Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: impact on reflux and weight loss

BACKGROUND

Sleeve gastrectomy (SG) is the most commonly performed weight loss operation, and its 2 most common complications are postoperative reflux and weight recurrence. There is limited evidence to guide decision-making in treating these conditions.

OBJECTIVES

To determine the efficacy of conversion of SG to Roux-en-Y gastric bypass (RYGB) for GERD management and weight loss.

SETTING

Forty-one hospitals in Michigan.

METHODS

We conducted a retrospective cohort study examining patients who underwent conversion of SG to RYGB from 2014 to 2022. The primary outcomes were changes in GERD-HRQL scores, anti-reflux medication use, and weight from baseline to 1 year after conversion. Secondary outcomes included 30-day postoperative complications and resource utilization.

RESULTS

Among 2133 patients undergoing conversion, 279 (13%) patients had baseline and 1-year GERD-HRQL survey data and anti-reflux medication data. GERD-HRQL scores decreased significantly from 24.6 to 6.6 (P < .01). Among these, 207 patients (74%) required anti-reflux medication at baseline, with only 76 patients (27%) requiring anti-reflux medication at 1 year postoperatively (P < .01). Of the 380 patients (18%) with weight loss data, mean weight decreased by 68.4lbs, with a 24.3% decline in total body weight and 51.5% decline in excess body weight. In terms of 30-day complications, 308 (14%) patients experienced any complication and 89 (4%) experienced a serious complication, but there were no leaks, perforations, or deaths. Three-hundred and fifty-five (17%) patients presented to the emergency department and 64 (3%) patients underwent reoperation.

CONCLUSIONS

This study represents the largest reported experience with conversion from SG to RYGB. We found that conversion to RYGB is associated with significant improvement in GERD symptoms, reduction in anti-reflux medication use, and significant weight loss and is therefore an effective treatment for GERD and weight regain after SG. However, the risks and benefits of conversion surgery should be carefully considered, especially in patients with significant comorbidity burden.

Depression as a risk factor for adverse outcomes and increased healthcare utilization in bariatric surgery patients

INTRODUCTION

Depression is strongly associated with obesity and is common among patients undergoing bariatric surgery. Little is known about the impact of depression on early postoperative outcomes or its association with substance use.

METHODS

The Michigan Bariatric Surgery Collaborative is a statewide quality improvement program that maintains a large clinical registry. We evaluated patients undergoing primary Roux-en-Y gastric bypass or sleeve gastrectomy between 2017 and 2022. Patients self-reported symptoms of depression (PHQ-8) and use of alcohol (AUDIT-C), smoking, prescription opiates, and marijuana at baseline. Preoperative PHQ-8 scores stratified patients based on severity: no depression (0-4), mild (5-9), moderate (10-14), or severe (15-24). We compared 30-day outcomes and substance use between patients with and without depression.

RESULTS

Among 44,301 patients, 30.8% had some level of depression, with 19.8% mild, 7.5% moderate, and 3.5% severe. Patients with depression were more likely to have an extended length of stay (LOS) (> 3 days) than those without depression (no depression 2.1% vs. severe depression 3.0%, p = 0.0452). There were no significant differences between no depression and severe depression groups in rates of complications (5.7% vs. 5.2%, p = 0.1564), reoperations (0.9%, vs. 0.8%, p = 0.7394), ED visits (7.7% vs. 7.8%, p = 0.5353), or readmissions (3.2% vs. 3.9%, p = 0.3034). Patients with severe depression had significantly higher rates of smoking (9.7% vs. 12.5%, p < 0.0001), alcohol use disorder (8.6% vs. 14.0%, p < 0.0001), opiate use (14.5% vs. 22.4%, p < 0.0001) and marijuana use (8.4%, vs. 15.5%, p = 0.0008).

CONCLUSIONS

This study demonstrated that nearly one-third of patients undergoing bariatric surgery have depression, with over 10% in the moderate to severe range. There was a significant association between preoperative depressive symptoms and extended LOS after bariatric surgery, as well as higher rates of smoking and use of marijuana, prescription opiates and alcohol. There was no significant effect on adverse events or other measures of healthcare utilization.

Abdominal Pain After Roux-en-Y Gastric Bypass: A Review

Importance

Roux-en-Y gastric bypass (RYGB) remains one of the most commonly performed operations for morbid obesity and is associated with significant long-term weight loss and comorbidity remission. However, health care utilization rates following RYGB are high and abdominal pain is reported as the most common presenting symptom for those seeking care.

Observations

Given the limitations of physical examination in patients with obesity, correct diagnosis of abdominal pain following RYGB depends on a careful history and appropriate use of radiologic, laboratory and endoscopic studies, as well as a clear understanding of post-RYGB anatomy. The most common etiologies of abdominal pain after RYGB are internal hernia, marginal ulcer, biliary disease (eg, cholelithiasis and choledocholithiasis), and jejunojejunal anastomotic issues. Early identification of the etiology of the pain is essential, as some causes, such as internal hernia or perforated gastrojejunal ulcer, may require urgent or emergent intervention to avoid significant morbidity. While laboratory findings and imaging may prove useful, they remain imperfect, and clinical judgment should always be used to determine if surgical exploration is warranted.

Conclusions and Relevance

The etiologies of abdominal pain after RYGB range from the relatively benign to potentially life-threatening. This Review highlights the importance of understanding key anatomical and technical aspects of RYGB to guide appropriate workup, diagnosis, and treatment.

The effect of marijuana use on short-term outcomes with bariatric surgery

BACKGROUND

Despite increasing marijuana use nationwide, there are limited data on implications of marijuana use on bariatric surgery outcomes.

OBJECTIVE

We investigated associations between marijuana use and bariatric surgery outcomes.

SETTING

Multicenter statewide study utilizing data from the Michigan Bariatric Surgery Collaborative, a payor-funded consortium including over 40 hospitals and 80 surgeons performing bariatric surgery statewide.

