Racial disparities in perioperative outcomes after bariatric surgery

Association of Socioeconomic Disadvantage With Postoperative Length of Stay

INTRODUCTION

Socioeconomic factors significantly influence postoperative recovery, which is a crucial consideration in reducing disparities within enhanced recovery after surgery (ERAS) protocols. The Area Deprivation Index (ADI) serves as a validated measure of neighborhood-level socioeconomic disadvantage; however, its association on postoperative length of stay (LOS) remains underexplored.

METHODS

This retrospective cohort study analyzed data from October 2016 to May 2022, examining the association between ADI and postoperative LOS among ERAS patients undergoing elective surgery. Addresses were geocoded and assigned ADI scores, categorizing patients into low, medium, and high ADI levels. Logistic regression models, adjusting for covariates such as insurance status and comorbidities, were used to assess the relationship between ADI and extended LOS, defined as above the 75th percentile.

RESULTS

The study included 11,640 patients with a median age of 56. Patients from high ADI neighborhoods had a significantly higher likelihood of extended LOS compared to those from low ADI neighborhoods (odds ratio 1.22; 95% confidence interval 1.10-1.36; P < 0.001), even after adjusting for demographic and clinical factors.

CONCLUSIONS

Higher socioeconomic disadvantage, as measured by ADI, is associated with prolonged postoperative hospital stays. These findings highlight the need for targeted interventions to mitigate disparities in surgical outcomes and enhance equity in ERAS 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.

Retrospective Cohort Study of Gastric Bypass Versus Sleeve Gastrectomy in Gastroesophageal Reflux Disease Patients: Procedure Use and Racial Disparity

BACKGROUND

Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are common bariatric procedures, with GERD being a frequent obesity-associated disease among individuals undergoing these surgeries. RYGB is recommended for patients with GERD due to the increased control of GERD symptoms. This study examines RYGB and SG use in this population and factors influencing procedure choice.

METHODS

This study analyzed 2016-2022 data from the MBSAQIP database comprising patients with GERD who underwent SG or RYGB. Statistical analysis included univariate and multivariable logistic regression to identify factors associated with procedure receipt.

RESULTS

RYGB rates are rising annually but remain lower than SG for GERD. Compared to White individuals, Hispanics are 14% less likely, and African Americans are 19% less likely, to receive RYGB.

CONCLUSIONS

The study notes a research gap in choosing RYGB or SG for patients with GERD, despite consensus favoring RYGB. It highlights a disparity between recommendations and practice, with GERD predicting the use of RYGB but SG being more prevalent in this population overall. The analysis links race to procedure choice, showing African American and Hispanic patients are less likely to undergo RYGB, indicating potential disparities in access and decision-making.

Black-vs-white racial disparities in 30-day outcomes following primary and revisional metabolic and bariatric surgery: a MBSAQIP database analysis

BACKGROUND

Previous studies have demonstrated Black-vs-White disparities in postoperative outcomes following primary metabolic and bariatric surgery (MBS). With the rising prevalence of MBS, it is important to examine racial disparities using quality indicators in primary and revisional procedures. This study explores Black-vs-White disparities in postoperative outcomes following primary and revisional MBS.

METHODS

We performed an observational cohort study using the 2015-2020 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database of adults who underwent primary or revisional Roux-en-Y gastric bypass, sleeve gastrectomy, duodenal switch, or one-anastomosis gastric bypass. Black and White patients were 1:1 matched using propensity scores across 19 covariates for primary and revisional MBS groups. McNemar's tests were used to compare 11 postoperative outcomes from the MBSAQIP semi-annual report and death, between matched cohorts.

RESULTS

We identified 112,495 Black and 434,266 White primary MBS and 10,838 Black and 37,075 White revisional MBS patients. A total of 219,114 primary and 21,314 revisional patients were matched. Following primary MBS, Black patients had higher rates of death (0.1% vs. 0.06%, p < 0.001), all occurrences morbidity (5.6% vs. 4.7%, p < 0.001), serious events (2.2% vs. 1.9%, p < 0.001), and all cause and related reoperations (1.2% vs. 1.1%, p = 0.006; 0.2% vs. 0.1%, p = 0.01), readmissions (4.6% vs. 3.4%, p < 0.001; 2.8% vs. 1.9%, p < 0.001), and interventions (1.4% vs. 1.1%, p < 0.001; 0.8% vs. 0.6%, p < 0.001) compared to White patients. In contrast, there were no significant Black-vs-White disparities in death, morbidity, serious events, reoperations, interventions, and bleeding following revisional MBS. Interestingly, Black patients had higher rates of all cause and related readmissions (7.4% vs. 6.2%, p = 0.005; 4.4% vs. 3.6%, p = 0.01), but lower surgical site infection rates (1.6% vs. 2.1%, p = 0.04).

CONCLUSIONS

Our findings demonstrate a measurable contrast between racial disparities in postoperative outcomes following primary and revisional MBS. Equity-focused measures in national MBS assessments are needed to elucidate and address these disparities.

Identifying At-Risk Populations for Reoperations, Readmissions, and Interventions in MBSAQIP Using a Novel Inpatient Postoperative Care Metric

INTRODUCTION

Metabolic and bariatric surgery (MBS) is increasingly used for obesity and metabolic disease, with safety profiles showing it is among the safest major operations. The last 20 + years have noted significantly improved safety that has been accompanied by decreasing length of stay and select populations electing for outpatient surgery, leading to continued decreases in cost. Regardless, readmissions and complications still occur, requiring inpatient postoperative care (IP-POC). The current study aimed to identify and characterize at-risk populations for MBS-related IP-POC.

STUDY DESIGN

The 2015-2021 MBSAQIP (n = 1,346,468 records) was used to extract 973,520 primary cases of laparoscopic sleeve gastrectomy, Roux-en-Y gastric bypass, duodenal switch, and associated IP-POC. Conversions, pediatric cases, and < 30-day follow-up were excluded. IP-POC severity scores were calculated by summing readmissions (1 point), interventions (5 points), and reoperations (15 points). Risk factors associated with IP-POC were identified using zero-inflated Poisson models.

RESULTS

GERD, COPD, smoking, and type of MBS procedure were significantly associated with increased IP-POC incidence and severity. Male sex was associated with increased severity but a lower likelihood of IP-POC, while Black and Hispanic race predicted increased IP-POC likelihood but not severity. ROC curve analysis identified IP-POC score thresholds of ≥ 6 and ≥ 10 as significantly associated with MACE (OR 2.4) and 30-day mortality (OR 4.7).

CONCLUSION

The weighted IP-POC model demonstrated associations between preoperative characteristics and increased IP-POC likelihood and severity. These findings add to the current understanding of MBS patient care dynamics, and can be used to improve patient counseling, refine postoperative protocols, and optimize resource allocation.

Racial disparities in the utilization and outcomes of robotic bariatric surgery: an 8-year analysis of Metabolic and Bariatric Surgery Accreditation Quality Improvement Program data

BACKGROUND

Robotic surgery utilization has been increasing across surgical specialties; however, racial disparities in patient access to care and outcomes have been reported.

OBJECTIVES

In this study, we examined racial disparities in the utilization and outcomes of robotic bariatric surgery over an 8-year period.

SETTING

Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP) centers of excellence across the United States.

METHODS

The MBSAQIP database was used to identify adult patients who underwent robotic bariatric surgery between 2015 and 2022. Patients were stratified according to race and ethnicity into non-Hispanic White, non-Hispanic Black or African American (AA), Indigenous, Asian, and Hispanic patients. Multivariable analyses were used to assess predictors of robotic surgery use, odds of minor and major complications, prolonged length of stay (prolonged length of stay (pLOS): ≥3 days), readmissions, reoperations, and mortality within 30 days.

RESULTS

Out of 1,288,359 patients included, robotic surgery was utilized in 196,314 patients (15.2%), with a mean age of 44 ± 12 years and 80.6% females. Rates of robotic surgery increased to 30% by 2022. Compared to White patients, Black/AA patients were more likely to undergo robotic surgery (adjusted odds ratio (aOR) = 1.22, 95% confidence interval (CI) = 1.21-1.24, P < .001). The safety of robotic bariatric surgery improved for both White and Black patients with decreased odds of major complications, readmissions, reoperations, and pLOS over the study period. However, Black/AA patients were more likely to experience minor and major complications, readmissions and have pLOS compared with White patients in 2022 (aOR:1.26, 95% CI:1.19-1.34, P < .001; aOR:1.22, 95% CI:1.06-1.41, P = .006; aOR:1.44, 95% CI:1.28-1.62, P < .001; aOR:2.26, 95% CI:2.06-2.47, P < .001, respectively).

