 (74.9%) primary RYGB cases compared to 16,142 (25.1%) RYGB revisions. The rate of VTE was similar in the revisional surgery group compared to the propensity matched primary RYGB group (0.4% vs. 0.3%, p > 0.580); however, transfusion was more common in the revisional group (1.4% vs. 1.0%, p = 0.005). Revisional group had higher rates of readmission, reoperation, increased length of stay, and operation length ≥ 180 min compared to matched primary RYGB group (p < 0.001).

CONCLUSIONS

VTE rates for both primary and revisional RYGB are similar. Revisional RYGB cases impose increased risk of bleeding among other outcomes. Thus, identifying those at higher risk of complications is critical.

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.

Efficacy of bariatric intervention as a bridge to cardiac transplant

BACKGROUND

Many patients with heart failure (HF) are denied cardiac transplants due to inability to meet transplantation body mass index (BMI) criteria. Bariatric intervention, including surgery, medication, and weight loss guidance, may help patients lose weight and become eligible for transplantation.

OBJECTIVE

We aim to contribute to the literature on the safety and efficacy of bariatric intervention on patients with obesity and HF who are awaiting cardiac transplantation.

SETTING

University hospital, United States.

METHODS

This was a mixed retrospective/prospective study. Eighteen patients with HF and BMI >35 kg/m2 were reviewed. Patients were divided based on whether they underwent bariatric surgery or nonsurgical intervention and whether they had left ventricular assist devices or other advanced heart failure therapy including inotropic support, guideline-directed medical therapy, and/or temporary mechanical circulatory support. Weight, BMI, and left ventricular ejection fraction (LVEF) were collected before bariatric intervention and 6 months after bariatric intervention.

RESULTS

No patients were lost to follow-up. Bariatric surgery led to statistically significant decreases in weight and BMI when compared with nonsurgical patients. At 6 months after intervention, surgical patients lost an average of 18.6 kg and decreased their BMI by 6.4 kg/m2 while nonsurgical patients lost 1.9 kg and decreased their BMI by .7 kg/m2. After bariatric intervention, surgical patients had an average LVEF increase of 5.9% and nonsurgical patients had an average decrease of 5.9%, although these findings lacked statistical significance.

CONCLUSION

Our study suggests that bariatric intervention among patients with HF and obesity is a safe and effective method of weight and BMI reduction.

Selection of Robotic Bariatric Surgery Candidates: a Nationwide Analysis

INTRODUCTION

This study aims to identify risk factors associated with 30-day major complications, readmission, and delayed discharge for patients undergoing robotic bariatric surgery.

METHODS

From the metabolic and bariatric surgery and accreditation quality improvement program (2015-2018) datasets, adult patients who underwent elective robotic bariatric operations were included. Predictors for 30-day major complications, readmission, and delayed discharge (hospital stay ≥ 3 days) were identified using univariable and multivariable analyses.

RESULTS

Major complications in patients undergoing robotic bariatric surgery were associated with both pre-operative and intraoperative factors including pre-existing cardiac morbidity (OR = 1.41, CI = [1.09-1.82]), gastroesophageal reflux disease [GERD] (OR = 1.23, CI = [1.11-1.38]), pulmonary embolism (OR = 1.51, CI = [1.02-2.22]), prior bariatric surgery (OR = 1.66, CI = [1.43-1.94]), increased operating time (OR = 1.003, CI = [1.002-1.004]), gastric bypass or duodenal switch (OR = 1.58, CI = [1.40-1.79]), and intraoperative drain placement (OR = 1.28, CI = [1.11-1.47]). With regard to 30-day readmission, non-white race (OR = 1.25, CI = [1.14-1.39]), preoperative hyperlipidemia (OR = 1.16, CI = [1.14-1.38]), DVT (OR = 1.48, CI = [1.10-1.99]), therapeutic anticoagulation (OR = 1.48, CI = [1.16-1.89]), limited ambulation (OR = 1.33, CI = [1.01-1.74]), and dialysis (OR = 2.14, CI = [1.13-4.09]) were significantly associated factors. Age ≥ 65 (OR = 1.18, CI = [1.04-1.34]), female gender (OR = 1.21, CI = [1.10-1.32]), hypertension (OR = 1.08, CI = [1.01-1.15]), renal insufficiency (OR = 2.32, CI = [1.69-3.17]), COPD (OR = 1.49, CI = [1.23-1.82]), sleep apnea (OR = 1.10, CI = [1.03-1.18]), oxygen dependence (OR = 1.47, CI = [1.10-2.0]), steroid use (OR = 1.26, CI = [1.02-1.55]), IVC filter (OR = 1.52, CI = [1.15-2.0]), and BMI ≥ 40 (OR = 1.12, CI = [1.04-1.21]) were risk factors associated with delayed discharge.