METHODS

We analyzed data from the Michigan Bariatric Surgery Collaborative clinical registry on patients who underwent a laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass between June 2019 and June 2020. Patients were surveyed at baseline and annually on medication use, depression symptoms, and substance use. Regression analysis was performed to compare 30-day and 1-year outcomes between marijuana users and nonusers.

RESULTS

Of 6879 patients, 574 reported baseline marijuana use and 139 reported use at baseline and 1 year. Marijuana users were more likely to be current smokers (14% versus 8%, P < .0001), screen positive for alcohol use disorder (20.0% versus 8.4%, P < .0001), and score higher on the Patient Health Questionnaire-8 (6.1 versus 3.0, P < .0001). There were no statistically significant differences in 30-day outcomes or co-morbidity remission at 1 year. Marijuana users had higher adjusted total mean weight loss (47.6 versus 38.1 kg, P < .0001) and body mass index reduction (17 versus 14 kg/m2, P < .0001).

CONCLUSIONS

Marijuana use is not associated with worse 30-day outcomes or 1-year weight loss outcomes and should not be a barrier to bariatric surgery. However, marijuana use is associated with higher rates of smoking, substance use, and depression. These patients may benefit from additional mental health and substance abuse counseling.

Financial Impact of Metabolic Surgery on Prescription Diabetes Medications in Michigan

This study compares expenditures for diabetes medications before and after metabolic surgery among patients with diabetes in Michigan.

Racial variation in baseline characteristics and wait times among patients undergoing bariatric surgery

BACKGROUND

Although bariatric surgery is the most effective treatment for obesity and weight-related comorbid diseases, utilization rates are disproportionately low among non-white patients. We sought to understand if variation in baseline characteristics or access to care exists between white and non-white patients.

METHODS

Using a statewide bariatric-specific data registry, we evaluated all patients who underwent bariatric surgery between 2006 and 2020 and completed a preoperative baseline questionnaire, which included a question about self-identification of race. Patient characteristics, co-morbidities, and time from initial preoperative clinic evaluation to date of surgery were compared among racial groups.

RESULTS

A total of 73,141 patients met inclusion criteria with 18,741 (25.5%) self-identified as non-white. These included Black/African American (n = 11,904), Hispanic (n = 3448), Asian (n = 121), Native Hawaiian/Pacific Islander (n = 41), Middle Eastern (n = 164), Multiple (n = 2047) and other (n = 608). Non-white males were the least represented group, accounting for only 4% of all bariatric cases performed. Non-white patients were more likely to be younger (43.0 years vs. 46.6 years, p < 0.0001), disabled (16% vs. 11.4%, p < 0.0001) and have Medicaid (8.4% vs. 3.8%, p < 0.0001) when compared to white patients, despite having higher rates of college education (78.0% vs. 76.6, p < 0.0001). In addition, median time from initial evaluation to surgery was also longer among non-white patients (157 days vs. 127 days, p < 0.0001), despite having higher rates of patients with a body mass index above 50 kg/m2 (39.0% vs. 33.2%, p < 0.0001).

CONCLUSIONS

Non-white patients undergoing bariatric surgery represent an extremely diverse group of patients with more socioeconomic disadvantages and longer wait times when compared to white patients despite presenting with higher rates of severe obesity. Current guidelines and referral patterns for bariatric surgery may not be equitable and need further examination when considering the management of obesity within diverse populations to reduce disparities in care-of which non-white males are particularly at risk.

Impact of concurrent hiatal hernia repair during laparoscopic sleeve gastrectomy on patient-reported gastroesophageal reflux symptoms: a state-wide analysis

BACKGROUND

Concurrent hiatal hernia repair (HHR) during laparoscopic sleeve gastrectomy (LSG) may improve gastroesophageal reflux disease (GERD) symptoms. However, patient-reported outcomes are limited, and the influence of surgeon technique remains unclear.

OBJECTIVES

To assess patient-reported GERD severity before and after LSG with and without concomitant HHR.

SETTING

Teaching and non-teaching hospitals participating in a state-wide quality improvement collaborative.

METHODS

Using a state-wide bariatric-specific data registry, all patients who underwent a primary LSG between 2015 and 2019 who completed a baseline and 1 year validated GERD health related quality of life (GERD-HRQL) survey were identified (n = 11,742). GERD severity at 1 year as well as 30-day risk-adjusted adverse events was compared between patients who underwent LSG with or without HHR. Results were also stratified by anterior versus posterior HHR.

RESULTS

A total of 4015 patients underwent a LSG-HHR (34%). Compared to patients who underwent LSG without HHR, LSG-HHR patients were older (47.8 yr versus 44.6 yr; P < .0001), had a lower preoperative body mass index (BMI) (45.8 kg/m² versus 48 kg/m²; P < .0001) and more likely to be female (85.2% versus 77.6%, P < .0001). Patients who underwent a posterior HHR (n = 3205) experienced higher rates of symptom improvement (69.5% versus 64.0%, P = .0014) and lower rates of new onset symptoms at 1 year (28.2% versus 30.2%, P = .0500). Patients who underwent an anterior HHR (n = 496) experienced higher rates of hemorrhage and readmissions with no significant difference in symptom improvement.

CONCLUSIONS

Concurrent posterior hiatal HHR at the time of sleeve gastrectomy can improve reflux symptoms. Patients undergoing anterior repair derive no benefit and should be avoided.

Patient characteristics and outcomes among bariatric surgery patients with high narcotic overdose scores

BACKGROUND

Obesity-related chronic pain can increase the risk of narcotic abuse in bariatric surgery patients. However, assessment of overdose risk has not been evaluated to date.

METHODS

A NARxCHECK® overdose score ("Narx score") was obtained preoperatively on all patients undergoing bariatric surgery (n = 306) between 2018 and 2020 at a single-center academic bariatric surgery program. The 3-digit score ranges from 000 to 999 and is based on patient risk factors found within the Prescription Drug Monitoring Program. A Narx score ≥ 200 indicates tenfold increased risk of narcotic overdose. Patient characteristics, comorbidities, and emergency room (ER) visits were compared between patients in the upper (≥ 200) and lower (000) terciles of Narx scores. Morphine milligram equivalent (MME) prescribed at discharge and refills was also evaluated.