CONCLUSION

The utilization of robotic bariatric surgery has increased significantly over the past 8 years with continued improvements in its safety profile. While Black/AA patients have improved access to robotic surgery, their clinical outcomes continue to be worse than those of White patients. Efforts to address racial disparities in bariatric surgery outcomes must remain a priority to achieve health equity.

Analyzing the Social Vulnerability Index With Metabolic Surgery

INTRODUCTION

The social vulnerability index (SVI) is a census tract-level population-based measure generated from 16 socioeconomic and demographic variables on a scale from 1 (least) to 100 (most) vulnerable. This study has three objectives as follows: 1) to analyze multiple ways of utilizing SVI, 2) compare SVI as a group measure of marginalization to individual markers, and 3) to understand how SVI is associated with choice of surgery in metabolic surgery.

METHODS

We retrospectively identified adults undergoing Roux-en-Y gastric bypass and gastric sleeve in 2013-2018 National Surgical Quality Improvement Program data from a single academic center. High SVI was defined as >75th percentile. Low SVI was coded as <75th percentile in measure 1 and < 25th percentile in measure 2. Chi-square and Mann-Whitney U tests were utilized for categorical and continuous variables, respectively. Multivariable regression models were performed comparing SVI to marginalized status as a predictor for type of metabolic surgery.

RESULTS

We identified 436 patients undergoing metabolic surgery, with a low overall morbidity (6.1%). Complication and readmission rates were similar across comparator groups. The logistic regression models had similar area under the curve, supporting SVI as a proxy for individual measures of marginalization.

CONCLUSIONS

SVI performed as well as marginalized status in predicting preoperative risk. This suggests the validity of using SVI to identify high risk patients. By providing a single, quantitative score encompassing many social determinants of health, SVI is a useful tool in identifying patients facing the greatest health disparities.

Unveiling Equitable Surgical Prioritization: Insights From a Comprehensive Analysis Using the Medically Necessary and Time-Sensitive (MeNTS) Scoring System

BACKGROUND

This study addresses the intricate landscape of racial disparities in healthcare delivery, with a specific focus on surgical procedures. The concern was accentuated by the challenges posed during the COVID-19 pandemic when resources became scarce. Recognizing the potential impact of provider bias in medical decision-making, the American College of Surgeons introduced the Medically Necessary and Time-Sensitive (MeNTS) scoring system. This methodology aims to address procedures that, while not emergent, are deemed medically necessary and time-sensitive. This study analyzed whether using this scoring system decreased racial disparities between patients receiving surgery during the pandemic.

METHODOLOGY

A retrospective cross-sectional study was conducted using Electronic Medical Records from June 1, 2020, to December 31, 2021. We analyzed variations in MeNTS scores and time to surgery based on racial and ethnic backgrounds using bivariate and multivariate analyses.

RESULTS

The analysis included 2,997 patients. Of these, 1,442 (42.84%) were Hispanic participants, 1,282 (38.09%) were non-Hispanic participants, and 642 (19.07%) were participants of other specified ethnic backgrounds. The racial composition comprised 2,955 (87.79%) White participants, 98 (2.91%) Asian participants, 50 (1.49%) African American participants, and 72 (2.14%) Alaska Native or American Indian participants. No significant differences in mean days to surgery or MeNTS scores were observed across racial and ethnic groups (Hispanic participants = 76.62 vs. non-Hispanic participants = 78.82, P = 0.8). A multivariate survival model showed that MeNTS scores below 30 were associated with higher surgery likelihood, with no significant disparities in race, ethnicity, or gender.

CONCLUSIONS

This comprehensive study utilizing the MeNTS scoring system reveals an absence of statistically significant racial disparities in surgical prioritization. These findings contribute valuable insights to the ongoing discourse surrounding equitable healthcare practices and emphasize the potential efficacy of standardized scoring systems in mitigating biases in medical decision-making.

Early postoperative outcomes following bariatric surgery in the United States: Are racial disparities improving?

BACKGROUND

Bariatric surgery offers effective treatment for morbid obesity and associated medical comorbidities, with excellent short- and long-term outcomes. Although it has been well documented that racial minority bariatric patients have worse outcomes than White patients, it remains unclear whether this recognition has led to improvement. Herein, we assess recent trends in bariatric surgery among Black and White patients and compare early postoperative outcomes by race.

METHODS

Primary sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) patients from 2015 to 2021 reported to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program were studied. Bariatric patients were stratified by race (Black and White) and perioperative outcomes were compared between matched Black and White patients. Primary outcome was 30-day mortality. Secondary outcomes included hospital readmissions, hospital length of stay (LOS), reoperation, and postoperative complications.

RESULTS

Overall, there were 193,071 Black and 645,224 White primary bariatric patients, with a higher volume of SG and RGYB performed among White patients. A total of 219,566 Black and White bariatric patients were matched and included in the case-control. Black patients were found to have higher rates of 30-day mortality (0.02% vs. 0.01%; p = 0.03) and readmissions (3.68% vs. 2.65%; p < 0.001). There were no significant differences in LOS, reoperations, or overall postoperative complications. However, there was a higher postoperative pulmonary thromboembolism rate (0.16% vs 0.08%; p < 0.001).). The differences in perioperative outcomes stratified by race persisted over the study period (Fig. 1).

CONCLUSION

Black bariatric surgery patients continue to have worse perioperative outcomes compared with their White counterparts. Further work must be done to determine contributing factors in order to effect improvement in outcomes in bariatric surgical care for racial minority patients.

Racial Disparities in Outcomes of Bariatric Surgery: An Analysis of 190,319 Patients

Background

Bariatric surgery has been increasingly utilized to reduce weight, manage obesity related morbidities, and improve quality of life. Racial discrepancies in surgical outcomes have been demonstrated across various surgical disciplines including bariatric surgery. However, studies have been limited to certain procedures, institutional data, or geographic-specific data.

Objective

Our aim is to investigate racial disparities in outcomes of bariatric surgery using the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database.

Methods

Preoperative information and postoperative results and complications were analyzed between January 2008 and December 2021. Statistical analysis was conducted to compare patients' characteristics and clinically relevant outcomes between the different racial groups.

Results

A total of 190,319 patients were included. The majority were White (81.4%) and females (79.8%), with a mean age of 44.7 years. After controlling for relevant demographic and preoperative characteristics, the Black group had higher length of hospital stay (odds ratio [OR] = 1.36 [1.23; 1.50]), higher 30 days postoperative mortality (OR = 1.80 [1.25; 2.60]), higher odds of unplanned readmission (OR = 1.40 [1.31; 1.50]), pulmonary embolism (OR = 2.23 [1.75; 2.85]), acute renal failure (OR = 1.25 [0.87; 1.79]).

Conclusion

Disparities exist between racial groups undergoing bariatric surgery. Additional studies are needed to further investigate these findings and their potential implications.

Race Does Not Affect Rates of Surgical Complications at Military Treatment Facility

INTRODUCTION

Racial minorities have been found to have worse health care outcomes, including perioperative adverse events. We hypothesized that these racial disparities may be mitigated in a military treatment facility, where all patients have a military service connection and are universally insured.

MATERIALS AND METHODS

This is a single institution retrospective review of American College of Surgeons National Surgical Quality Improvement Program data for all procedures collected from 2017 to 2020. The primary outcome analyzed was risk-adjusted 30-day postoperative complications compared by race.

RESULTS

There were 6,941 patients included. The overall surgical complication rate was 6.9%. The complication rate was 7.3% for White patients, 6.5% for Black patients, 12.6% for Asian patients, and 3.4% for other races. However, after performing patient and procedure level risk adjustment using multivariable logistic regression, race was not independently associated with surgical complications.

CONCLUSIONS

Risk-adjusted surgical complication rates do not vary by race at this military treatment facility. This suggests that postoperative racial disparities may be mitigated within a universal health care system.

Racial Disparity in Length of Stay Following Implementation of a Bariatric Enhanced Recovery Program

INTRODUCTION

Enhanced Recovery Programs (ERPs) mitigate racial disparities in postoperative length of stay (LOS) for colorectal populations. It is unclear, however, if these effects exist in the bariatric surgery population. Therefore, this study aimed to evaluate the racial disparities in LOS before and after implementation of bariatric surgery ERP.

