Predictors and outcomes of leak after Roux-en-Y gastric bypass: an analysis of the MBSAQIP data registry

Is it Safe to Perform Concomitant Cholecystectomy in Patients With Confirmed Gallbladder Disease Undergoing Metabolic and Bariatric Surgery? An Updated Meta-Analysis

INTRODUCTION

Obesity is a global public health issue, and metabolic and bariatric surgery (MBS) remains most effective intervention for achieving and maintaining long-term weight loss. However, rapid weight loss following MBS increases the risk of gallstone formation. Concomitant cholecystectomy (CC) during MBS has been proposed to mitigate this risk, but recent studies present conflicting evidence regarding its safety and efficacy, leaving no clear consensus.

METHODS

We conducted a meta-analysis by systematically searching MEDLINE, Cochrane Central, Embase, and ClinicalTrials.gov for studies comparing CC plus BS versus BS alone. Odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Statistical analyses were performed with Review Manager v5.4 and RStudio v4.3.3.

PROSPERO ID

CRD42023480360.

RESULTS

We included 26 studies encompassing 656,830 patients with confirmed gallstones, among whom 34,409 (5.2%) underwent CC.The mean age was 41.5 years, and 79.2% were female. Patients undergoing CC + MBS had increased postoperative bleeding (OR 1.31; 95% CI 1.06-1.62; p = 0.01), wound complications (OR 1.61; 95% CI 1.34-1.95; p < 0.01), respiratory complications (OR 1.49; 95% CI 1.13-1.95; p < 0.01), and anastomotic complications (OR 1.86; 95% CI 1.28-2.70; p < 0.01). No significant differences in operation time, rates of postoperative mortality, length of hospital stay, and vein thrombosis were found between groups.

CONCLUSION

CC during MBS increases operative time and postoperative complications, though only anastomotic complications are clinically significant. Therefore, CC should be reserved for high-risk or symptomatic patients and avoided in bariatric procedures involving an anastomosis due to the elevated risk of complications.

Incidence and Risk Factors of In-Hospital Gastrointestinal-Related Complications Following Bariatric Surgery: A Retrospective Nationwide Inpatient Sample Database Study

BACKGROUND

Obesity is associated with numerous serious physiological and psychological health problems. Bariatric surgery (BS) remains the most effective treatment for obesity, but early postoperative gastrointestinal complications may require additional surgical intervention. The objective of this study was to analyze gastrointestinal-related complications (GRCs) and their risk factors following BS, including sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), using a nationwide database.

METHODS

An analysis of the Nationwide Inpatient Sample data from 2010 to 2019 was conducted to compare patients following BS with versus without postoperative GRCs. Variables included demographics, hospital characteristics, length of stay, costs, comorbidities, and complications. Risk factors were identified through stepwise multivariate logistic regression.

RESULTS

Among 323,066 BS patients, 12,248 (3.79%) developed GRCs, with a decreasing trend observed over the study period. Common complications included gastrointestinal bleeding (1.37%), bowel obstruction (1.84%), and anastomotic issues (0.99%). Significant risk factors included advanced age, anemia (deficiency and chronic blood loss), cardiovascular conditions (heart failure, valve disease, peripheral vascular disorders), coagulation abnormalities, rheumatoid arthritis or collagen vascular diseases, drug abuse, electrolyte imbalances, neurological conditions, renal failure, non-bleeding peptic ulcer disease, and weight loss. Interestingly, liver disease emerged as a risk factor for GRCs after SG while acting as a protective factor for GRCs after RYGB.

CONCLUSION

Understanding the risk factors for GRCs after BS would allow for improved patient management and clinical outcomes.

The role of drain placement in post-bariatric surgery bleeding and leak detection: Palestinian main center experience (2017-2021)

INTRODUCTION

Bariatric surgery, such as sleeve gastrectomy (SG) and gastric bypass, is a common option for weight loss in patients with obesity and metabolically ill individuals. However, complications like bleeding and leaks can occur. Surgeons often use intraoperative drains to detect these issues, but their effectiveness is debated due to conflicting evidence. Our study aims to evaluate the benefits of intra-abdominal drains in detecting postoperative bleeding and leaks.

METHODS

This is a retrospective cross-sectional study, with data from 494 patients who underwent bariatric surgery at the primary bariatric center in Palestine, between 2017 and 2021. Patient demographics, comorbidities, surgical complications, and drain usage were collected, managed, and analyzed using SPSS.

RESULTS

The study included 494 patients, predominantly females (69.0%) with a median age of 39.5 years. Sleeve gastrectomy was the most common procedure (78.1%). Postoperative complications occurred in 3.0% of patients, with bleeding being the most prevalent (1.4%). Drain placement was routine (82.0%), but no significant correlation was found between drain output volume and signs of bleeding, such as heart rate and blood pressure. However, a weak inverse correlation was observed between volume for bloody drain character and hemoglobin levels on the first postoperative day.

CONCLUSION

Drains are commonly used in bariatric surgery; however, their effectiveness in detecting complications like bleeding and leaks remains uncertain. There was no association between drain output volume and signs of bleeding and leak complications, and the clinical assessment, especially the vital signs, is the most effective method in identifying postoperative issues.

CLINICAL TRIAL NUMBER

Not applicable.