CONCLUSION

When selecting patients for bariatric surgery, surgeons early in their learning curve for utilizing robotics should avoid individuals with pre-existing cardiac or renal morbidities, venous thromboembolism, and limited functional status. Patients who have had previous bariatric surgery or require technically demanding operations are at higher risk for complications. An evidence-based approach in selecting bariatric candidates may potentially minimize the overall costs associated with adopting the technology.

Thromboembolic Complications After Bariatric Surgery: Is the High Risk Real?

INTRODUCTION

Nowadays, a large number of bariatric surgery (BS) procedures are undertaken worldwide as surgery has become an efficient strategy to treat the obesity epidemic. The risk of venous thromboembolism (VTE) is increased in patients undergoing BS not only due to the intrinsic surgical risk but also because patients with obesity have a 2-3-fold higher risk of VTE. The optimal strategy for VTE prevention in BS setting, including optimal dose and thromboprophylaxis regimen, is still not fully clarified. The aim of this study was to report a bariatric high-volume center experience and to propose a practical thromboprophylaxis protocol for this population.

METHODS

A single-center, observational, retrospective, and longitudinal study was conducted from January 2018 to December 2020, a total of 901 patients who underwent primary and revisional bariatric surgery were included.

RESULTS

The overall frequency of VTE events was 0.44% (n=4), one patient had pulmonary embolism (PE) during index hospital admission; another patient had simultaneous deep venous thrombosis (DVT) and PE, two months after surgery; and two other patients had DVT, nine and 16 months after surgery. The median time for VTE was four months. The incidence of females was 75% (n=3) and the median age was 57 years. Only one female patient was using oral contraception. None had a previous history of thromboembolic events, chronic venous insufficiency, or other known diseases that could increase the VTE risk.

CONCLUSION

Considering the outcomes reported by this experienced center with low rates of thromboembolic events, we suggest a thromboprophylaxis protocol that can be easily applied to the majority of bariatric patients.

Pulmonary Embolism in Women: A Systematic Review of the Current Literature

Cardiovascular disease is the leading cause of death in women. Pulmonary embolism (PE) is the third most-common cause of cardiovascular death, after myocardial infarction (MI) and stroke. We aimed to evaluate the attributes and outcomes of PE specifically in women and explore sex-based differences. We conducted a systematic review of the literature using electronic databases PubMed and Embase up to 1 April 2022 to identify studies investigating PE in women. Of the studies found, 93 studies met the eligibility criteria and were included. The risk of PE in older women (especially >40 years of age) superseded that of age-matched men, although the overall age- and sex-adjusted incidence of PE was found to be lower in women. Risk factors for PE in women included age, rheumatologic disorders, hormone replacement therapy or oral contraceptive pills, pregnancy and postpartum period, recent surgery, immobilization, trauma, increased body mass index, obesity, and heart failure. Regarding pregnancy, a relatively higher incidence of PE has been observed in the immediate postpartum period compared to the antenatal period. Women with PE tended to be older, presented more often with dyspnea, and were found to have higher NT-proBNP levels compared to men. No sex-based differences in in-hospital mortality and 30-day all-cause mortality were found. However, PE-related mortality was higher in women, particularly in hemodynamically stable patients. These differences form the basis of future research and outlets for reducing the incidence, morbidity, and mortality of PE in women.

Racial disparities in complications and mortality after bariatric surgery: A systematic review

BACKGROUND

Studies have shown racial discrepancies in the rates of postoperative adverse events following bariatric surgery (BS). We aim to systematically review the literature examining racial disparities in postoperative adverse events.

METHODS

PubMed, Embase, and SCOPUS databases were searched for studies that reported race, postoperative adverse events and/or length of stay.

RESULTS

Thirty-five studies were included. Most compared Black and White patients using standardized databases. Racial/ethnic terminology varied. The majority found increased 30-day mortality and morbidity and length of stay in Black relative to White patients. Differences between White and Hipanic patients were mostly non-significant in these outcomes.

CONCLUSIONS

Black patients may experience higher rates of adverse events than White patients within 30 days following bariatric surgery. Given the limitations in the large multicenter databases, explanations for this disparity were limited. Future research would benefit from longer-term studies that include more races and ethnicities and consider socioeconomic factors.

Risk factors for postdischarge venous thromboembolism among bariatric surgery patients and the evolving approach to extended thromboprophylaxis with enoxaparin

BACKGROUND

Venous thromboembolism (VTE) is one of the most common causes of postoperative mortality following bariatric surgery. The majority of VTE events occur after discharge from the hospital. Little consensus exists regarding who should receive extended enoxaparin thromboprophylaxis or how they should be dosed, namely whether to use weight-based or BMI-stratified dosing strategies.