METHODS

A retrospective cohort study was performed using data from a single institution. Patients undergoing minimally invasive sleeve gastrectomy or Roux-en-Y gastric bypass from 2017 to 2019 (pre-ERP) or 2020-2022 (ERP) were included. Chi-square, Kruskal-Wallis, and analysis of variance were used to compare groups, and estimated LOS (eLOS) was assessed via multivariable regression.

RESULTS

Seven hundred sixty four patients were identified, including 363 pre-ERPs and 401 ERPs. Pre-ERP and ERP cohorts were similar in age (median 44.3 years versus 43.8 years, P = 0.80), race (53.4% Black versus 56.4% Black, P = 0.42), and preoperative body mass index (median 48.3 versus 49.4, P = 0.14). Overall median LOS following bariatric surgery decreased from 2 days pre-ERP to 1 day following ERP (P < 0.001). Average LOS for Black and White patients decreased by 0.5 and 0.48 days, respectively. However, overall eLOS remained greater for Black patients compared with White patients despite ERP implementation (eLOS 0.21 days, P = 0.01).

CONCLUSIONS

Implementation of a bariatric surgery ERP was associated with decreased LOS for both Black and White patients. However, Black patients did have slightly longer LOS than White patients in both pre-ERP and ERP eras. More work is needed to understand the driving mechanism(s) of these disparities to eliminate them.

The impact of gender, race, and ethnicity on bariatric surgery outcomes

BACKGROUND

The rates of postoperative complications can vary among specific patient populations.

OBJECTIVES

The aim of this study is to examine how gender, race, and ethnicity can affect short-term postoperative complications in bariatric surgery patients.

SETTING

United States.

METHODS

Patients who underwent bariatric surgery between the years 2016 and 2021 were included and stratified based on gender, race/ethnicity, and procedure type. The 30-day outcomes were assessed using Clavien-Dindo (CD) classification of III-V. Wilcoxon rank-sum test was performed to compare continuous variables among groups and Chi-squared test for categorical variables. Logistic regression was performed to examine the effects of gender, race/ethnicity on CD classification ≥ III complications by the procedure type.

RESULTS

A total of 975,642 bariatric surgery patients were included. Descriptive univariate analysis showed that CD ≥ III complications were higher among non-Hispanic blacks (NHB) and lowest in Hispanic patients, regardless of their gender, except in the duodenal switch DS group, where non-Hispanic whites (NHW) had the lowest complication rate. There was no difference between male and female patients with regards to postoperative complications, except in the sleeve gastrectomy (SG) group, where NHW males had more complications than NHW females. Sleeve gastrectomy showed the lowest complication rates followed by gastric bypass and DS in all groups. In multivariate logistic regression model, for both females and males NHBs had higher odds of postoperative complications compared to NHWs in sleeve gastrectomy (Female aOR:1.31, 95% CI: [1.23-1.40]; Male aOR:1.24, 95% CI: [1.08-1.43], P < .001) and gastric bypass (Female aOR:1.24, 95% CI: [1.16-1.33]; Male aOR:1.25, 95% CI: [1.06-1.48], P < .01).

CONCLUSIONS

Non-Hispanic Black patients are at a higher rate of developing CD ≥ III complications compared to non-Hispanic Whites after bariatric surgery. The male gender was not a significant risk factor for serious postoperative complications. Among the different types of bariatric procedures, sleeve gastrectomy has the lowest rates of severe complications, followed by gastric bypass and duodenal switch. These results highlight the significance of considering gender, race, ethnicity, and procedure type during preoperative evaluation, surgical planning, and postoperative care.

The Use of Noninvasive Scores in Predicting NAFLD Progression After Bariatric Surgery

BACKGROUND

Bariatric surgery has been postulated to impact liver function resulting in favorable effects on nonalcoholic fatty liver disease (NAFLD). We aimed to analyze the long-term impact of bariatric surgery on noninvasive scores predicting the progression of liver fibrosis in a bariatric population.

METHODS

We retrospectively reviewed the records of patients without pre-existing liver disease who underwent sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) at our center between 2010 and 2018. Four predictive scores for liver fibrosis (AST/ALT, APRI, Fib-4, and BARD) were calculated preoperatively, 6 months post-operatively, and annually up to 5 years. Correlations were analyzed with Pearson R. Subgroup and sensitivity analyses were performed to identify populations at increased risk.

RESULTS

A total of 2769 patients were included. The mean age was 40 years, and the majority was females (88.5%) and of Hispanic ethnicity (59.2%). There was a steady post-operative increase in the percentage of patients at increased risk of progression of liver fibrosis. The Fib-4 score showed the largest increase in the population at risk for liver fibrosis (11.3% preoperatively to 28.9% at 5 years). Patients with diabetes and those who underwent a sleeve gastrectomy continued to display a higher risk for liver fibrosis than did patients without diabetes and those who underwent RYGB, respectively.

CONCLUSION

There was an overall trend to increased liver fibrosis scores over the 5-year post-operative follow-up, but this increase remained lower than that reported in previous literature. Bariatric surgery offers NAFLD risk reduction in a high-risk population.

Patient and Provider Perceptions About Communication After Bariatric Surgery: A Qualitative Analysis

INTRODUCTION

Communication between patients and providers can strongly influence patient behavior after surgery. The objective of this study was to assess patient and provider perceptions of how communication affected weight-related behaviors after bariatric surgery.

MATERIALS AND METHODS

Semistructured interviews with bariatric surgery patients and providers were conducted from April-November 2020. Patients who had Medicaid within 3 y of surgery were defined as socioeconomically disadvantaged. Interview guides were derived from Andersen's Behavioral Model of Health Services and Torain's Framework for Surgical Disparities. Participants described postoperative experiences regarding diet, physical activity, and follow-up care. A codebook was developed deductively based on the two theories. Directed content analysis identified themes pertaining to patient-provider communication.

RESULTS

Forty-five participants were interviewed, including 24 patients (83% female; 79% White), six primary care providers, four health psychologists, five registered dietitians, and six bariatric surgeons. Four themes regarding communication emerged: (1) Patients experiencing weight regain did not want to follow-up with providers to discuss their weight; (2) Patients from socioeconomically disadvantaged backgrounds had less trust and required more rapport-building from providers to enhance trust; (3) Patients felt that providers did not get to know them personally, which was perceived as a lack of personalized communication; and (4) Providers often changed their language to be simpler, so patients could understand them.

CONCLUSIONS

Patient-provider communication after bariatric surgery is essential, but perceptions about the elements of communication differ between patients and providers. Reassuring patients who have attained less weight loss than expected and establishing trust with socioeconomically vulnerable patients could strengthen care after bariatric surgery.

Revisional Procedures after Sleeve Gastrectomy for Weight Recurrence or Inadequate Weight Loss: An Analysis of the MBSAQIP Database

INTRODUCTION

The safety of conversional bariatric procedures after sleeve gastrectomy (SG) for weight recurrence (WR) or inadequate weight loss (IWL) is debated due to limited evidence. Conversion options include Roux-en-Y gastric bypass (RYGB), single anastomosis duodeno-ileal bypass (SADI), and biliopancreatic diversion with duodenal switch (BPD-DS). We aimed to compare serious complications and mortality rates between these procedures within 30 days.

METHODS

Using the 2020 and 2021 MBSAQIP databases, we identified patients who underwent a conversion from SG to RYGB, SADI, or BPD-DS. We performed a multivariable logistic regression to assess predictors of 30-day complications and mortality.

RESULTS

Among 7388 patients (77.6% RYGB, 8.7% SADI, 13.7% BPD-DS), those undergoing SADI and BPD-DS had higher preoperative body mass index. Conversion reasons included WR (63.0%) and IWL (37.0%). SADI and BPD-DS patients had longer operative times (p < 0.001) and higher leak rates (p = 0.001). Serious complications, reoperations, readmissions, and 30-day mortality were similar across groups. Conversion procedure type was not an independent predictor of complications.

CONCLUSION

RYGB was the most performed conversional procedure after SG. The study indicated a similar safety profile for revisional RYGB, SADI, and BPD-DS, with comparable 30-day complications and mortality rates. However, SADI and BPD-DS patients had longer operative time and higher leak rates.