RESULTS

Patients in the upper tercile represented 32% (n = 99) of the study population, and compared to the lower tercile (n = 101, 33%), were more likely to have depression (63.6% vs 38.6%, p = 0.0004), anxiety (47.5% vs 30.7%, p = 0.0150), and bipolar disorder (6.1% vs 0.0%, p = 0.0120). Median MME prescribed at discharge was the same between both groups (75); however, high-risk patients were more likely to be prescribed more than 10 tablets of a secondary opioid (83.3% vs 0.0%, p = 0.0111), which was prescribed by another provider in 67% of cases. ER visits among patients who did not have a complication or require a readmission was also higher among high-risk patients (7.8% vs 0.0%, p = 0.0043). There were no deaths or incidents of mental health-related ER visits in either group.

CONCLUSION

Patients with a Narx score ≥ 200 were more likely to have mental health disorders and have potentially avoidable ER visits in the setting of standardized opioid prescribing practices. Narx scores can help reduce ER visits by identifying at-risk patients who may benefit from additional clinic or telehealth follow-up.

Independent predictors and timing of portomesenteric vein thrombosis after bariatric surgery

BACKGROUND

Portomesenteric vein thrombosis (PVT) is a rare complication following bariatric surgery but can result in severe morbidity as well as death.

OBJECTIVE

Identification of risk factors for PVT to facilitate targeted management strategies to reduce incidence.

SETTING

Prospective, statewide bariatric-specific clinical registry.

METHODS

We identified all patients who underwent primary bariatric surgery between June 2006 and November 2021 (n = 102,869). Patient characteristics, procedure type, operative details, and 30-day postoperative complications were analyzed with multivariable logistic regression to evaluate for independent predictors of PVT.

RESULTS

A total of 117 patients (.11%) developed a postoperative PVT, with 6 (5.1%) associated deaths. The majority of PVTs occurred in patients who underwent sleeve gastrectomy (109 patients; 93.2%), and the PVT occurred most commonly during the second (37%), third (31%), and fourth weeks (23%) after surgery. Independent risk factors for PVT included a prior history of venous thromboembolism (odds ratio [OR] = 3.1; 95% confidence interval [CI]: 1.64-5.98; P = .0005), liver disorder (OR = 2.3; 95% CI: 1.36-4.00; P = .0021), undergoing sleeve gastrectomy (OR = 12.4; 95% CI: 4.98-30.69; P < .0001), and postoperative complications including obstruction (OR = 12.5; 95% CI: 4.65-33.77; P < .0001), leak (OR = 7.9; 95% CI: 2.76-22.64; P = .0001), and hemorrhage (OR = 7.6; 95% CI: 3.57-16.06; P < .0001).

CONCLUSIONS

Independent predictors of PVT include a prior history of venous thromboembolism, liver disease, undergoing sleeve gastrectomy, and experiencing a serious postoperative complication. Given that the incidence of PVT is most common within the first month after surgery, extending postdischarge chemoprophylaxis during this time frame is advised for patients with increased risk.

Impact of hiatal hernia repair technique on patient-reported gastroesophageal reflux symptoms following laparoscopic sleeve gastrectomy

INTRODUCTION

Repairing a hiatal hernia at the time of laparoscopic sleeve gastrectomy (SG) can reduce or even prevent gastroesophageal reflux disease (GERD) symptoms in the post-operative period. Several different hiatal hernia repair techniques have been described but their impact on GERD symptoms after SG is unclear.

METHODS

Surgeons (n = 74) participating in a statewide quality collaborative were surveyed on their typical technique for repair of hiatal hernias during SG. Options included posterior repair with mesh (PRM), posterior repair (PR), and anterior repair (AR). Patients who underwent SG with concurrent hiatal hernia repair (n = 7883) were compared according to their surgeon's reported technique. Patient characteristics, baseline and 1-year GERD health-related quality of life surveys, weight loss and 30-day risk-adjusted complications were analyzed.

RESULTS

The most common technique reported by surgeons for hiatal hernia repair was PR (n = 64, 85.3%), followed by PRM (n = 7, 9.3%) and AR (n = 4, 5.3%). Patients who underwent SG by surgeons who perform AR had lower rates of baseline GERD diagnosis (AR 55.3%, PR 59.5%, PRM 64.8%, p < 0.01), but were more likely to experience worsening GERD symptoms at 1 year (AR 29.8%, PR 28.7%, PRM 28.2%, p < 0.0001), despite similar weight loss (AR 29.8%, PR 28.7%, PRM 28.2%, p = 0.08). Satisfaction with GERD symptoms at 1 year was high (AR 73.2%, PR 76.3%, PRM 75.7%, p = 0.43), and risk-adjusted 30-day outcomes were similar among all groups.

CONCLUSIONS

Patients undergoing SG with concurrent hiatal hernia repair by surgeons who typically perform an AR were more likely to report worsening GERD at 1 year despite excellent weight loss. Surgeons who typically performed an AR had nearly one-half of their patients report increased GERD severity after surgery despite similar weight loss. While GERD symptom control may be multifactorial, technical approach to hiatal hernia repair at the time of SG may play a role and a posterior repair is recommended.

Comparison of early outcomes between Roux-en-Y gastric bypass and sleeve gastrectomy among patients with body mass index ≥ 60 kg/m2

BACKGROUND

There is no consensus on the ideal bariatric operation to choose for patients with extremely high body mass index (BMI). The aim of this study was to compare the perioperative complications, weight loss, and comorbidity remission between laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) among patients with BMI ≥ 60 kg/m2.

METHODS

Data from a statewide bariatric surgery registry were used to identify all patients with BMI ≥ 60 kg/m2 undergoing LRYGB or LSG between January 2006 and June 2019. Risk and reliability adjustment were used to compare outcomes between the two groups.