Trends of Drain Placement During Revisional Bariatric Surgeries and Its Association with 30-Day Morbidity: An MBSAQIP Analysis of 64,495 Patients

Background: Drains are often placed during bariatric procedures; however, their use in conversional or revisional bariatric surgery (CRBS) has not been thoroughly explored. Our study sought to identify the frequency of drain placement in CRBS, and characterize factors associated with drain placement and their influence on 30-day serious complications. Methods: Patients undergoing CRBS between 2020 and 2022 were included from the MBSAQIP database. Patients were placed into drain placed (DP) versus no drain (ND) cohorts and baseline characteristics and complication rate were compared. Multivariable logistic regression models were used to identify independent predictors of drain placement and complications. Results: of 64,495 included patients, drains were placed in 19.1% in 2020; this was down to 14.4% in 2022. Drain placement was associated with increased risk of multiple complications such as hemorrhage, readmission, surgical site infection, and gastrointestinal bleeding. On multivariate analysis, drain placement was an independent predictor of serious complications (aOR 1.45, p < 0.001), anastomotic leak (aOR 2.25, p < 0.001), organ space infection (aOR 2.12, p < 0.001), and reoperation (aOR 1.37, p < 0.001), as well as excess LOS (aOR 2.06, p < 0.001). Predictors of drain placement include older age, higher BMI, smoking status, history of venous thromboembolism, and procedural factors, such as undergoing non-sleeve revisional surgery or having an intraoperative leak test. Conclusions: Drain placement during CRBS surgical procedures is common and more likely in higher risk patients and anastomotic revisional procedures. Though the reasons for drain placement were not available, these data suggest that surgeons should be judicious in selecting patients for drain placement due to its association with increased LOS and postoperative morbidity in CRBS.

Modern Trends of Drain Placement in Primary Bariatric Surgery: An MBSAQIP Analysis of 526,723 Patients

BACKGROUND

Prophylactic drain use during primary bariatric surgeries continues despite previous literature cautioning against their routine use. Modern drain utilization and associated outcomes remain largely poorly studied which limits selective utilization and perhaps may lead to excess morbidity and healthcare resource utilization. This study aimed to reassess current trends of drain use in primary bariatric procedures, factors driving surgeons to place drains, and patient outcomes associated with drain placement.

METHODS

Patients undergoing the most common primary bariatric surgery operations from 2020 to 2022 were included using the Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) database. Two cohorts were created, a drain placed (DP) cohort and no drain (ND) cohort, which were then compared in terms of baseline characteristics, rates of complications, and length of stay. Multivariate modeling was performed to assess the effect of drains on various complications and factors associated with drain placement.

RESULTS

Of 526,723 included patients, drain utilization decreased across operative years (8.7% in 2020 to 6.1% in 2022, p < 0.001). Factors associated with drain placement in multivariate models included older age, higher BMI, partially dependent functional status, renal insufficiency, venous thromboembolism, hypoalbuminemia, and non-sleeve anastomotic procedures. Drain placement was associated with increased risk of numerous complications on bivariate analysis, which was still significant in multivariate analysis, including 30-day serious complications (adjusted odds ratio [aOR] 1.24, p < 0.001), anastomotic leak (aOR 2.1, p < 0.001), organ space infection (aOR 2.0, p < 0.001), reoperation (aOR 1.2, p = 0.036), and excess length of stay (LOS, aOR 1.45, p < 0.001).

CONCLUSIONS

The frequency of prophylactic drain placement during primary bariatric surgical procedures has decreased in recent years and patients with drain placement seem to have increased 30-day morbidity, including longer length of stay. Independent predictors of drain placement include increased age and metabolic burden along with anastomotic procedures. Surgeons should be judicious in selecting patients for drain placement and future prospective, controlled studies may better answer drain placement association with complications.

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.

Evaluation of patients on immunosuppressants undergoing sleeve gastrectomy, Roux-en-Y gastric bypass, and duodenal switch: analysis of 19,414 patients

BACKGROUND

Bariatric surgery is being offered to more medically complex patients, including patients on immunosuppressants, although outcomes after different bariatrics surgeries have not been studied in this population.

OBJECTIVES

We compared perioperative safety of sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and duodenal switch (DS) in patients on immunosuppression.

SETTING

National sample from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.

METHODS

The MBSAQIP database was queried from the years 2015 to 2021 for adult patients on chronic immunosuppression who underwent SG, RYGB, or DS. Revisional, open, endoscopic, or emergency surgeries were excluded, as were patients with an American Society of Anesthesiologists class of 5 and patients without full 30-day follow-up. Propensity-score matching was performed with a 3:3:1 ratio (SG:RYGB:DS) controlling for surgical approach, sex, age, functional status, American Society of Anesthesiologists, body mass index, and comorbidities.

RESULTS

There were 19,414 patients on immunosuppression who underwent SG (n = 14,358), RYGB (n = 4864), or DS (n = 192). After propensity-score matching , RYGB and DS had longer LOS (P < .01), greater global 30-day complication (P < .01), and 30-day reoperation rates (P = .048). Compared with SG and RYGB, DS had greater rates of patients requiring mechanical ventilation >48-hour postoperatively (P < .05). Compared with SG, DS had greater rates of renal insufficiency (P = .01), organ space infection (P = .01), unplanned intubation (P < .01), and unplanned intensive care unit admission (P < .01).

CONCLUSIONS

For patients on immunosuppression, SG carried the lowest complication and reoperation rates, whereas DS had overall complication rates in line with RYGB.

Endoscopic Management of Bariatric Surgery Complications: Fistulas, Leaks, and Ulcers

Bariatric surgery is a safe and effective treatment option for patients with obesity and obesity-related comorbidities, with Roux-en-Y gastric bypass and sleeve gastrectomy being the two most common procedures. Despite the success of these interventions, adverse events are not uncommon. Endoscopic management has become first-line therapy when complications occur, and the armamentarium of devices and techniques continues to grow. This article focuses on the management of fistulas, leaks, and ulcers and also focuses on the etiology and endoscopic management strategy of each complication.

Effectiveness of bedside staplers in bariatric robotic procedures

BACKGROUND

Few studies have evaluated the use of laparoscopic staplers in robotic procedures (bedside stapling, BS). This study aims to evaluate the effectiveness of BS compared with robotic staplers (RS) in bariatric robotic procedures.