The Mediating Effect of Operative Approach on Racial Disparities in Bariatric Surgery Complications

INTRODUCTION

A laparoscopic approach to bariatric surgeries confers a favorable side-effect profile as compared to an open approach. However, literature regarding the independent association of race with access to and postoperative outcomes in laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (GS) is scarce.

MATERIALS AND METHODS

All RYGB and GS cases recorded in American College of Surgeons National Quality Improvement Program data from 2012 to 2020 were subjected to propensity score matching to assess the independent association between Black self-identified race on access to a laparoscopic approach and postoperative complications. Finally, a series of logistic regressions enabled evaluation of the mediating effect of operative approach on racial disparities in postoperative complications.

RESULTS

55,846 cases of RYGB and 94,209 cases of GS were identified. Following propensity score matching, logistic regression identified Black race as an independent predictor of open approach to RYGB (P < 0.001) and GS (P = 0.019). Black patients had increased incidence of any, minor and severe postoperative complications and unplanned readmissions in both RYGB (P < 0.001, P < 0.001, P = 0.0412, and P < 0.001, respectively) and GS (P < 0.001, P < 0.001, P = 0.0037, and P < 0.001, respectively). Open approach to RYGB was identified as a partial mediator of the independent association between Black race and any complication, minor complications, and unplanned readmission.

CONCLUSIONS

This methodology identified racial disparities in complications following RYGB and GS. Interestingly, reduced access to a laparoscopic approach mediated racial disparities in complications following RYGB but not GS. Further research might elucidate upstream determinants of health that catalyze these disparities.

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.

Black-versus-White racial disparities in 30-day outcomes at Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited centers: a needed quality indicator

BACKGROUND

Creating a metric in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) to assess Black-versus-White disparities is critical if we are to ensure equitable care for all.

OBJECTIVE

To investigate Black-versus-White disparities while replicating MBSAQIP methodology with regard to covariates and modeling so that the results can serve as the foundation to create a benchmarked site-level Disparities Metric for MBSAQIP.

SETTING

United States and Canada.

METHODS

Across the 2015-2019 MBSAQIP cohorts, 543,976 adults underwent primary or revision sleeve gastrectomy or Roux-en-Y gastric bypass and were reported as either White or Black. Using a set of covariates derived from published MBSAQIP performance models, we performed multivariable logistic modeling with 10-fold cross-validation for the 11 outcomes evaluated in MBSAQIP Semiannual Reports, plus venous thromboembolism (VTE) and death. We analyzed primary and revision cases separately.

RESULTS

After risk adjustment, Black patients experienced higher odds of all-occurrence morbidity (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.19-1.25; P < .001), serious events (OR, 1.08; 95% CI, 1.04-1.13; P < .001), all-cause intervention (OR, 1.31; 95% CI, 1.24-1.37; P < .001), related intervention (OR, 1.29; 95% CI, 1.22-1.37; P < .001), all-cause readmission (OR, 1.37; 95% CI, 1.33-1.41; P < .001), related readmission (OR, 1.41; 95% CI, 1.36-1.46; P < .001), venous thromboembolism (OR, 1.49; 95% CI, 1.34-1.65; P < .001), and death (OR, 1.59; 95% CI, 1.34-1.89; P < .001) after primary procedures. Black patients experienced lower odds of morbidity (OR, .94; 95% CI, .91-.98; P = .004) and surgical-site infection (OR, .72; 95% CI, .66-.78; P < .001).

CONCLUSIONS

Black patients experienced a higher risk for serious complications and required more readmissions, reoperations, and postoperative interventions. This study supports the creation of a site-level Disparities Metric for the MBSAQIP and provides the framework to do so.

Gastric Bypass Mortality Trends in Racial Cohorts: Are We Improving?

INTRODUCTION

Roux-en-Y gastric bypass (RYGB) continues to be safely performed in racial cohorts. However, studies continue to report differences in complications, with non-Hispanic black (NHB) patients having a higher rate of adverse outcomes, including mortality. It is unclear how these disparate outcomes have evolved over time. Our objective was to determine RYGB procedure and mortality trends in racial cohorts.

METHODS

Using the 2015 to 2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project (MBSAQIP) database, we identified primary RYGB cases performed laparoscopically or robotically. Non-Hispanic white (NHW) and non-Hispanic black (NHB) patient cohorts were matched based on patient and surgical characteristics. Conditional logistic regression analysis was conducted on the matched pairs. Primary outcomes of interest included year-to-year all-cause and procedure-related mortality. Stata/MP 16.1 was utilized for analysis, and a p-value of < 0.05 and a 95% confidence interval that excluded 1 were considered significant.

RESULTS

A total of 148,829 RYGB cases in NHW (82.8%) and Black (17.2%) patients were analyzed. RYGB trends remain similar for NHB and NHW patients over 5 years. In matched cohorts, all-cause mortality (OR 2.23; 95% CI: 1.16-4.29), aggregate related readmission (OR 1.39; 95% CI: 1.27-1.51), related reintervention (OR 1.36; 95% CI: 1.19-1.56), and VTE (OR 1.86; 95% CI: 1.40-2.45) were more likely in NHB patients. During the study period, year-to-year mortality was higher in NHB patients compared to NHW patients.

CONCLUSION

Over a 5-year period, year-to-year mortality remains higher in NHB patients after RYGB. While bariatric outcomes continue to improve, outcome gaps between racial cohorts seem to persist.

Outcomes and Trends of Endoscopic Bariatric Therapies (EBT) Among Minority Populations

INTRODUCTION

Endoscopic bariatric therapies (EBT) have emerged as effective options for weight loss. While the benefits of EBT have been documented, data regarding such therapies among minority populations remains scant. We aim to investigate EBT trends and outcomes in minority populations.

METHODS

Data were extracted from the 2015 to 2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project (MBSAQIP) databases. Intragastric balloon (IGB) and endoscopic sleeve gastroplasty (ESG) cases were identified, and procedure volume assessed by year and race/ethnicity. Measures of interest included year-to-year mortality, surgical complications, and 30-day adverse outcomes.

RESULTS

Of 966,646 cases in the MBSAQIP databases, 5209 (0.54%) IGB and ESG cases were included. 10.7% were black, and 81.6% were female patients. Compared to white patients, black and Hispanic patients were younger (p < 0.01) with a higher body mass index (p < 0.001). Mortality (0.03% vs. 0% vs. 0%, p = 0.99), reoperation (1.1% vs. 0.8% vs. 0.6%, p = 0.30), and reintervention (3.9% vs. 3.2% vs. 2.3%, p = 0.09) rates were similar between racial/ethnic cohorts. All complications were similar between racial/ethnic cohorts, except a higher rate of venous thromboembolism, in Hispanic (1.04%, p < 0.01) compared to black (0.18%) and white (0.21%) patients. IGB and ESG were predominantly performed in white and Hispanic patients, respectively. ESG was associated with a higher leak (0.6% vs. 0.02%, p < 0.01) and venous thromboembolism (VTE) (1.0% vs. 0.12%, p < 0.01) rate.

CONCLUSION

While EBTs have increased annually, they are performed less in black patients. Future studies are needed to identify access barriers for black patients. They are safely performed with similar outcomes in racial/ethnic cohorts, except for a higher VTE rate in Hispanic patients.

Comparison of endoscopic sleeve gastroplasty versus surgical sleeve gastrectomy: a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database analysis

BACKGROUND AND AIMS

Endoscopic sleeve gastroplasty (ESG) is an incisionless, transoral, restrictive bariatric procedure designed to imitate sleeve gastrectomy (SG). Comparative studies and large-scale population-based data are limited. Additionally, no studies have examined the impact of race on outcomes after ESG. This study aims to compare short-term outcomes of ESG with SG and evaluate racial effects on short-term outcomes after ESG.

METHODS

We retrospectively analyzed over 600,000 patients in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database from 2016 to 2020. We compared occurrences of adverse events (AEs), readmissions, reoperations, and reinterventions within 30 days after procedures. Multivariate regression evaluated the impact of patient factors, including race, on AEs.

RESULTS

A total of 6054 patients underwent ESG and 597,463 underwent SG. AEs were low after both procedures with no significant difference in major AEs (SG vs ESG: 1.1% vs 1.4%; P > .05). However, patients undergoing ESG had more readmissions (3.8% vs 2.6%), reoperations (1.4% vs .8%), and reinterventions (2.8% vs .7%) within 30 days (P < .05). Race was not significantly associated with AEs after ESG, with black race associated with a higher risk of AEs in SG.