OBJECTIVES

Provide an overview of the risk factors associated with VTE in procedures among bariatric patients including the use of predictive tools to stratify risk and the various approaches to enoxaparin chemoprophylaxis in obesity.

SETTING

Multiple centers.

METHODS

A review of the literature identified studies evaluating risk factors for VTE including demographic characteristics, co-morbidities, and operative factors. The use of calculators to stratify patients by risk and approaches to extended thromboprophylaxis in obesity were evaluated as well.

RESULTS

VTE was associated with increased age, weight, male sex, and prior history of VTE, all frequently included in risk calculators. Outside of those major risk factors, there is little consensus about the importance of patient diagnoses. Weight-based dosing was often superior to standardized dosing in studies across disciplines in generating target anti-Xa levels however there is no consistent association of reduced risk of VTE with therapeutic anti-Xa levels.

CONCLUSIONS

Risk calculators may be a valuable tool for identifying patients at high-risk for VTE, but their efficacy depends on the rating algorithm and inclusion of various risk factors and is methodologically limited by prophylactic interventions. Future work should consider if biochemical factors should be included in patient stratification approaches in particular when defining the ideal chemoprophylaxis approach. Transparency and consistency in data collection and reporting is needed to better assess and inform the ideal dosing strategy to prevent VTE following bariatric surgery.

Safety of Bariatric Surgery in Patients With Congestive Heart Failure: Results of an 11-Year Retrospective Study

INTRODUCTION

Congestive heart failure (CHF) is a known risk factor for increased postoperative morbidity. However, the safety in patients with CHF has not been well established. The objective of this study was to assess the safety of surgery in patients with a history of CHF undergoing bariatric surgical procedures.

METHODS

Retrospective review of a prospectively maintained Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Center of Excellence database. Patients with known CHF undergoing bariatric procedures over an 11-year period were reviewed.

RESULTS

Over the 11-year period, 4470 total bariatric surgeries were performed, of which 41 (.92%) patients had known CHF. Twenty-one patients were men (51.2%) with a mean age of 55.8 years and mean body mass index (BMI) of 51.9. Comorbidities included hypertension (87.8%), obstructive sleep apnea (80.5%), osteoarthritis (63.4%), gastroesophageal reflux disease (56%), and diabetes (53.7%). Surgical procedures included 16 sleeve gastrectomies (SGs) (39%), 11 Roux-en-Y gastric bypasses (RYGBs) (26.8%), 10 laparoscopic adjustable gastric bands (LAGBs) (24.4%), 1 removal of a gastric band and conversion to SG (2.4%), 1 removal of a gastric band to RYGB (2.4%), 1 gastric band over RYGB pouch (2.4%), and 1 gastric band replacement (2.4%). All cases were performed minimally invasively (73.2% laparoscopic and 26.8% robotic). Mean LOS was 2.53 days. Thirty-day complications included 2 readmissions (4.9% [1 small bowel obstruction and 1 pulmonary edema]), 1 reoperation (2.4% [small bowel obstruction]), and 1 mortality (2.4%) on postoperative day 30 unrelated to the surgery.

CONCLUSIONS

Bariatric surgery can be performed safely in patients with CHF.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

Racial disparities in inferior vena cava filter use in metabolic and bariatric surgery patients: Nationwide insights from the MBSAQIP database

BACKGROUND

Prophylactic inferior vena cava (IVC) filter use in bariatric surgery patients is a physician- and patient-dependent practice pattern with unclear safety and efficacy. Factors that mediate physicians' decisions for IVC filter placement preoperatively remain unclear. The role of race in decision-making also remains unclear.

METHODS

From the 2015-2016 MBASQIP database, patient characteristics leading to IVC filter use and outcomes after IVC filter placement were compared between Black and White primary bariatric surgery patients.

RESULTS

Prophylactic IVC filter was used in 0.66% of Black and White patients. IVC filter use was three-fold higher in Black patients, despite this cohort having a lower venous thromboembolism (VTE) risk profile than White counterparts. Black race was an independent predictor for IVC filter placement on multivariate analysis. After receiving an IVC filter, Black patients had higher rates of 30-day adverse outcomes.

CONCLUSIONS

In this study, Black race was independently associated with the likelihood of receiving a prophylactic IVC filter, despite lower rates of VTE risk factors and lack of recommendations for its use. Further research is needed to explore why this disparity in clinical practice exists.