METHODS

Patients who underwent robotic sleeve gastrectomy or gastric bypass elective procedures between 1/1/2021 and 12/31/2021 were extracted from PINC AI™ Healthcare Data. The following clinical outcomes were compared: blood transfusion, bleeding, anastomotic leak, intensive care unit (ICU) visit, and 30-day readmission, operating room (OR) time, inpatient costs, and length of stay. We evaluated baseline balance in BS and RS and bivariate association between covariates and outcomes using Chi-square or Fisher exact test and t-test or ANOVA. Multivariable general linear mixed models (GLMMs) with respective gamma or binomial distribution and log-link function were used to obtain adjusted outcomes variations between BS and RS.

RESULTS

Total of 7268 discharges were included with 1603 (22.1%) BS and 5665 (77.9%) RS cases. RS cases consisted of a higher number of patients who were Hispanic (17.0% vs. 9.4%), had Medicaid (26.9% vs. 19.4%) and underwent sleeve gastrectomy (68.4% vs. 53.5%). Higher proportions of RS cases were done by providers in Northeast region (35.5% vs. 24.3%), smaller size (< 500 beds; 71.1% vs. 52.3%), and teaching hospitals (59.4% vs. 39%). The adjusted outcomes variations demonstrated that patients that had RS were significantly more likely to have blood transfusions, ICU stays, increased ORT (19 min) and costs ($1273). Sensitivity analysis showed similar results, except no significant differences in blood transfusion rates in both groups.

CONCLUSIONS

Bedside staplers significantly reduce healthcare resource utilization with equivalent effectiveness and fewer ICU stays compared to robotic staplers.

Evaluating the incidence, risk factors and postoperative complications associated with leaks following duodenal switch procedures: an analysis of the MBSAQIP

BACKGROUND

Metabolic and Bariatric Surgery (MBS) is the most effective management for patients with obesity and weight-related medical conditions. Duodenal switch (DS) is a recent MBS procedure with increasing attention in recent years, however the risk of anastomotic or staple line leaks and the lack of efficient surgical expertise hinders the procedure from becoming fully adopted.

OBJECTIVES

To determine the 30-day predictors of leaks following DS and explore their association with other 30-day postoperative complications.

SETTING

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.

METHODS

Patients who underwent a primary biliopancreatic diversion with DS or single-anastomosis duodenoileostomy with sleeve procedure, categorized as DS, were assessed for 30-day leaks. A multivariable logistic regression was constructed to identify the predictors of leaks. The assessment of postoperative complications arising from leaks was also performed.

RESULTS

A total of 21,839 DS patients were included, of which 177 (.8%) experienced leaks within 30 postoperative days. The most significant predictor of leaks was steroid immunosuppressive use (adjusted odds ratio [aOR] = 3.01, 95% confidence interval [CI] [1.56-5.13], P < .001) and age, with each decade of life associated with a 26% increase in risk (aOR = 1.26, 95% CI [1.09-1.45], P = .001). Operative length was also associated with leaks, with every additional 30 minutes increasing the odds of a leak by 23% (aOR = 1.23, 95% CI [1.18-1.29], P < .001). The occurrence of leaks was correlated with postoperative septic shock (Crude Odds Ratio [COR] = 280.99 [152.60-517.39]) and unplanned intensive care unit (ICU) admissions (COR = 79.04 [56.99-109.59]). Additionally, mortality rates increased 17-fold with the incidence of leaks (COR = 17.64 [7.41-41.99]).

CONCLUSIONS

Leaks following DS are a serious postoperative complication with significant risk factors of steroid use, prolonged operative time and advanced age. Leaks are also associated with other severe complications, highlighting the need for early diagnosis and intervention along with additional studies to further validate our results.

Analysis of the effect of staple line reinforcement on leaking and bleeding after sleeve gastrectomy from the UK National Bariatric Surgery Registry

INTRODUCTION

Sleeve gastrectomy (SG) is currently the most frequently performed procedure for obesity worldwide. Staple line reinforcement (SLR) has been suggested as a strategy to reduce the risk of staple line leak or bleeding; however, its use for SG in the United Kingdom (UK) is unknown. This study examined the effect of SLR on the development of postoperative complications from SG using a large national dataset from the UK.

METHODS

Patients undergoing either primary or revision SG over 10 years from Jan 2012 to Dec 2021 were identified by the National Bariatric Surgery Registry. Comparative and logistic regression analyses were undertaken to determine the effect of SLR on staple line leak and bleeding.

RESULTS

During this time, 14,231 patients underwent SG for whom there were complete data. Of these, 76.5% were female and the median age was 46 years (IQR: 36-53). The rate of surgical complications was 2.3% (n = 219/14,231). The incidence of bleeding was 1.3% (n = 179/14,231) and leak was 1.0% (n = 140/14,231). Over time, the use of SLR of any variety declined significantly from 99.7% in 2012 to 57.3% in 2021 (p < 0.001). Multivariable (adjusted) regression analysis demonstrated that neither the use of nor the type of reinforcement had any effect on the rate of bleeding or leaking.

CONCLUSION

SLR for SG has declined in the UK since 2012. There were no differences in staple line leak or bleed with or without reinforcement.

The role of radiology in diagnosing gastrointestinal tract perforation

Spontaneous, iatrogenic or surgical perforation of the whole gastrointestinal wall can lead to serious complications, resulting in increased morbidity and mortality. Optimal patient management requires early clinical appraisal and prompt imaging evaluation. Both radiologists and referring clinicians should recognize the importance of choosing the ideal imaging modality and the usefulness of oral and rectal contrast medium. Surgeons and radiologists should be familiar with CT and fluoroscopy findings of the normal and pathologic anatomy after esophageal, stomach or colon surgery. Specifically, they should be able to differentiate innocuous from clinically-relevant, life-threatening postoperative complications to guide appropriate treatment. Advantages of esophagram, CT-esophagram, CT after rectal contrast enema and other imaging modalities are discussed.