CONCLUSIONS

ESG demonstrates a comparable major AE rate with SG. Race did not impact short-term AEs after ESG. Further prospective studies long-term studies are needed to compare ESG with SG.

Racial Disparities in Tympanoplasty Surgery: A 30-Day Morbidity and Mortality National Cohort Study

OBJECTIVES

To assess the impact of race and ethnicity on 30-day complications after tympanoplasty surgery.

METHODS

The National Surgical Quality Improvement Program database was queried for tympanoplasty procedures from 2005 to 2019. Demographic, comorbidity, and postoperative complication data were compared according to race using univariate and binary logistic regression analyses.

RESULTS

A total of 11,701 patients were included, consisting of 80.3% White, 3.0% Black, 7.7% Asian, 5.7% Hispanic, 2.5% American Indian/Alaska Native, and 0.8% other. Binary logistic regression model indicated that Black patients had increased odds of unplanned readmittance (p = 0.033; odds ratio [OR], 3.110) and deep surgical site infections (p = 0.008; OR, 6.292). American Indian/Alaska Native patients had increased odds of reoperation (p = 0.022; OR, 6.343), superficial surgical site infections (p < 0.001; OR, 5.503), urinary tract infections (p < 0.001; OR, 18.559), surgical complications (p < 0.001; OR, 3.820), medical complications (p = 0.001; OR, 10.126), and overall complications (p < 0.001; OR, 4.545).

CONCLUSION

Although Black and American Indian/Alaskan Native patients were more likely to have complications after tympanoplasty surgery after adjusting for comorbidities, age, and sex, these results are tempered by an overall low rate of complications. Future studies should be devoted to understanding the drivers of these health inequities in access to otologic care and surgical treatment to improve outcomes and achieve equitable care.

Comparative Safety and Effectiveness of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy for Weight Loss and Type 2 Diabetes Across Race and Ethnicity in the PCORnet Bariatric Study Cohort

Importance

Bariatric surgery is the most effective treatment for severe obesity; yet it is unclear whether the long-term safety and comparative effectiveness of these operations differ across racial and ethnic groups.

Objective

To compare outcomes of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) across racial and ethnic groups in the National Patient-Centered Clinical Research Network (PCORnet) Bariatric Study.

Design, Setting, and Participants

This was a retrospective, observational, comparative effectiveness cohort study that comprised 25 health care systems in the PCORnet Bariatric Study. Patients were adults and adolescents aged 12 to 79 years who underwent a primary (first nonrevisional) RYGB or SG operation between January 1, 2005, and September 30, 2015, at participating health systems. Patient race and ethnicity included Black, Hispanic, White, other, and unrecorded. Data were analyzed from July 1, 2021, to January 17, 2022.

Exposure

RYGB or SG.

Outcomes

Percentage total weight loss (%TWL); type 2 diabetes remission, relapse, and change in hemoglobin A1c (HbA1c) level; and postsurgical safety and utilization outcomes (operations, interventions, revisions/conversions, endoscopy, hospitalizations, mortality, 30-day major adverse events) at 1, 3, and 5 years after surgery.

Results

A total of 36 871 patients (mean [SE] age, 45.0 [11.7] years; 29 746 female patients [81%]) were included in the weight analysis. Patients identified with the following race and ethnic categories: 6891 Black (19%), 8756 Hispanic (24%), 19 645 White (53%), 826 other (2%), and 783 unrecorded (2%). Weight loss and mean reductions in HbA1c level were larger for RYGB than SG in all years for Black, Hispanic, and White patients (difference in 5-year weight loss: Black, -7.6%; 95% CI, -8.0 to -7.1; P < .001; Hispanic, -6.2%; 95% CI, -6.6 to -5.9; P < .001; White, -5.9%; 95% CI, -6.3 to -5.7; P < .001; difference in change in year 5 HbA1c level: Black, -0.29; 95% CI, -0.51 to -0.08; P = .009; Hispanic, -0.45; 95% CI, -0.61 to -0.29; P < .001; and White, -0.25; 95% CI, -0.40 to -0.11; P = .001.) The magnitude of these differences was small among racial and ethnic groups (1%-3% of %TWL). Black and Hispanic patients had higher risk of hospitalization when they had RYGB compared with SG (hazard ratio [HR], 1.45; 95% CI, 1.17-1.79; P = .001 and 1.48; 95% CI, 1.22-1.79; P < .001, respectively). Hispanic patients had greater risk of all-cause mortality (HR, 2.41; 95% CI, 1.24-4.70; P = .01) and higher odds of a 30-day major adverse event (odds ratio, 1.92; 95% CI, 1.38-2.68; P < .001) for RYGB compared with SG. There was no interaction between race and ethnicity and operation type for diabetes remission and relapse.

Conclusions and Relevance

Variability of the comparative effectiveness of operations for %TWL and HbA1c level across race and ethnicity was clinically small; however, differences in safety and utilization outcomes were clinically and statistically significant for Black and Hispanic patients who had RYGB compared with SG. These findings can inform shared decision-making regarding bariatric operation choice for different racial and ethnic groups of patients.

Bariatric surgery: to bleed or not to bleed? This is the question

BACKGROUND

Bariatric surgery procedures are the most successful and durable treatment for morbid obesity. Hemorrhage represents a life-threatening complication, occurring in 1.3-1.7% of bariatric surgeries.

MATERIALS AND METHODS

We examined patients undergoing Bariatric Surgery from July 2017 to June 2020 (Group A) and those operated from July 2020 to June 2022 (Group B) in our Department. Starting from July 2020 we have implemented intraoperative measures to prevent postoperative bleeding, increasing mean arterial pressure (MAP) by 30% compared to preoperative and reducing the pneumoperitoneal pressure of CO2 to 8 mmHg in the last 15 min of the operation.

RESULTS

The study gathered 200 patients divided into the two described groups. The mean age of Group A is 44 ± 8.49 and 43.73 ± 9.28. The mean preoperative BMI is 45.6 kg/m2 ± 6.71 for Group A and 48.9 ± 7.15 kg/m2 for Group B. Group A recorded a mean MAP of 83.06 ± 18.58 mmHg and group B a value of 111.88 ± 12.46 mmHg (p value < 0.05 and z-score is 4.15226 and the value of U is 13,900). We observed 9 cases of bleeding in group A, most of them being treated with medical therapy and transfusions; only 1 hemodynamically unstable patient underwent re-laparoscopy. We reported only 2 cases of bleeding in group B, one of which required blood transfusions.

CONCLUSION

From our study we can conclude that increasing mean arterial pressure (MAP) by 30% compared to preoperative and reducing the pneumoperitoneum pressure of CO2 to 8 mmHg in the last 15 min of the operation led to a decrease in bleeding cases in group B and, most importantly, all the bleedings were easily controllable with medical therapy and/or transfusions. These measures allowed us to reduce postoperative bleeding.

Prediction Factors of Early Postoperative Bleeding after Bariatric Surgery

PURPOSE

Identifying the possible predictors of postoperative bleeding is advantageous to reduce healthcare costs and promote patients' recovery. The aim of this study was to determine early postoperative bleeding predictors after bariatric surgery.

MATERIALS AND METHODS

This retrospective study was conducted using data from 2260 patients who underwent bariatric surgery. We diagnosed early postoperative bleeding by the following symptoms: abdominal pain, hypotension, tachycardia, hematemesis, melena, decreased hemoglobin level, the need for at least two units of packed red blood cells (PRBCs) transfusion, and reoperation within the first 48 h after surgery.

RESULTS

Our results showed the odds of early postoperative bleeding in laparoscopic Roux-en-Y gastric bypass (LRYGB) were higher than in laparoscopic sleeve gastrectomy (LSG) (OR 3.49, 95% CI 1.79 to 6.80). In addition, prior intragastric balloon (IGB) (OR 3.14, 95% CI 1.18 to 8.34) and oral non-aspirin non-steroidal anti-inflammatory drugs (NSAIDs) (OR 5.91, 95% CI 1.79 to 20.63) were positively associated with the occurrence of postoperative bleeding. In contrast, there was an inverse relationship between staple line oversewing and the odds of postoperative bleeding (OR 0.18, 95% CI 0.04 to 0.81). After stratification data based on the type of the surgery, the positive association between IGB and the odds of bleeding was constant in the LRYGB group. In the LSG group, use of non-aspirin NSAIDs was linked to a higher incidence of postoperative bleeding, while oversewing of the staple line lowered the incidence of this event.