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Venous thromboembolism prophylaxis using the Caprini score

Venous thromboembolism (VTE) including pulmonary embolism (PE) and deep vein thrombosis (DVT) is one of the leading causes of preventable cardiovascular disease in the United States (US) and is the number one preventable cause of death following a surgical procedure. Post-operative VTE is associated with multiple short and long-term complications. We will focus on reviewing the many faces of VTE in detail as they represent common challenging scenarios in clinical practice.

A Population-Based Study of Early Postoperative Outcomes in Patients with Heart Failure Undergoing Bariatric Surgery

BACKGROUND

Weight loss following bariatric surgery can improve cardiac function among patients with heart failure (HF). However, perioperative morbidity of bariatric surgery has not been evaluated in patients with HF.

STUDY DESIGN

The National Surgical Quality Improvement Project (NSQIP) database for 2006-2014 was queried to identify patients undergoing adjustable gastric band, gastric bypass, sleeve gastrectomy, and biliopancreatic diversion-duodenal switch. Patients with HF were propensity matched to a control group without HF (1:5). Univariate analyses evaluated differences in complications, and multivariate analysis was completed to predict all-cause morbidity.

RESULTS

There were 237 patients identified with HF (mean age 52.8 years, 59.9% female, mean body mass index 50.6 kg/m2) matched to 1185 controls without HF who underwent bariatric surgery. Preoperatively, patients with HF were more likely to be taking antihypertensive medication and have undergone prior percutaneous cardiac intervention and cardiac surgery. There was no difference in operative time, surgical site infections, acute renal failure, re-intubation, or myocardial infarction. HF was associated with increased likelihood of length of stay more than 7 days, likelihood to remain ventilated > 48 h, venous thromboembolism, and reoperation. For patients with HF, the adjusted odds ratio for all-cause morbidity was 2.09 (1.32-3.22).

CONCLUSION

The NSQIP definition of HF, which includes recent hospitalization for HF exacerbation or new HF diagnosis 30 days prior to surgery, predicts a more than two-fold increase in odds of morbidity following bariatric surgery. This must be balanced with the longer-term potential benefits of weight loss and associated improvement in cardiac function in this population.

Outcomes after bariatric surgery according to large databases: a systematic review

PURPOSE

The rapid development of technological tools to record data allows storage of enormous datasets, often termed "big data". In the USA, three large databases have been developed to store data regarding surgical outcomes: the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). We aimed to evaluate the clinical impact of studies found in these databases concerning outcomes of bariatric surgery.

METHODS

We performed a systematic review using the Meta-analysis of Observational Studies in Epidemiology guidelines. Research carried out using the PubMed database identified 362 papers. All outcomes related to bariatric surgery were analysed.

RESULTS

Fifty-four studies, published between 2005 and February 2017, were included. These articles were divided into (1) outcomes related to surgical techniques (12 articles), (2) morbidity and mortality (12), (3) 30-day hospital readmission (10), (4) outcomes related to specific diseases (11), (5) training (2) and (6) socio-economic and ethnic observations in bariatric surgery (7). Forty-two papers were based on data from ACS-NSQIP, nine on data from NIS and three on data from MBSAQIP.

CONCLUSIONS

This review provides an overview of surgical management and outcomes of bariatric surgery in the USA. Large databases offer useful complementary information that could be considered external validation when strong evidence-based medicine data are lacking. They also allow us to evaluate infrequent situations for which randomized control trials are not feasible and add specific information that can complement the quality of surgical knowledge.

Predictors of complications and readmission following spinal stereotactic radiosurgery

AIM

to identify preoperative factors associated with morbidity/mortality, hospital length of stay (LOS), 30-day readmission and operation rates following spinal stereotactic radiosurgery (SRS) for spinal tumors.

METHODS

The American College of Surgeons National Quality Improvement Program was queried from 2012 to 2014 to identify patients undergoing SRS for spinal tumors. Logistic regression was performed to identify predictors.

RESULTS

2714 patients were identified; 6.8% had major morbidity or mortality, 6.9% were readmitted within 30 days and 4.3% had a subsequent operation within 30 days. Age, BMI and American Society of Anesthesiologist (ASA) class were predictive of LOS. Major morbidity was predicted by age >80, BMI >35, high ASA, pretreatment functional dependence and baseline comorbidities. Predictors of operation within 30 days included preoperative steroid use, renal failure, BMI >35 and if the treatment was nonelective.

DISCUSSION

4-7% of patients undergoing SRS for spinal tumors have morbidity following the procedure. Factors predictive of morbidity, LOS, and subsequent operation included age, BMI, baseline comorbidities and functional status.

CONCLUSION

Identification of preoperative patient-specific factors that are predictive of post-treatment outcome will aid in patient selection and patient counseling leading to greater patient satisfaction and hospital efficiency.