The Impact of Drain Placement on Postoperative Complications in Bariatric Surgery: A Systematic Review and Meta-Analysis

Obesity in individuals can have consequences ranging from metabolically healthy obesity to serious morbidities and reduce the quality and duration of life. A meta-analysis was conducted to assess the role of abdominal drainage on postoperative complications after bariatric surgery. PubMed, Embase, and the Cochrane Library were systematically searched for eligible studies. The results revealed that abdominal drainage was associated with surgical complications, with a pooled odds ratio (OR) of 1.70 (P < .001), but not associated with wound infection (OR: 1.04; P = .762). Associations with surgical complications were mainly detected from retrospective cohort studies. The use of abdominal drainage showed associations with death (OR: 1.68; P < .001) and reoperation (OR: 1.49; P < .001). These findings revealed that abdominal drainage during bariatric surgery was associated with surgical complications, death, and reoperation. These results should be taken with caution since randomized controlled trials and retrospective studies were analyzed together.

Analysis of risk factors for duodenal leak after repair of a duodenal perforation

BACKGROUND

Repairing of a duodenal perforation is a well accepted procedure, but clinically, approximately 4% of patients develop duodenal leaks after perforation repair, increasing the risk of death. We retrospectively analyzed clinical data from 168 patients at our hospital to explore risk factors for duodenal leak after perforation repair and developed a nomogram for predicting postoperative duodenal leak.

METHODS

This retrospective case-control study totalled 168 patients undergoing repair of a duodenal perforation with omentopexy at the General Surgery Department, Dongnan Hospital of Xiamen University, from January 2012 to January 2022. The patients were divided into the non-leak group and the leak group. Risk factors were evaluated by analyzing the patient's sex, shock, diameter and anatomic position of the ulcer, use of NSAIDS and Glucocorticoid, history of drinking, diabetes, chronic diseases, age, time of onset of symptoms and lab tests.

RESULT

One hundred fifty-six patients (92.9%) who did not develop leaks after repair of a duodenal perforation were included in the non-leak group, and 12 (7.1%) developed leaks were included in the leak group. In univariate analysis, there were significant differences between the two groups referring to age, shock, NSAIDs, albumin, and perforation size (P < 0.05). The area under the ROC curve for perforation diameter was 0.737, the p-value was 0.006, the optimal cutoff point was 11.5, sensitivity was 58.3%, and specificity was 93.6%, the positive predictive value is 41.1%, and the negative predictive value is 98.0%. In the internal validation of the performance of the nomogram, the C-index and AUC of the model were 0.896(95%CI 0.81-0.98), demonstrating that the nomogram model was well calibrated.

CONCLUSION

The study discussed the risk factors for postoperative duodenal leak in patients undergoing repair of a duodenal perforation, and a nomogram was constructed to predict the leak. Future prospective studies with large sample sizes and multiple centres are needed to further elucidate the risk of duodenal leak after repair of a duodenal perforation.

Gastrojejunostomy Closure Technique and Risk of Leak: an Evaluation in Ex Vivo Porcine Models

INTRODUCTION

Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed bariatric operations worldwide. Leaks following RYGB are rare, but the consequences can be devastating. Although most leaks occur at the gastrojejunostomy (GJ) anastomosis, there is a lack of data on modifiable technical factors that can reduce the risk of leaks. Therefore, we evaluated whether the leak pressure of a GJ linear stapled anastomosis is dependent on the closure technique.

METHODS

Two expert surgeons constructed gastric pouches and GJ anastomoses on ex vivo porcine models in a laparoscopic simulator using 30-mm and 45-mm endoscopic staplers. The GJ anastomosis was closed using either a single layer suture, double layer suture or stapler. The endpoints were leak pressure to air insufflation, measured by two independent observers, site of leak and internal circumference of the GJ anastomosis.

RESULTS

In total, 30 GJ anastomoses were constructed (30 mm, n = 15; 45 mm, n = 15). The GJ anastomosis was closed using single layer (n = 9), double layer (n = 9) and stapled techniques (n = 12). Inter-observer agreement was high. Stapled and double layer closures were more resilient than a single layer closure, with 75% (9/12) stapled closures remaining intact at < 70 mmHg. GJ stoma circumference was lower using a 30-mm stapler (64.8 mm vs 80.2 mm; p < 0.05) but independent of closure technique. The most common leak site was the corner of the closure (67%).

CONCLUSION

In summary, the GJ anastomosis closure technique may be a modifiable factor to prevent anastomotic leak.

Implementation of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program and outcomes of bariatric surgery

INTRODUCTION

This study evaluates the performance of bariatric surgery prior to and after the implementation of Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).

METHODS

The eras prior to (2007-2015) and after (2016-2018) the transition to MBSAQIP were compared for patients, operations and outcomes using adjusted logistic regression estimates.

RESULTS

Thirty-day surgical (6%vs.2.9%,p < 0.01) and medical (3.4%vs.1.7%,p < 0.01) complications rates were reduced over the period 2007 through 2018. Th use of sleeve gastrectomy has steadily increased from 2010 to 2018 (14%vs.66.6%,p < 0.01). The proportion of patients who were discharged early continued to rise (9.8%vs.46.9%,p < 0.01) from 2007 to 2018. The MBSAQIP period was associated with reduced odds for 30-day surgical (OR = 0.86,CI = [0.81-0.91]) and medical (OR = 0.81,CI = [0.75-0.88]) complications. Implementation of the MBSAQIP was also predictive of early discharge (OR = 1.93,CI = [1.90-2.00]).

CONCLUSION

The type of bariatric procedure, in addition to trends in morbidity and hospital stays, gradually changed from 2007 to 2018. Our findings suggest that outcomes of bariatric operations have improved over the past decade. The MBSAQIP era is associated with lower rates of complications and greater likelihood of early discharge, independent of the procedure type.