CONCLUSIONS

Our results demonstrated a positive association between type of procedure, history of IGB, and oral non-aspirin NSIADs use, as well as an inverse relationship between staple line oversewing and the odds of bleeding after bariatric surgery.

Systemic and Environmental Contributors to Obesity Inequities in Marginalized Racial and Ethnic Groups

Obesity is a multifactorial disease that disproportionally affects diverse racial and ethnic groups. Structural racism influences racial inequities in obesity prevalence through environmental factors, such as racism and discrimination, socioeconomic status, increased levels of stress, and bias in the health care delivery system. Researchers, clinicians, and policy makers must work to address the environmental and systematic barriers that contribute to health inequities in the United States. Specifically, clinicians should quantitatively and qualitatively assess environmental and social factors and proactively engage in patient-centered care to tailor available treatments based on identified needs and experiences.

Racial disparity in causes for readmission following bariatric surgery

BACKGROUND

Readmission after bariatric surgery is not cost-effective and is a preventable quality metric within standardized practices. However, reasons for readmission among racial/ethnic bariatric cohorts are less explored and understood.

OBJECTIVE

Our study objective was designed to compare reasons for readmission among racial/ethnic cohorts of bariatric patients.

SETTING

Academic hospital.

METHODS

We performed a retrospective analysis of the 2015-2018 MBSAQIP databases to identify Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) cases. Regression analyses determined predictors of all-cause and bariatric-related readmissions. Reasons for readmission were compared between racial/ethnic cohorts using propensity score matching.

RESULTS

More than 550 000 RYGB and SG cases were analyzed. The readmission rate was 3%-4%. Black race, RYGB, robot-assisted approach, and numerous co-morbidities were independently associated with readmission (P <.05). In RYGB cases, black (versus white) patients were at decreased odds of leak-related (P < .001) and cardiovascular-related (P < .001) readmissions but at increased odds of readmissions related to renal complications (P < .001). Hispanic (versus white) patients had a higher likelihood of venous thromboembolism-related readmissions (P < .001). In SG cases, black (versus white) patients had a similar lower likelihood of readmission related to leaks or cardiovascular complications but higher odds of readmission related to renal complications (P < .001). Hispanic (versus black) patients had a higher likelihood of leak-related readmissions (P < .001).

CONCLUSION

Readmission reasons after bariatric surgery vary by race/ethnicity. Perioperative pathways to mitigate complications, including readmissions, should consider these disparate findings.

An analysis of readmission trends by urgency and race/ethnicity in the MBSAQIP registry, 2015-2018

BACKGROUND

Large-scale analyses stratifying bariatric surgery readmissions by urgency are lacking.

OBJECTIVES

Identify predictors of urgent/nonurgent readmission among "ideal" bariatric candidates, using a national registry.

SETTING

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) national database.

METHODS

We extracted an "ideal" patient cohort from the 2015-2018 Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP) registry, characterized by only typical weight-related comorbidities (hypertension [HTN], obstructive sleep apnea [OSA], gastroesophageal reflux disease [GERD], and diabetes (insulin-dependent diabetes mellitus [IDDM] and non-insulin-dependent diabetes mellitus [NIDDM]) undergoing primary bariatric surgery with an uneventful postoperative course. Readmissions were classified as "urgent" (UR; e.g., leak, obstruction, bleeding) or "nonurgent" (NUR; e.g., dehydration, nonspecific abdominal pain). χ² or t test analyses were used for bivariate significance testing. Multivariate logistic regression models were constructed to assess independent predictors of readmission.

RESULTS

The cohort (N = 292,547) comprised 38.5% of all MBSAQIP patients (mean age [standard deviation] = 43.2 [11.7]; body mass index [BMI] = 44.9 [6.6]; 81% female; 62% White, 17% Black, 14% Hispanic). Total readmission rates were 2.75% (n = 8046) and decreased from 2015-2018 (3.00%-2.63%; P < .001). Independent predictors of readmissions included Roux-en-Y gastric bypass (RYGB) (odds ratio [OR] = 1.97, p < .001), Black (OR = 1.46, P < .001) and Hispanic race (OR = 1.14, P < .001), GERD (OR = 1.27, P < .001), HTN (OR = 1.08, P = .003), and IDDM (OR = 1.39, P < .001). NUR and UR readmission rates were 1.27% (n = 3702) and 1.06% (n = 3090), respectively. NURs decreased over time (1.42%-1.16%, P < .001), with no change in Urs (1.01%-1.06%, P = .51); this trend persisted in multivariate analysis (2017: NUR OR = .85, P < .001; 2018: NUR OR = .82, p < .001). Independent predictors of both URs and NURs included Black (NUR OR = 1.71, p < .001; UR OR = 1.27, p < .001) and Hispanic (NUR OR = 1.15, P < .001; UR OR = 1.19, P < .001) race, RYGB (NUR OR = 1.84, P < .001; UR OR = 2.34, P < .001), and GERD (NUR OR = 1.39, p < .001; UR OR = 1.17, P < .001). Female sex (NUR OR = 1.64, P < .001), age (NUR OR = .98, P < .001), HTN (NUR OR = 1.22, P < .001), and IDDM (NUR OR = 1.41, P < .001) predicted NURs, while higher BMI (UR OR = 1.01, P < .001), and OSA (UR OR = 1.10, P = .02) predicted URs.

CONCLUSION

Readmission rates for "ideal" bariatric patients improved over time, driven by reductions in non-urgent etiologies. Racial disparities persist for both urgent and non-urgent causes of readmission.

Racial disparities in bariatric perioperative outcomes among the elderly

BACKGROUND

Bariatric surgery outcomes in elderly patients have been shown to be safe, but with a higher rate of adverse outcomes compared with nonelderly patients. The impact of race on bariatric surgery outcomes continues to be explored, with recent studies showing higher rates of adverse outcomes in black patients. Perioperative outcomes in racial cohorts of elderly bariatric patients are largely unexplored.

OBJECTIVE

The goal of this study was to compare outcomes between elderly non-Hispanic black (NHB) and non-Hispanic white (NHW) bariatric surgery patients to determine whether outcomes are mediated by race.

SETTING

Academic hospital.

METHODS

Patients who had a primary Roux-en-Y (RYGB) and sleeve gastrectomy (SG) in the period 2015-2018 and were at least 65 years of age were identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Data File (MBSAQIP PUF). Selected cases were stratified by race. Outcomes were compared between matched racial cohorts. Multivariate regression analyses were performed to determine whether race independently predicted morbidity.

RESULTS

From 2015 to 2018, 29,394 elderly NHW (90.8%) and NHB (9.2%) patients underwent an RYGB or SG. At baseline, NHB elderly patients had a higher burden of co-morbid conditions, resulting in higher rates of overall (7.7% versus 6.4%, P = .009) and bariatric-related (5.4% versus 4.1%, P = .001) morbidity. All outcome measures were similar between propensity-score-matched racial elderly bariatric patient cohorts. On regression analysis, NHB race remained independently correlated with morbidity (odds ratio [OR] 1.3, 95% CI 1.08-1.47, P = .003).

CONCLUSION

RYGB and SG are safe in elderly patient cohorts, with no differences in adverse outcomes between NHB and NHW patients, accounting for confounding factors. While race does not appear to impact outcomes in the elderly cohorts, NHB race may play a role in access.

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.

Venous thromboembolism: risk factors in the sleeve gastrectomy era

BACKGROUND

Of complications after bariatric surgery, venous thromboembolism (VTE) has the greatest impact on mortality.

OBJECTIVES

To examine risk factors for postoperative VTE and identify high-risk patients who may benefit from prolonged prophylaxis.

SETTING

National Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database METHODS: Patients who underwent primary, laparoscopic bariatric surgery 2015-2019 were identified. Risk factors were sex, age, body mass index (BMI), history of VTE, immobility, venous stasis disease, operative time greater >3 hours, and procedure type. Multivariable logistic regression was used to examine associations between factors and the outcome of postoperative VTE. We examined contributions of each factor through average marginal effects and E-values. We added Black versus White race to the same regression model to understand whether race acted as a moderating factor.