RESULTS

A total of 6015 patients were identified and 2505 (41.6%) underwent LRYGB and 3510 (58.4%) underwent LSG. The overall mean age was 43.1 ± 11.2 years with a mean preoperative BMI of 66.7 ± 6.4 kg/m2. Females accounted for 69.3% and the majority were either white (68.5%) or black (21.2%). LRYGB was associated with a higher rate of adjusted 30-day postoperative serious complications (4.0% vs 2.2%; p < 0.01) including anastomotic leak, obstruction, and bleeding. Resource utilization was also higher with LRYGB (23.7% vs 14.8%; p < 0.01) and included more emergency department visits, readmissions, reoperations, and length of stay ≥ 4 days. The overall 1-year follow-up rate was 38.8%. The adjusted percent total weight loss at 1 year was significantly higher following LRYGB compared to LSG (36.6 ± 9.3 vs 31.3 ± 9.3%; p < 0.01). LRYGB was associated with a higher rate of treatment discontinuation for diabetes mellitus, hyperlipidemia, and obstructive sleep apnea.

CONCLUSIONS

In patients with BMI ≥ 60 kg/m2, LRYGB was associated with better weight loss and medication discontinuation 1 year following surgery at the expense of an increase in perioperative complications and resource utilization compared to LSG.

Am I on Track? Evaluating Patient-Specific Weight Loss After Bariatric Surgery Using an Outcomes Calculator

PURPOSE

Individual weight loss outcomes after bariatric surgery can vary considerably. As a result, identifying and assisting patients who are not on track to reach their weight loss goals can be challenging.

MATERIALS AND METHODS

Using a bariatric surgery outcomes calculator, which was formulated using a state-wide bariatric-specific data registry, predicted weight loss at 1 year after surgery was calculated on 658 patients who underwent bariatric surgery at 35 different bariatric surgery programs between 2015 and 2017. Patient characteristics, postoperative complications, and weight loss trajectories were compared between patients who met or exceeded their predicted weight loss calculation to those who did not based on observed to expected weight loss ratio (O:E) at 1 year after surgery.

RESULTS

Patients who did not meet their predicted weight loss at 1 year (n = 237, 36%) had a mean O:E of 0.71, while patients who met or exceeded their prediction (n = 421, 63%) had a mean O:E = 1.14. At 6 months, there was a significant difference in the percent of the total amount of predicted weight loss between the groups (88% of total predicted weight loss for those that met their 1-year prediction vs 66% for those who did not, p < 0.0001). Age, gender, procedure type, and risk-adjusted complication rates were similar between groups.

CONCLUSION

Using a bariatric outcomes calculator can help set appropriate weight-loss expectations after surgery and also identify patients who may benefit from additional therapy prior to reaching their weight loss nadir.

Factors associated with completion of patient surveys 1 year after bariatric surgery

BACKGROUND

Patient-reported outcomes (PRO) obtained from follow-up survey data are essential to understanding the longitudinal effects of bariatric surgery. However, capturing data among patients who are well beyond the recovery period of surgery remains a challenge, and little is known about what factors may influence follow-up rates for PRO.

OBJECTIVES

To assess the effect of hospital practices and surgical outcomes on patient survey completion rates at 1 year after bariatric surgery.

SETTING

Prospective, statewide, bariatric-specific clinical registry.

METHODS

Patients at hospitals participating in the Michigan Bariatric Surgery Collaborative are surveyed annually to obtain information on weight loss, medication use, satisfaction, body image, and quality of life following bariatric surgery. Hospital program coordinators were surveyed in June 2017 about their practices for ensuring survey completion among their patients. Hospitals were ranked based on 1-year patient survey completion rates between 2011 and 2015. Multivariable regression analyses were used to identify associations between hospital practices, as well as 30-day outcomes, on hospital survey completion rankings.

RESULTS

Overall, patient survey completion rates at 1 year improved from 2011 (33.9% ± 14.5%) to 2015 (51.0% ± 13.0%), although there was wide variability between hospitals (21.1% versus 77.3% in 2015). Hospitals in the bottom quartile for survey completion rates had higher adjusted rates of 30-day severe complications (2.6% versus 1.7%, respectively; P = .0481), readmissions (5.0% versus 3.9%, respectively; P = .0157), and reoperations (1.5% versus .7%, respectively; P = .0216) than those in the top quartile. While most hospital practices did not significantly impact survey completion at 1 year, physically handing out surveys during clinic visits was independently associated with higher completion rates (odds ratio, 13.60; 95% confidence interval, 1.99-93.03; P =.0078).

CONCLUSIONS

Hospitals vary considerably in completion rates of patient surveys at 1 year after bariatric surgery, and lower rates were associated with hospitals that had higher complication rates. Hospitals with the highest completion rates were more likely to physically hand surveys to patients during clinic visits. Given the value of PRO on longitudinal outcomes of bariatric surgery, improving data collection across multiple hospital systems is imperative.

Association Between Surgeon Practice Knowledge and Venous Thromboembolism

BACKGROUND

The most common cause of mortality following bariatric surgery is venous thromboembolism. Our study aimed to (1) determine the practice patterns of venous thromboembolism (VTE) chemoprophylaxis among bariatric surgeons participating in a large statewide quality collaborative and (2) compare the results of surgeon self-reported chemoprophylaxis practices to actual practices from abstracted chart data.

METHODS

We administered a 13-question survey to 66 surgeons across a statewide collaborative aimed at revealing VTE practice patterns such as medication type, dosage, timing, duration, and level of trainee involvement (response rate 93%). We conducted on-site data audits to examine the charts of all patients that had developed VTE during the study period and 15 other randomly selected patient charts per site. We then evaluated both the ordered perioperative chemoprophylaxis and the actual administered chemoprophylaxis from nursing and electronic records.