Prediction of thirty-day morbidity and mortality after duodenal switch using an artificial neural network

BACKGROUND

Understanding factors that increase risk of both mortality and specific measures of morbidity after duodenal switch (DS) is important in deciding to offer this weight loss operation. Artificial neural networks (ANN) are computational deep learning approaches that model complex interactions among input factors to optimally predict an outcome. Here, a comprehensive national database is examined for patient factors associated with poor outcomes, while comparing the performance of multivariate logistic regression and ANN models in predicting these outcomes.

METHODS

2907 DS patients from the 2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database were assessed for patient factors associated with the previously validated composite endpoint of 30-day postoperative reintervention, reoperation, readmission, or mortality using bivariate analysis. Variables associated (P ≤ 0.05) with the endpoint were imputed in a multivariate logistic regression model and a three-node ANN with 20% holdback for validation. Goodness-of-fit was assessed using area under receiver operating curves (AUROC).

RESULTS

There were 229 DS patients with the composite endpoint (7.9%), and 12 mortalities (0.4%). Associated patient factors on bivariate analysis included advanced age, non-white race, cardiac history, hypertension requiring 3 + medications (HTN), previous foregut/obesity surgery, obstructive sleep apnea (OSA), and higher creatinine (P ≤ 0.05). Upon multivariate analysis, independently associated factors were non-white race (odds ratio 1.40; P = 0.075), HTN (1.55; P = 0.038), previous foregut/bariatric surgery (1.43; P = 0.041), and OSA (1.46; P = 0.018). The nominal logistic regression multivariate analysis (n = 2330; R² = 0.02, P < 0.001) and ANN (R² = 0.06; n = 1863 [training set], n = 467 [validation]) models generated AUROCs of 0.619, 0.656 (training set) and 0.685 (validation set), respectively.

CONCLUSION

Readily obtainable patient factors were identified that confer increased risk of the 30-day composite endpoint after DS. Moreover, use of an ANN to model these factors may optimize prediction of this outcome. This information provides useful guidance to bariatricians and surgical candidates alike.

Single-anastomosis duodenoileal bypass with sleeve in the United States: a first comparative safety analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database

BACKGROUND

The single-anastomosis duodenoileal bypass with sleeve (SADI-S) is a relatively new bariatric procedure. In 2020, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) started reporting outcomes for SADI-S.

OBJECTIVES

We aimed to study the perioperative safety of SADI-S and compare it with other established bariatric procedures utilizing the MBSAQIP database.

SETTING

Academic hospital, United States.

METHODS

The 2020 MBSAQIP Participant Use File was used to evaluate SADI-S outcomes. We included SADI-S primary cases and excluded revisions and concurrent operations. A 5:1 propensity matched analysis (PMA) for 20 variables was performed to compare the outcomes of the SADI-S with the Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) and a 2:1 PMA to the biliopancreatic diversion with duodenal switch (BPD/DS).

RESULTS

There were 255 primary SADI-S reported in 2020. After PMA, the only significant complications between the RYGB and SADI-S cohorts were Clavien-Dindo grade IVa and IVb (.1% and 1.4% versus 1.6% and 7.1%, respectively). SADI-S had more Clavien-Dindo grade II, IVa, and IVb complications than the SG cohort (1.3% versus 3.5%, P = .03; .2% versus 1.6%, P = 0; 1.% versus 7.1%, P = 0). When compared with BPD/DS, outcomes including readmission, reoperation, and intervention were not statistically significant.

CONCLUSION

SADI-S, in its early adoption stage, has a higher incidence of perioperative complications than RYGB and SG. It has comparable 30-day outcomes to BPD/DS.

Comparison of 5-Year Follow-up Outcomes Between Primary and Revision Roux-en-Y Gastric Bypasses After Open Vertical Banded Gastroplasty: an Inverse Propensity Score-Weighted Analysis

INTRODUCTION

Vertical banded gastroplasty (VBG) is associated with high weight regain; Roux-en-Y gastric bypass (RYGB) is used as a revision procedure in patients with VBG experiencing weight regain. This study compared the 5-year follow-up outcomes of primary (PRYGB) and revision RYGB after VBG (RRYGB).

METHODS

Patients who underwent PRYGB or RRYGB after VBG from 2008 to 2016 were enrolled. Data on weight regain, weight loss (WL), food tolerance (FT), early and late complications, and resolution or improvement in associated medical conditions were analyzed.

RESULTS

PRYGB and RRYGB groups had 558 and 156 patients, respectively, after exclusion of the lost to follow-up patients. PRYGB group showed significantly lower mean body mass index (over the entire follow-up period), early complications, reintervention rates for late complications, and overall reintervention rates than that of the RRYGB group. On the other hand, FT scores, odds of late complications, and improvements (in the fifth year) in associated medical conditions were comparable between the two groups.

CONCLUSION

RRYGB in patients with VBG who regained weight showed comparable safety and resolution of associated diseases to that of PRYGB over the 5-year follow-up period. The WL in the RRYGB group was acceptable despite being less than that of the PRYGB group. FT was better after RRYGB than that of PRYGB in the first year; however, both were comparable at the fifth year follow-up. Patients with VBG undergoing RYGB should receive attentive treatment and evaluation of associated factors.

META‐ANALYSIS OF PATIENT RISK FACTORS ASSOCIATED WITH POST‐BARIATRIC SURGERY LEAK

Objective

Modifiable risk factors such as diabetes, hyperlipidemia, hypertension, obstructive sleep apnea (OSA), chronic kidney disease (CKD), chronic steroid use and smoking, have been shown in observational studies to negatively affect surgical outcomes. The purpose of this study is to identify and determine the effect of modifiable risk factors on post-operative bariatric surgery leak, as pre-operative risk modification has been shown to reduce the impact on complications.