RESULTS

In our study, 1677 of 605,782 (.28%) patients experienced postoperative VTE. On multivariable analysis, previous history of VTE had the greatest association, increasing risk of postoperative VTE by +.90% points (95% CI [confidence interval] +.73% to +1.07%). Lower-95% CI E-value bounds were 1.43 for men, 1.11 preoperative BMI, 7.38 history of VTE, and 2.15 operative length >3 hours. Black patients had an additional +.18% (95% CI +.14 to +.22%) risk of postoperative VTE, corresponding to a lower E-value bound of 2.50.

CONCLUSION

In this study using recent years' national bariatric surgery data, we find history of VTE is the greatest driver of postoperative VTE. Most importantly, Black patients are more likely to suffer postoperative VTE. Now is the time to use the power of quality improvement programs to ensure health equity for all our patients.

Racial Disparities in Bariatric Surgery Complications and Mortality Using the MBSAQIP Data Registry

Background

Racial disparities in postoperative complications have been demonstrated in bariatric surgery, yet the relationship of race to complication severity is unknown.

Study Design

Adult laparoscopic primary bariatric procedures were queried from the 2015 and 2016 MBSAQIP registry. Adjusted logistic and multinomial regressions were used to examine the relationships between race and 30-day complications categorized by the Clavien-Dindo grading system.

Results

A total of 212,970 patients were included in the regression analyses. For Black patients, readmissions were higher (OR = 1.39, p < 0.0001) and the odds of a Grade 1, 3, 4, or 5 complication were increased compared with White patients (OR = 1.21, p < 0.0001; OR = 1.21, p < 0.0001; OR = 1.22, p = 0.01; and OR = 1.43, p = 0.04) respectively. The odds of a Grade 3 complication for Hispanic patients were higher compared with White patients (OR = 1.59, p < 0.0001).

Conclusion

Black patients have higher odds of readmission and multiple grades of complications (including death) compared with White patients. Hispanic patients have higher odds of a Grade 3 complication compared with White patients. No significant differences were found with other races. Specific causes of these disparities are beyond the limitations of the dataset and stand as a topic for future inquiry.

Racial Disparity in 30-Day Outcomes of Metabolic and Bariatric Surgery

Background

There is evidence of racial disparity in the long-term weight loss outcomes of bariatric surgery. However, there has been a more limited evaluation of the impact of race on immediate perioperative outcomes. The aim of this study was to compare 30-day postoperative outcomes among different races.

Study Design

The 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried to identify patients aged ≥ 18 and body mass index ≥ 35 who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) with known information on race. We then evaluated the effect of five different races on four different 30-day outcomes.

Results

Of the total 106,932 patients (79.5% White, 19.3% African American (AA), 0.5% Asian, 0.4% American Indian or Alaska Native, 0.3% Native Hawaiian or other Pacific Islander), 30-day rates of postoperative complication, readmission, re-intervention, and reoperation were 6, 3.8, 1.3, and 1.2%, respectively. After controlling for other covariates in multivariate logistic regression and selecting White as reference, AA was the only race associated with a higher risk of postoperative complications (odds ratio [OR] 1.13; confidence interval [CI] 1.06–1.2) and readmissions (OR 1.47; CI 1.3–1.6). AA and American Indian or Alaska Native were also associated with higher re-interventions (OR 1.31; CI 1.15–1.51 and OR 2.11; CI 1.03–4.34). Furthermore, AA was associated with lower 30-day reoperations (OR 0.83; CI 0.7–0.9).

Conclusion

This study found significant racial differences in short-term outcomes following bariatric surgery. Factors underlying these disparities are unclear and warrant further investigation.

Factors Associated with Weight Loss After Metabolic Surgery in a Multiethnic Sample of 1012 Patients

BACKGROUND

Metabolic surgery is the most effective method for weight loss in the long-term treatment of morbid obesity and its comorbidities. The primary aim of this study was to examine factors associated with percent total weight loss (%TWL) after metabolic surgery among an ethnically diverse sample of patients.

METHODS

A retrospective review was performed on 1012 patients who underwent either a sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) at our institution between January 2008 and June 2015.

RESULTS

African Americans had a lower %TWL than non-Hispanic/Latino Whites at 6, 9, 12, 18, and 48 months. At all timeframes, there was a negative association between pre-surgery TWL and %TWL after surgery. Female sex was negatively associated with %TWL at 3 months only. Higher initial BMI was also associated with greater post-operative %TWL at 18, 24 and 36 months. Older patients had lower %TWL at 6, 9, 12 and 24 months post-surgery. Patients who received RYGB had greater %TWL than those who received SG at 3, 6, 9, 12, 24 and 36 months.

CONCLUSIONS

African Americans had a lower %TWL than non-Hispanic/Latino Whites at most time points; there were no other significant race/ethnicity or sex differences. BMI (greater initial BMI), age (lower) and RYGB were associated with a greater post-operative %TWL at certain post-surgery follow-up time points. A limitation of this study is that there was missing data at a number of time points due to lack of attendance at certain follow-up visits.

Can a brief assessment of social support predict outcomes after bariatric surgery?

Social support is important to optimize bariatric surgery outcomes, but limited tools exist for brief and effective assessment preoperatively. The aims of the study were to determine the extent to which two ratings of social support can predict bariatric surgery outcomes, and to examine any associations between these two methods.In this retrospective study, patients were included for whom the Cleveland clinic behavioral rating system (CCBRS) and Flanagan quality of life scale (FQoLS) scores were obtained as part of their preoperative psychosocial evaluation. They were followed up for 6 to 24 months after bariatric surgery. Linear and logistic regressions were performed with patients' CCBRS and FQoLS scores as independent variables, and percent excess weight loss (%EWL), length of stay (LOS), complications, readmissions and loss to follow-up as dependent variables. The prediction of CCBRS ratings from FQoLS social support items was also evaluated. A total of 415 patients were included in the analysis. There were significant associations between the CCBRS and three of the four relevant FQoLS self-ratings. As CCBRS and FQoLS scores increased, complications decreased significantly. The CCBRS alone additionally predicted decreased length of hospital stay and approached significance for predicting decreased readmission rates. There were no associations between %EWL and behavior ratings. The degree of patients' social support is associated with important bariatric surgery outcomes. It is possible to obtain this valuable information via the administration of brief assessments prior to bariatric surgery.

Racial disparities exist in surgical outcomes for patients with inflammatory bowel disease

BACKGROUND

Racial disparities in surgical outcomes exist for Black patients with IBD compared to White patients. However, previous studies fail to include other racial/ethnic populations. We hypothesized these disparities exist for Hispanic and Asian patients.

METHODS

This is a retrospective cohort study of patients undergoing surgery for IBD using the American College of Surgeons National Surgical Quality Improvement Program (ACS- NSQIP) database (2005-2017). Bivariate comparisons and adjusted multivariable regressions were performed to evaluate associations between race and outcomes.

RESULTS

Of 23,901 patients with IBD, the racial/ethnic makeup were: 88.7% White, 7.6% Black, 2.4% Hispanic and 1.4% Asian. Overall mean LOS was 8 days (SD 8.2) and significantly varied between groups (8d for White, 10d for Black, 8.5d for Hispanic, and 11.1d for Asian; p < 0.001). Hispanic patients had the highest odds of readmission (OR: 1.4; 95% CI 1.1-1.8). Black patients had increased odds of renal insufficiency (OR: 1.8; 95% CI 1.1-2.9), bleeding requiring transfusions (OR: 1.7; 95% CI 1.4-1.9), and sepsis (OR: 1.7; 95% CI 1.4-2.02) compared to White patients.

CONCLUSIONS

Racial disparities exist among IBD patients undergoing surgery. Black, Hispanic and Asian IBD patients experience major disparities in post-operative complications, readmissions and LOS, respectively, when compared to White patients with IBD. Future research is needed to better understand the mechanisms of these disparities including evaluation of social determinants of health.

Interaction of Surgeon Volume and Nurse-to-Patient Ratio on Post-operative Outcomes of Medicare Beneficiaries Following Pancreaticoduodenectomy

BACKGROUND

We sought to assess the effect of nurse-to-patient ratio on outcomes with a focus on defining whether nurse-to-patient ratio altered outcomes relative to pancreaticoduodenectomy (PD) surgeon specific volume.