RESULTS

There was 31% overall discordance between self-reported and abstracted chart data for pre-operative VTE dosing regimens. Among patients who had a VTE, 39% of administered chemoprophylaxis did not match surgeon responses. Conversely, among patients who did not have a VTE, only 29% were discordant (p = 0.03). In contrast, for post-operative VTE dosing, there was no significant difference in the rate of discordance in patients with and without a VTE (47% discordance vs 38%, p = 0.0552, respectively).

CONCLUSIONS

Greater discordance between surgeon self-reported and actual perioperative VTE chemoprophylaxis is associated with significantly increased risk of VTE. Further understanding of the system characteristics associated with these practices may yield insights into how best to improve appropriate VTE chemoprophylaxis.

Perioperative and 1-year outcomes of bariatric surgery in septuagenarians: implications for patient selection

BACKGROUND

Although bariatric surgery is an effective treatment for obesity, utilization of bariatric procedures in older adults remains low. Previous work reported higher morbidity in older patients undergoing bariatric surgery. However, the generalizability of these data to contemporary septuagenarians is unclear.

OBJECTIVES

We sought to evaluate differences in 30-day outcomes, 1-year weight loss, and co-morbidity remission after bariatric surgery among 3 age groups as follows: <45 years, 45-69 years, and ≥70 years.

SETTING

Statewide quality improvement collaborative.

METHODS

Using a large quality improvement collaborative, we identified patients undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) between 2006 and 2018. We used multivariable logistic regression models to evaluate the association between age cohorts and 30-day outcomes, 1-year weight loss, and co-morbidity remission.

RESULTS

We identified 641 septuagenarians who underwent SG (68.5%) or RYGB (31.5%). Compared with 45-69 year olds, septuagenarians had higher rates of hemorrhage (5.1% versus 3.1%; P = .045) after RYGB and higher rates of leak/perforation (.9% versus .3%; P = .044) after SG. Compared with younger patients, septuagenarians lost less of their excess weight, losing 64.8% after RYGB and 53.8% after SG. Remission rates for diabetes and obstructive sleep were similar for patients aged ≥70 years and 45-69 years.

CONCLUSIONS

Bariatric surgery in septuagenarians results in substantial weight loss and co-morbidity remission with an acceptable safety profile. Surgeons with self-imposed age limits should consider broadening their selection criteria to include patients ≥70 years old.

Association of Race With Bariatric Surgery Outcomes

Importance

The outcomes of bariatric surgery vary considerably across patients, but the association of race with these measures remains unclear.

Objective

To examine the association of race on perioperative and 1-year outcomes of bariatric surgery.

Design, Setting, and Participants

Propensity score matching was used to assemble cohorts of black and white patients from the Michigan Bariatric Surgery Collaborative who underwent a primary bariatric operation (Roux-en-Y gastric bypass, sleeve gastrectomy, or adjustable gastric banding) between June 2006 and January 2017. Cohorts were balanced on baseline characteristics and procedure. Conditional fixed-effects models were used to evaluate the association of race on outcomes within hospitals and surgeons. Data analysis occurred from June 2006 through August 2018.

Main Outcomes and Measures

Thirty-day complications and health care resource utilization measures, as well as 1-year weight loss, comorbidity remission, quality of life, and satisfaction.

Results

In each group, 7105 patients were included. Black patients had a higher rate of any complication (628 [8.8%] vs 481 [6.8%]; adjusted odds ratio, 1.33 [95% CI, 1.17-1.51]; P = .02), but there were no significant differences in the rates of serious complications (178 [2.5%] vs 135 [1.9%]; adjusted odds ratio, 1.32 [95% CI, 1.05-1.66]; P = .29) or mortality (5 [0.10%] vs 7 [0.10%]; adjusted odds ratio, 0.73 [95% CI, 0.23-2.31]; P = .54). Black patients had a greater length of stay (mean [SD], 2.2 [3.0] days vs 1.9 [1.7] days; adjusted odds ratio, 0.30 [95% CI, 0.20-0.40]; P < .001), as well as a higher rate of emergency department visits (541 [11.6%] vs 826 [7.6%]; adjusted odds ratio, 1.60 [95% CI, 1.43-1.79]; P < .001) and readmissions (414 [5.8%] vs 245 [3.5%]; adjusted odds ratio, 1.73 [95% CI, 1.47-2.03]; P < .001). At 1 year, black patients had lower mean total body weight loss and as a percentage of weight (32.0 kg [26%]; vs 38.3 kg [29%]; P < .001) and this held true across procedures. Remission of hypertension was lower for black patients (564 [40.0%] vs 1096 [56.0%]; P < .001), but the rate of sleep apnea remission (467 [62.6%] vs 615 [56.1%]; P = .005) and gastroesophageal reflux disease (309 [78.6%] vs 453 [75.4%]; P = .049) were higher. There were no significant differences in remission of diabetes with insulin dependence, diabetes without insulin dependence,or hyperlipidemia hyperlipidemia. Fewer black patients than white patients reported a good or very good quality of life (1379 [87.2%] vs 2133 [90.4%]; P = .002) and being very satisfied with surgery (1908 [78.4%] vs 2895 [84.2%]; P < .001) at 1 year.

Conclusions and Relevance

Black patients undergoing bariatric surgery in Michigan had significantly higher rates of 30-day complications and resource utilization and experienced lower weight loss at 1 year than a matched cohort of white patients. While sleep apnea and gastroesophageal reflux disease remission were higher and hypertension remission lower in black patients, comorbidity remission was otherwise similar between matched cohorts. Racial and cultural differences among patients should be considered when designing strategies to optimize outcomes with bariatric surgery.

Effect of new persistent opioid use on physiologic and psychologic outcomes following bariatric surgery

INTRODUCTION

New persistent opioid use following surgery is a common iatrogenic complication, developing in roughly 6% of patients after elective surgery. Despite increased awareness of misuse and associated morbidity, opioids remain the cornerstone of pain management in bariatric surgery. The potential impact of new persistent opioid use on long-term postoperative outcomes is unknown. We sought to determine the relationship between new persistent opioid use and 1-year postoperative outcomes for patients undergoing bariatric surgery.