Methods

Electronic literature searches of MEDLINE, PUBMED, OVID and Cochrane Library databases were performed, including a manual reference check, over the period of 2010 and 2020. 620 articles were screened according to the PRISMA protocol.

Results

Twenty articles were included in the meta-analysis of risk factors. Significant risk factors and the associated effect sizes include: 1. Smoking with an overall OR of 1.31 [1.06, 1.61] and an OR of 1.72 [1.44, 2.05] in Sleeve gastrectomy (SG) patient cohorts; 2. Diabetes with an overall OR of 1.23 [1.08, 1.39] and an OR of 1.33 [1.02, 1.73] in Roux-en-Y patient cohorts; 3. Chronic kidney disease with an overall OR of 2.41 [1.62, 3.59] and 4. Steroid use with an overall OR of 1.57 [1.22, 2.02]. Non-significant risk factors include hypertension with an OR of 0.85, 1.83, OSA with an OR of 1.08 [0.83, 1.39] and hyperlipidemia with an OR of 0.80 [0.61, 1.04]. Combined SG and Roux-en-Y patient cohorts with hyperlipidemia have shown a protective effect of 0.78 [0.65, 0.94].

Conclusions

Significant risk factors for leak post bariatric surgery are smoking in all patients and particularly SG patients, diabetes for all patients and particularly Roux-en-Y patients, and CKD and chronic steroid for all patients. Hyperlipidemia in two combined patient cohorts (SG and Roux-en-Y) appears to have a weak protective effect.

Stapler Malfunctions in Bariatric Surgery: An Analysis of the MAUDE Database

Background

Staple line leaks are a serious problem in bariatric surgery and a major cause of serious morbidity and mortality. Adverse events caused by medical devices are reported to the Food and Drug Administration which maintains the Manufacturer and User Facility Device Experience (MAUDE) database. We examined adverse stapler events reported to the MAUDE database, specifically with regards to bariatric surgery.

Methods

The MAUDE database was queried for adverse events caused by staplers between January 1, 2018 - December 31, 2020; events reported by Intuitive, Ethicon, and Medtronic/Covidien; and limited our search to "gastric bypass", "sleeve gastrectomy", "stapler malfunction" combined with each company.

Results

There were 883 adverse events reported for Medtronic, 353 for Ethicon, and 35 for Intuitive. Approximately 3.5 million staple reloads sold in the study period. The reported misfire rate for Medtronic was 0.04% and for Ethicon was 0.02%. Data for Intuitive was unavailable. The most common reported event for Medtronic was failure to fire (n = 349), followed by misfire (n = 186). For Ethicon, the most common event was failure to fire (n = 146), followed by mechanical problems (n = 27). The most common event with the Intuitive stapler was leak (n = 10) and bleeding from staple line (n = 8).

Conclusions

Stapler malfunction is a very rare event in metabolic and bariatric surgery. All of the major stapler producers have transitioned to powered staplers with excellent safety profiles. Open and honest reporting about stapler malfunction is essential to determine the true safety of these ubiquitous devices.

Endoscopic Bariatric Therapies: Current Status and Future Perspectives

Background:

Obesity is a chronic, multifactorial disease associated with multiple cardiometabolic conditions. The successful management of this condition includes a multidisciplinary approach with interventions focused on lifestyle modification, pharmaceutical therapies, and bariatric surgery. Endoscopic bariatric therapies (EBT) have been proposed as a way to bridge the gap between medical management and bariatric surgery. The Association for Bariatric Endoscopy in conjunction with the American Society for Gastrointestinal Endoscopy published the position statement approving and integrating EBT into practice. The aim of this article is to review the most common primary EBT’s, their indications, outcomes, and complications.

Database:

A medical literature review was conducted using the defined keywords. Databases included PubMed, Google Scholar, Embase, and EBSCO. Articles in English were considered for review from June 1, 2000 to June 30, 2021.

Conclusion:

Endoscopic bariatric therapies should be offered in conjunction with lifestyle modification and with nutritional guidance, as part of a multidisciplinary approach in obesity management. They require a formal training process for endoscopists and bariatric surgeons to obtain the endoscopic skills needed before performing these procedures. Longer follow-up and larger trials are needed to validate current evidence, in order to enhance the process of standardization of these techniques.

The Choice of Gastric Bypass or Sleeve Gastrectomy for Patients Stratified by Diabetes Duration and Body Mass Index (BMI) level: Results from a National Registry and Meta-analysis

PURPOSE

To determine whether sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) should be the optimal choice in patients stratified by diabetes duration and body mass index (BMI) level.

METHODS

Classification tree analysis was performed to identify the influential factors for surgical procedure selection in real setting. Meta-analyses stratified by influential factors were conducted to compare the complete diabetes remission rates between SG and RYGB. The cost-effectiveness analysis was performed when results from meta-analysis remain uncertain.

RESULTS

Among 3198 bariatric procedures in China, 824 (73%) SGs and 191 (17%) RYGBs were performed in patients with T2DM. Diabetes duration with a cutoff value of 5 years and BMI level with 35.5 kg/m² were identified as the influential factors. For patients with diabetes duration > 5 years, RYGB showed a significant higher complete diabetes remission rate than SG at 1 year: 0.52 (95% confidence interval (CI): 0.46-0.58) versus 0.36 (95% CI: 0.30-0.42). For patients with diabetes duration ≤ 5 years and BMI ≥ 35.5 kg/m², there was no significant difference between 2 procedures: 0.57 (95% CI: 0.43-0.71) for SG versus 0.66 (95% CI: 0.62-0.70) for RYGB. The cost-effectiveness ratios of SG and RYGB were 244.58 and 276.97 dollars per QALY, respectively.

CONCLUSIONS

For patients with diabetes duration > 5 years, RYGB was the optimal choice with regard to achieving complete diabetes remission at 1 year after surgery. However, for patients with diabetes duration ≤ 5 years and BMI ≥ 35.5 kg/m², SG appeared to provide a cost-effective choice.