METHODS

Medicare SAFs from 2013-2015 were used to identify patients who underwent PD. Nurse-to-patient ratio, PD specific surgeon volume were stratified. Association of factors associated with short term outcomes was evaluated.

RESULTS

Overall, 6668 patients (median age 73, IQR 68-77; 52.8% male) were identified. The median annual PD volume of surgeons in the highest volume tier was 24 (IQR 21-29), whereas surgeons in the lowest tier performed 2 PDs annually (IQR 1-3) (p < 0.001). Compared with hospitals that had the highest nurse-to-patient ratio tier, patients at hospitals with the lowest nurse-to-patient ratio tier were 26% more likely to have a complication (OR 1.26, 95% CI 1.02-1.55). Additionally, patients of surgeons in the lowest tier had 43% greater odds of suffering a complication compared to patients of surgeons in the highest tier (OR 1.43, 95% CI 1.11-1.84). However, patients who underwent a PD by a surgeon within the lowest tier had similar odds of a complication irrespective of nurse-to-patient ratio (OR 1.34, 95% CI 0.97-1.86).

CONCLUSION

Compared with patients who underwent an operation by a surgeon in highest PD volume tier, patients treated by surgeons in the lowest tier had higher odds of post-operative complications which was not mitigated by a higher nurse-to-patient ratio.

Disparities in Access to Bariatric Surgery in Texas 2013-2017

Background

Access to bariatric care varies across regions, ethnic, and racial groups. Some of these variations may be due to insurance status or socioeconomic status. There are also regional and state variations in access to metabolic and bariatric surgery (MBS). The Texas Inpatient Public Use Data File (IPUDF) and Texas Outpatient Public Use Data File is a state-mandated database that collects information on demographics, procedures, diagnoses, and cost on almost all admissions in Texas. We used them to examine racial disparities in MBS over a 5-y period.

Methods

The IPUDF and Texas Outpatient Public Use Data File were examined from the years 2013 through, 2017. We included all patients undergoing a laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy and examined the demographics of these patients. Race and ethnicity are reported separately. We used U.S. Census Bureau statistics and the Texas Department of State Health Services statistics to determine the crude (unadjusted) and adjusted procedure rates of patients undergoing MBS.

Results

In the IUPUDF, the crude unadjusted procedure rate for blacks undergoing MBS was 7.29 per 10,000 population followed by 6.85 per 10,000 for non-Hispanic whites. Hispanics had the lowest rate at 3.20 per 10,000. When adjusted for sex, obesity, age, and race, blacks still had a higher rate of access followed by whites and then Hispanics.

Conclusions

There are disparities to access for bariatric surgery in Texas. Blacks have the greatest access followed by whites. Hispanics have the lowest procedure rate per population.

Outcomes in racial and ethnic minorities after revisional robotic-assisted metabolic and bariatric surgery: an analysis of the MBSAQIP database

BACKGROUND

Robotic-assisted metabolic and bariatric surgery (MBS) is being performed with increased frequency in the United States, including for revisional MBS. However, little is known about perioperative outcomes between racial and ethnic cohorts after revisional robotic-assisted MBS.

OBJECTIVE

The goal of our study was to determine if there are racial differences in outcomes after robotic-assisted revisional MBS.

SETTING

University Hospital, United States.

METHODS

Using the 2015-2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, we identified patients undergoing revisional MBS by a robotic-assisted approach. Univariate analyses were performed of unmatched and matched racial and ethnic cohorts, comparing black versus white patients and Hispanic versus white patients.

RESULTS

Of 2027 robotic-assisted revisional MBS cases in the database, 1922 were included in our analysis, including 67%, 22.6%, and 10.4% white, black, and Hispanic patients, respectively. At baseline, there were some differences in patient characteristics between racial and ethnic cohorts. After propensity matching, outcomes between black and white patients were similar, except for higher rates of superficial surgical site infection among white patients (P = .05) and higher rates of organ space surgical site infection in black patients (P = .05). Outcomes were also similar between matched white and Hispanic patients, except for a higher bleeding in white patients (2% versus 0%, P = .04). There were no mortality or morbidity differences between racial and ethnic cohorts.

CONCLUSION

Morbidity and mortality after robotic-assisted revisional MBS do not seem to be mediated by race or ethnicity.

Cardiovascular Risk Factors Following Vertical Sleeve Gastrectomy in Black Americans Compared with White Americans

OBJECTIVE

Bariatric surgery presents a long-term solution for clinical obesity. Given that Black Americans (BA) carry a greater burden of obesity-related comorbidities than White Americans (WA), understanding the racial disparities regarding remission of obesity comorbidities following the most common bariatric surgery, sleeve gastrectomy (SG). The goal of the current study was to provide quantitative values related to cardiovascular and lipid outcomes following SG and determine if racial disparities exist between BA and WA.

METHODS

Data was collected from de-identified electronic medical records for patients receiving SG surgery at the University of Mississippi Medical Center in Jackson, MS, USA.

RESULTS

Of 464 patients who obtained SG from (2013-2019), 64% were WA, and 36% were BA. Before surgery, BA had significantly greater body weight (BW), body mass index (BMI), and systolic (SBP) and diastolic (DBP) blood pressures (BP) in comparison with WA. Compared with WA, BA were predicted to lose 5.1 kg less BW than WA at 1-year follow-up. Reduction in SBP (- 0.96 vs. - 0.60 mmHg/doubling of days) and DBP (- 0.51 vs. - 0.26 mmHg/doubling of days) was significantly higher in WA compared with BA. There was no racial difference in the change to total cholesterol, high-density lipoprotein (HDL)-cholesterol, low-density lipoprotein (LDL)-cholesterol, or triglycerides by race. When normalized to weight loss, the racial disparity in BP reduction was mitigated.

CONCLUSIONS

These data indicate that BA lose less body weight following SG; however, loss of excess body weight loss is associated with improvement to BP similarly in both BA and WA.

Outcomes of Bariatric Surgery in African Americans: an Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Data Registry

Background

The incidence of obesity is disproportionally high in African Americans (AA) in the United States. This study compared outcomes for AA patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) with non-AA patients.

Methods

The MBSAQIP database was reviewed for RYGB and SG patients (2015–2017). Patients were identified as AA or non-AA and grouped to RYGB or SG. Combined and univariate analyses were performed on unmatched/propensity matched populations to assess outcomes.

Results

After applying exclusion criteria, 75,409 AA and 354,305 non-AA patients remained. Univariate analysis identified AA-RYGB and AA-SG patients were heavier and younger than non-AA patients. Overall, AA patients tended to have fewer preoperative comorbidities than non-AA patients with the majority of AA comorbidities related to hypertension and renal disease. Analysis of propensity matched data confirmed AA bariatric surgery patients had increased cardiovascular-related disease incidence compared with non-AA patients. Perioperatively, AA-RYGB patients had longer operative times, increased rates of major complications/ICU admission, and increased incidence of 30-day readmission, re-intervention, and reoperation, concomitant with lower rates of minor complications/superficial surgical site infection (SSI) compared with non-AA patients. For SG, AA patients had longer operative times and higher rates of major complications and 30-day readmission, re-intervention, and mortality, coupled with fewer minor complications, superficial/organ space SSI, and leak.

Conclusion

African American patients undergoing bariatric surgery are younger and heavier than non-AA patients and present with different comorbidity profiles. Overall, AAs exhibit worse outcomes following RYGB or SG than non-AA patients, including increased mortality rates in AA-SG patients.

Racial disparities in surgical outcomes of patients with Inflammatory Bowel Disease

BACKGROUND

Inflammatory Bowel Disease (IBD) has not historically been a focus of racial health disparities research. IBD has been increasing in the black community. We hypothesized that outcomes following surgery would be worse for black patients.

METHODS

A retrospective cohort study of death and serious morbidity (DSM) of patients undergoing surgery for IBD was performed using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP 2011-2014). Multivariable logistic regression modeling was performed to evaluate associations between race and outcomes.

RESULTS

Among 14,679 IBD patients, the overall rate of DSM was 20.3% (white: 19.3%, black 27.0%, other 23.8%, p < 0.001). After adjustment, black patients remained at increased risk of DSM compared white patients (OR: 1.37; 95% CI 1.14-1.64).

CONCLUSIONS

Black patients are at increased risk of post-operative DSM following surgery for IBD. The elevated rates of DSM are not explained by traditional risk factors like obesity, ASA class, emergent surgery, or stoma creation.