METHODS

Using data from the MBSC registry, we identified patients undergoing primary bariatric surgery between 2006 and 2016. Using previously validated patient-reported survey methodology, we evaluated patient opioid use preoperatively and at 1 year following surgery. New persistent use was defined as a previously opioid-naïve patient who self-reported opioid use 1 year after surgery. We used multivariable logistic regression models to evaluate the association between new persistent opioid use, risk-adjusted weight loss, and psychologic outcomes (psychological wellbeing, body image, and depression).

RESULTS

27,799 patients underwent primary bariatric surgery between 2006 and 2016. Among opioid-naïve patients, the rate of new persistent opioid use was 6.3%. At 1-year after surgery, patients with new persistent opioid user lost significantly less excess body weight compared to those without new persistent use (57.6% vs. 60.3%; p < 0.0001). Patients with new persistent opioid use had significantly worse psychological wellbeing (35.0 vs. 33.1; p < 0.0001), body image (19.9 vs. 18.0; p < 0.0001), and depression scores (2.4 vs. 5.0; p < 0.0001). New persistent opioid users also reported less overall satisfaction with their bariatric surgery (75.1% vs. 85.7%; p < 0.0001).

CONCLUSIONS

New persistent opioid use is common following bariatric surgery and associated with significantly worse physiologic and psychologic outcomes. More effective screening and postoperative surveillance tools are needed to identify these patients, who likely require more aggressive counseling and treatment to maximize the benefits of bariatric surgery.

Factors Associated With Achieving a Body Mass Index of Less Than 30 After Bariatric Surgery

Importance

Achieving a body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) of less than 30 is an important goal of bariatric surgery, given the increased risk for weight-related morbidity and mortality with a BMI above this threshold.

Objective

To identify predictors for achieving a BMI of less than 30 after bariatric surgery.

Design, Setting, and Participants

This retrospective study used data from the Michigan Bariatric Surgery Collaborative, a statewide quality improvement collaborative that uses a prospectively gathered clinical data registry. A total of 27 320 adults undergoing primary bariatric surgery between June 2006 and May 2015 at teaching and nonteaching hospitals in Michigan were included.

Exposure

Bariatric surgery.

Main Outcomes and Measures

Logistic regression was used to identify predictors for achieving a BMI of less than 30 at 1 year after surgery. Secondary outcome measures included 30-day postoperative complications and 1-year self-reported comorbidity remission.

Results

A total of 9713 patients (36%; mean [SD] age, 46.9 [11.3] years; 16.6% male) achieved a BMI of less than 30 at 1 year after bariatric surgery. A significant predictor for achieving this goal was a preoperative BMI of less than 40 (odds ratio [OR], 12.88; 95% CI, 11.71-14.16; P < .001). Patients who had a sleeve gastrectomy, gastric bypass, or duodenal switch were more likely to achieve a BMI of less than 30 compared with those who underwent adjustable gastric banding (OR, 8.37 [95% CI, 7.44-9.43]; OR, 21.43 [95% CI, 18.98-24.19]; and OR, 82.93 [95% CI, 59.78-115.03], respectively; P < .001). Only 8.5% of patients with a BMI greater than 50 achieved a BMI of less than 30 after bariatric surgery. Patients who achieved a BMI of less than 30 had significantly higher reported rates of medication discontinuation for hyperlipidemia (60.7% vs 43.2%, P < .001), diabetes (insulin: 67.7% vs 50.0%, P < .001; oral medications: 78.5% vs 64.3%, P < .001), and hypertension (54.7% vs 34.6%, P < .001), as well as a significantly higher rate of sleep apnea remission (72.5% vs 49.3%, P < .001) and higher satisfaction rate (92.8% vs 78.0%, P < .001) compared with patients who did not.

Conclusions and Relevance

Patients with a preoperative BMI of less than 40 are more likely to achieve a BMI of less than 30 after bariatric surgery and are more likely to experience comorbidity remission. Policies and practice patterns that delay bariatric surgery until the BMI is 50 or greater can result in significantly inferior outcomes.

Far from Standardized: Using Surgical Videos to Identify Variation in Technique for Laparoscopic Sleeve Gastrectomy

BACKGROUND

Video assessment is an emerging tool for understanding variation in surgical technique.

METHODS

Representative videos of laparoscopic sleeve gastrectomy (LSG) were voluntarily submitted by 20 surgeons who participated in a statewide quality improvement collaborative. The amount of time required to complete the salient steps of the operation was measured and variations in the tasks performed during each step were captured.

RESULTS

Twenty-two videos of LSG were submitted and 11 videos included concurrent hiatal hernia repair. Data obtained from video analysis identified variation in time to complete each step of the procedure: prestapling dissection of stomach (5-25 minutes), gastric stapling (8-20 minutes), and management of the staple line (1-25 minutes). Time required to perform a hiatal hernia repair also varied (1-26 minutes), as did the type of repair: 55% were performed with a posterior cruropexy, 27% were performed with an anterior cruropexy, and 18% were performed with both. Ten different permutations of staple heights and buttressing material were used during division of the stomach with a gastric stapler. Management of the staple line included use of buttressing (64%), fibrin sealant (36%), oversewing (9%), surgical clips (18%), imbrication of the staple line (36%), and omentoplasty (55%).

CONCLUSIONS

LSG technique is not uniform. Video analysis identified variation in (1) time to complete each step of the procedure, (2) hiatal hernia repair technique, (3) stapling technique, and (4) post-transection staple line management. Future efforts linking video analysis with clinical outcomes can provide objective evidence to support best practices.