Development of the "OS-SEV90 Score" to Predict Severe Postoperative Complications at 90 Days Following Bariatric Surgery

BACKGROUND

Bariatric surgery may be associated with severe postoperative complications (SPC). Factors associated with the risk of SPC have not been fully investigated.

OBJECTIVES

This study aimed to identify preoperative risk factors of SPC within 90 days and to develop a risk prediction model based on these factors.

METHODS

We conducted a retrospective single-center cohort study based on a prospectively maintained database of obese patients undergoing laparoscopic bariatric surgery from October 2005 to May 2019. All SPC occurring up to the 90th postoperative day were recorded according to the Dindo-Clavien classification. Associations between potential risk factors and SPC were analyzed using a logistic regression model, and the risk prediction ("OS-SEV90 score") was computed. Based on the OS-SEV90 score, the patients were grouped into 3 categories of risk: low, intermediate, and high.

RESULTS

Among 1963 consecutive patients, no patient died and 82 (4.2%) experienced SPC within 90 days. History of gastric or esophageal surgery (adjusted odds ratio (aOR) 3.040, 95% confidence interval; CI 1.78-5.20, p< 0.0001), past of thromboembolic event aOR 2.26, 95%; CI 1.12-4.55, p = 0.0225), and surgery performed by a junior surgeon (aOR 1.99, 95%; CI 1.26-3.13, p = 0.003) were all independently associated with risk for SPC, adjusting for ASA physical status system (ASA) score ≥ 3, severe OSA, psychiatric disease, asthma, a history of abdominal surgery, alcohol, cardiac disease, and dyslipidemia. "the OS-SEV90 score" based on these factors was constructed to classify patients into 3 risk groups: low (≤2), intermediate (3-4), and high (≥5). According to "the OS-SEV90 score," SPC increased significantly from 2.9% in the low-risk group, 7.7% in the intermediate-risk group, and 23.3% in the high-risk group.

CONCLUSIONS

A predictive model of SPC within 90 days "the OS-SEV90 score" has been developed using 9 baseline risk factors. The use of the OS-SEV90 score may help the multidisciplinary team to identify the specific risk of each patient and inform them about and optimize the comorbidities before the surgery. Further studies are warranted to validate this score in a new independent cohort before using it in clinical practice.

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.

One anastomosis gastric bypass versus Roux-en-Y gastric bypass: a 30-day follow-up review

BACKGROUND

One anastomosis gastric bypass (OAGB) type procedures have been widely adopted outside the United States. International experience of OAGB commonly suggests improved early postoperative safety with OAGB over Roux-en-Y gastric bypass (RYGB). This study aims to report on the early experience with OAGB in Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) accredited centers, and compare with RYGB in terms of complication rates.

METHODS

The MBSAQIP public use files from 2015 to 2018 were used to identify adult patients who underwent primary OAGB and RYGB. Propensity score analysis was used to estimate the marginal population-average differences between OAGB and RYGB patients. Based on the matched samples, McNemar's tests and Wilcoxon signed rank test were carried out for binary and continuous outcomes. P-value < 0.05 was considered statistically significant.

RESULTS

Propensity score matching analysis resulted in 279 matched pairs for OAGB and RYGB. Twelve OAGB patients (4.3%) experienced a complication; 3 of them (1.1%) were diagnosed with anastomotic leaks. Compared to 14 (5%) of RYGB patients experiencing a complication; 5 (1.8%) were diagnosed with anastomotic leaks. Reintervention, reoperation and readmission rates for OAGB were 2.5%, 3.2% and 5%, compared to 1.8%, 1.8%, and 3.2% for RYGB.

DISCUSSION

Our study supports previous data that suggests OAGB has a similar early safety profile compared to RYGB and perioperative risks of OAGB should not be of a concern regarding its adoption. Conversely, OAGB does not seem to be associated with an improved safety profile over RYGB.

Safety of Single Stage Revision Laparoscopic Sleeve Gastrectomy Compared to Laparoscopic Roux-Y Gastric Bypass after Failed Gastric Banding

Background

Reoperation, after failed gastric banding, is a controversial topic. A common approach is band removal with conversion to laparoscopic Roux-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) in a single-step procedure.

Objective

This study aimed to assess the safety of revisional surgery to LSG compared to LRYGB after failed laparoscopic adjustable gastric banding (LAGB) based on MBSAQIP Participant User File from 2015 to 2018.

Methods

Patients who underwent a one-stage conversion of LAGB to LSG (Conv-LSG) or LRYGB (Conv-LRYGB) were identified in the MBSAQIP PUF from 2015 to 2017. Conv-LRYGB cases were matched (1:1) with Conv-LSG patients using propensity scoring to control for potential confounding. The primary outcome was all-cause mortality.

Results

A total of 9974 patients (4987 matched pairs) were included in the study. Conv-LRYGB, as compared with conv-SG, was associated with a similar risk of mortality (0.02% vs. 0.06%; relative risk [RR], 0.33; 95% confidence interval [CI], 0.03 to 3.20, p = 0.32). Conversion to LRYGB increased the risk for readmission (6.16% vs. 3.77%; RR, 1.63; 95%CI, 1.37 to 1.94, p < 0.01); reoperation (2.15% vs. 1.36%; RR, 1.57; 95%CI, 1.17 to 2.12, p = <0.01); leak (1.76% vs. 1.02%; RR, 1.57; 95%CI, 1.72 to 2.42, p < 0.01); and bleeding (1.66% vs. 1.00%; RR, 1.66; 95%CI, 1.7 to 2.34, p < 0.01).

Conclusions

The study shows that single-stage LRYGB and LSG as revisional surgery after gastric banding, are safe in the 30-day observation with an acceptable complication rate and low mortality. However, conversion to LRYGB increased the risk of perioperative complications.