Adipocyte hypertrophy-hyperplasia balance contributes to weight loss after bariatric surgery

Predictors of weight loss responses are not well-defined. We hypothesized that adipose tissue phenotypic features related to remodeling would be associated with bariatric surgery weight loss responses. Visceral and subcutaneous adipose tissues collected from patients during bariatric surgery were studied with flow cytometry, immunohistochemistry, and QRTPCR, and results correlated with weight loss outcomes. Age, male sex, and a diagnosis of type 2 diabetes were associated with less weight loss. Adipocyte size was increased and preadipocyte frequency was decreased in visceral adipose tissue from diabetic subjects. Decreased adipose tissue preadipocyte frequency was associated with less weight loss in women but not men. These data suggest that phenotypic features of adipose tissue remodeling may predict responses to weight loss interventions.

Diabetes-Specific Regulation of Adipocyte Metabolism by the Adipose Tissue Extracellular Matrix

CONTEXT

The role of the extracellular matrix (ECM) in regulating adipocyte metabolism in the context of metabolic disease is poorly defined.

OBJECTIVE

The objective of this study was to define the metabolic phenotype of adipocytes associated with human diabetes (DM) and the role of the ECM in regulating adipocyte metabolism.

DESIGN

Adipose tissues from obese patients were studied in standard 2-dimensional (2D) cell culture and an in vitro model of decellularized adipose tissue ECM repopulated with human adipocytes, and results were correlated with DM status.

SETTING

This study was conducted at the Academic University Medical Center and Veteran's Administration Hospital.

PATIENTS

Seventy patients with morbid obesity undergoing bariatric surgery were included in the study.

INTERVENTIONS

Visceral and subcutaneous adipose tissues were collected at the time of bariatric surgery.

OUTCOME MEASURES

This study used metabolic assays for glucose uptake, lipolysis, and lipogenesis in adipocytes in 2D cell culture and 3-dimensional ECM culture.

RESULTS

Adipocytes from subjects with DM manifest decreased glucose uptake and decreased lipolysis in 2D culture. ECM supports differentiation of mature adipocytes and recapitulates DM-specific differences in adipocyte metabolism observed in 2D culture. ECM from subjects without DM partially rescues glucose uptake and lipolytic defects in adipocytes from subjects with DM, whereas ECM from subjects with DM impairs glucose uptake in adipocytes from subjects without DM.

CONCLUSIONS

DM is associated with adipocyte metabolic dysfunction. The ECM regulates adipocyte metabolism. Nondiabetic ECM rescues metabolic dysfunction in DM adipocytes, whereas DM ECM imparts features of metabolic dysfunction to nondiabetic adipocytes. These findings suggest the ECM as a target for manipulating adipose tissue metabolism.

Evaluating the effect of operative technique on leaks after laparoscopic sleeve gastrectomy: a case-control study

OBJECTIVE

To assess the effect of operative technique on staple line leaks after laparoscopic sleeve gastrectomy (LSG).

BACKGROUND

Staple-line leaks after LSG are a major source of morbidity and mortality. Variations in operative technique exist; however, their effect on leaks is poorly understood.

METHODS

We analyzed data from the Michigan Bariatric Surgery Collaborative (MBSC) to perform a case-control study comparing patients who had a clinically significant leak after undergoing a primary LSG to those who did not. A total of 45 patients with leaks were identified between January 2007 and December 2013. The leak group was matched 1:2 to a control group based on procedure type, age, body mass index, sex, and year the procedure was performed. Technique-specific factors were assessed by reviewing operative notes from all primary bariatric procedures in our study population. Conditional logistic regression was used to identify techniques associated with leaks. To increase the power of our analysis, we used a significance level of .10.

RESULTS

Leak rates with LSG have decreased over the past 5 years (1.18% to .36%) as annual case volume has increased (846 cases/yr to 4435 cases/yr). Surgeons who performed 43 or more cases per year had a leak rate<1%. Leaks were more common among cases requiring a blood transfusion (26.2% versus 1.08%, P = .0031) and when cases were converted to open surgery (7.14% versus 0%, P = .0741). However, there was no significant difference in operative time between cases involving a leak and their matched controls (95.4 min versus 87.1 min, P = .1197). Oversewing of the staple line was the only technique associated with less leaks after controlling for confounding factors (OR .397 CI .174, .909, P = .0665). Notably, surgeons who oversewed routinely were also found to have higher case volume (307 versus 140, P = .0216) and less overall complication rates (4.81% versus 7.95%, P = .0027). Furthermore, oversewing technique varied widely as only 22.6% of cases involved oversewing of the entire staple line.

CONCLUSION

Despite considerable variation in operative technique, leak rates with laparoscopic sleeve gastrectomy have decreased over time as operative volume has increased. Oversewing of the staple line was associated with fewer leaks, but specific suturing technique was not uniform and oversewing was performed routinely by more experienced surgeons with higher case volumes and less complication rates overall. Before standardizing surgical technique one must take into account variations in surgeon skill and experience.

Doctors of tomorrow: An innovative curriculum connecting underrepresented minority high school students to medical school

BACKGROUND

Racial minorities continue to be underrepresented in medicine (URiM). Increasing provider diversity is an essential component of addressing disparity in health delivery and outcomes. The pool of students URiM that are competitive applicants to medical school is often limited early on by educational inequalities in primary and secondary schooling. A growing body of evidence recognizing the importance of diversifying health professions advances the need for medical schools to develop outreach collaborations with primary and secondary schools to attract URiMs. The goal of this paper is to describe and evaluate a program that seeks to create a pipeline for URiMs early in secondary schooling by connecting these students with support and resources in the medical community that may be transformative in empowering these students to be stronger university and medical school applicants.

METHODS

The authors described a medical student-led, action-oriented pipeline program, Doctors of Tomorrow, which connects faculty and medical students at the University of Michigan Medical School with 9th grade students at Cass Technical High School (Cass Tech) in Detroit, Michigan. The program includes a core curriculum of hands-on experiential learning, development, and presentation of a capstone project, and mentoring of 9th grade students by medical students. Cass Tech student feedback was collected using focus groups, critical incident written narratives, and individual interviews. Medical student feedback was collected reviewing monthly meeting minutes from the Doctors of Tomorrow medical student leadership. Data were analyzed using thematic analysis.