From the Knife to the Endoscope-a History of Bariatric Surgery

PURPOSE OF REVIEW

Current bariatric surgical practice has developed from early procedures, some of which are no longer routinely performed. This review highlights how surgical practice in this area has developed over time.

RECENT FINDINGS

This review outlines early procedures including jejuno-colic and jejuno-ileal bypass, initial experience with gastric bypass, vertical banded gastroplasty and biliopancreatic diversion with or without duodenal switch. The role laparoscopy has played in the widespread utilization of surgery for treatment of obesity will be described, as will the development of procedures which form the mainstay of current bariatric surgical practice including gastric bypass, sleeve gastrectomy and adjustable gastric banding. Endoscopic therapies for the treatment of obesity will be described. By outlining how bariatric surgical practice has developed over time, this review will help practicing surgeons understand how individual procedures have evolved and also provide insight into potential future developments in this field.

Drain Placement During Bariatric Surgery, Helpful or Harmful?

INTRODUCTION

Routine drain placement is still widely used in both sleeve gastrectomy (SG) and Roux en Y gastric bypass (REYGB). There is mounting evidence that drains may increase complication risk without preventing reoperation or other complications.

METHODS

Data from 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use File was evaluated for drain use during laparoscopic REYGB and SG. Primary outcomes were superficial and deep surgical site infections (SSI), reintervention/reoperation, and readmission. Preoperative patient risk factors were also compared to evaluate for association with drain placement.

RESULTS

A total of 148 260 patients fit the inclusion criteria. Drains were used in 23 190 (15.6%) cases and not used in 125 070 (84.4%). Drain placement during surgery was associated with increased odds of superficial SSI, deep incisional SSI, and organ space SSI. Patients with drains were found to have increased odds of requiring at least 1 reoperation or intervention within 30 days of surgery. Preoperative risk factors associated with drain placement included diabetes mellitus, a history of chronic obstructive pulmonary disease, and oxygen dependence. Smokers were slightly less likely to have a drain placed. There was no significant association with chronic steroid and immunosuppressant usage.

CONCLUSION

There is mounting data against drain placement during bariatric surgery. Prior studies using MBSAQIP data have shown an increased complication rate with drains, and our data set supports the idea that drains may increase complications after surgery. While no randomized prospective trials have been performed looking at drain usage in bariatric surgery, the growing retrospective data certainly inform against the regular use of drains.

Surgical resident training program to perform laparoscopic bariatric procedures: Are safety and postoperative outcomes compromised?

INTRODUCTION

Laparoscopic bariatric procedures such as laparoscopic Roux-en-Y gastric bypass (LRYGB) are technically demanding and require a long learning curve. Little is known about whether surgical resident (SR) training programs to perform these procedures are safe and feasible. This study aims to evaluate the results of our SR training program to perform LRYGB.

METHODS

We designed a retrospective study including patients with LRYGB between January 2014 and December 2018, comparing SR results to experienced bariatric surgeons (EBS). In our country, SR have a five-year surgical formative period, and in the fourth year they are trained for 6 months in our bariatric surgery unit, from January to June. In the beginning, they perform different steps of this procedure, to finally complete an LRYGB. We collected demographic data, comorbidities, intraoperative outcomes, and postoperative complications and outcomes after a one-year follow-up.

RESULTS

Two hundred and eight patients were eligible for inclusion: 67 in group I (SR), and 141 in group II (EBS). Both groups were comparable. There was no statistically significant difference in operating time (166.45min in group I vs. 156.69min in group II; P=0.156). Conversion to open surgery, hospital stay, postoperative complications, and short-term outcomes had no significant differences between the two groups. There was no mortality registered during this period.

CONCLUSION

Implementation of LRYGB stepwise learning as part of an SR training program is safe, and results are comparable to EBS, without loss of efficiency. Therefore, it is feasible to train SR in bariatric surgery under EBS supervision.

Development and validation of machine learning models to predict gastrointestinal leak and venous thromboembolism after weight loss surgery: an analysis of the MBSAQIP database

BACKGROUND

Postoperative gastrointestinal leak and venous thromboembolism (VTE) are devastating complications of bariatric surgery. The performance of currently available predictive models for these complications remains wanting, while machine learning has shown promise to improve on traditional modeling approaches. The purpose of this study was to compare the ability of two machine learning strategies, artificial neural networks (ANNs), and gradient boosting machines (XGBs) to conventional models using logistic regression (LR) in predicting leak and VTE after bariatric surgery.

METHODS

ANN, XGB, and LR prediction models for leak and VTE among adults undergoing initial elective weight loss surgery were trained and validated using preoperative data from 2015 to 2017 from Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Data were randomly split into training, validation, and testing populations. Model performance was measured by the area under the receiver operating characteristic curve (AUC) on the testing data for each model.

RESULTS

The study cohort contained 436,807 patients. The incidences of leak and VTE were 0.70% and 0.46%. ANN (AUC 0.75, 95% CI 0.73-0.78) was the best-performing model for predicting leak, followed by XGB (AUC 0.70, 95% CI 0.68-0.72) and then LR (AUC 0.63, 95% CI 0.61-0.65, p < 0.001 for all comparisons). In detecting VTE, ANN, and XGB, LR achieved similar AUCs of 0.65 (95% CI 0.63-0.68), 0.67 (95% CI 0.64-0.70), and 0.64 (95% CI 0.61-0.66), respectively; the performance difference between XGB and LR was statistically significant (p = 0.001).

CONCLUSIONS

ANN and XGB outperformed traditional LR in predicting leak. These results suggest that ML has the potential to improve risk stratification for bariatric surgery, especially as techniques to extract more granular data from medical records improve. Further studies investigating the merits of machine learning to improve patient selection and risk management in bariatric surgery are warranted.