RESULTS

Two strong themes emerged from the Cass Tech student feedback: (i) Personal identity and its perceived effect on goal achievement and (ii) positive affect of direct mentorship and engagement with current healthcare providers through Doctors of Tomorrow. A challenge noted by the medical students was the lack of structured curriculum beyond the 1st year of the program; however, this was complemented by their commitment to the program for continued longitudinal development.

DISCUSSION

The authors propose that development of outreach pipeline programs that are context specific, culturally relevant, and established in collaboration with community partners have the potential to provide underrepresented students with opportunities and skills early in their formative education to be competitive applicants to college and ultimately to medical school.

Classifying Cause of Death After Cancer Surgery

A retrospective, single-center study was conducted to understand variation in mortality after elective cancer surgery. Fifty-two patients who died perioperatively after elective cancer resections (colon, esophageal, pancreatic, lung, gastric and liver) were identified. A methodology was developed and used during medical record review to capture the occurrence and chronology of 21 postoperative complications. Data were reviewed by 3 attending surgeons who assigned cause of death based on information from the entire clinical record. This methodology demonstrated good construct validity, with 81% agreement between cause of death assigned by expert review of data from the instrument and that assigned by expert review of the clinical records (κ = 0.75, P < .005). Cause-specific mortality can be reliably and systematically measured after cancer surgery. Understanding variation in cause-specific mortality can inform future quality improvement efforts.

Adipose tissue fibrosis, hypertrophy, and hyperplasia: Correlations with diabetes in human obesity

OBJECTIVE

The relationship between adipose tissue fibrosis, adipocyte hypertrophy, and preadipocyte hyperplasia in the context of obesity and the correlation of these tissue-based phenomena with systemic metabolic disease are poorly defined. The goal of this study was to clarify the relationship between adipose tissue fibrosis, adipocyte hypertrophy, and preadipocyte hyperplasia in human obesity and determine the correlation of these adipose-tissue based phenomena with diabetes.

METHODS

Visceral and subcutaneous adipose tissues from humans with obesity collected during bariatric surgery were studied with QRTPCR, immunohistochemistry, and flow cytometry for expression of collagens and fibrosis-related proteins, adipocyte size, and preadipocyte frequency. Results were correlated with clinical characteristics including diabetes status.

RESULTS

Fibrosis was decreased, hypertrophy was increased, and preadipocyte frequency and fibrotic gene expression were decreased in adipose tissues from diabetic subjects compared to non-diabetic subjects. These differences were greater in visceral compared to subcutaneous adipose tissue.

CONCLUSIONS

These data are consistent with the hypothesis that adipose tissue fibrosis in the context of human obesity limits adipocyte hypertrophy and is associated with a reciprocal increase in adipocyte hyperplasia, with beneficial effects on systemic metabolism. These findings suggest adipose tissue fibrosis as a potential target for manipulation of adipocyte metabolism.

Hospital volume and outcomes for laparoscopic gastric bypass and adjustable gastric banding in the modern era

BACKGROUND

Over the past decade, there has been a rapid decline in adverse events after bariatric surgery. As a result, it is possible that the influence of hospital volume on outcomes has attenuated over time. The objective of the present study was to examine whether the relationship between hospital volume and adverse events has persisted in the era of laparoscopic surgery. This study is based on analysis of State Inpatient Databases (SID) for 12 states from 2006 through 2011, which included 446,127 patients.

METHODS

Using hospital discharge data, changes in serious complications, reoperations and mortality over time, and the impact of hospital volume on outcomes among patients undergoing laparoscopic adjustable gastric band (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) were studied. Hospitals were stratified by operative volume, and using multivariable logistic regression to adjust for patient characteristics and procedure-type, the relationships between hospital volume and outcomes during 3 2-year periods were examined: 2006-2007, 2008-2009, and 2010-2011.

RESULTS

The rate of reoperations and mortality were low, and there were no significant differences between the highest (>125 cases/yr) and lowest (<50 cases/yr) volume hospitals for both LAGB and LRYGB. The volume-outcome relationship was most prominent when examining rates of adjusted odds ratios for serious complications at the lowest volume hospitals compared with the highest volume hospitals (LAGB: 1.65 [CI: 1.18, 2.30] for 2006-2007, 1.81 [CI: 1.36, 2.41] for 2008-2009, and 2.08 [CI:1.40, 3.09] for 2010-2011; LRYGB: 1.55 [CI:1.23, 1.95] for 2006-2007, 1.39 [CI:1.09, 1.76], and 1.39 [CI:1.07, 1.80] for 2010-2011).

CONCLUSIONS

Outcomes improved over the study period at both high- and low-volume volume hospitals. There remain significant differences in serious complications between the highest and lowest volume hospitals for both stapled and nonstapled procedures.

Fundamentals of Laparoscopic Surgery manual test: is videotaped performance assessment an option?

BACKGROUND

In efforts to maintain standards required to evaluate the high-stakes assessment, Society of American Gastrointestinal and Endoscopic Surgeons Fundamentals of Laparoscopic Surgery (FLS) requires all new proctors to complete the train-the-proctor workshop. As the pool of FLS proctors expands, new methods to streamline training and quality assurance programs should be considered. We propose that videotaped performances of the FLS manual tasks may be an alternative proxy to live assessment for training of new proctors, but evaluation of proctors' measures from videotaped FLS performances is required before implementation.

METHODS

A 2-phased research consisted of capturing newly trained proctors' (n = 20) ratings of 3 similar FLS performances across 3 stations-live (Live), videotaped-laparoscopic only (Lap Only) view, and videotaped-dual (Dual) views, during the 2012 Society of American Gastrointestinal and Endoscopic Surgeons FLS train-the-proctor workshop. A month later, a sample of proctors (n = 9) viewed videotaped versions of live FLS performances originally observed during the workshop. Captured metrics include recognition of a predefined critical error for each task (dichotomously scored and summed) and time to complete each of the 5 tasks. Analysis of variance compared the proctors' summed ratings for similar performances across Live, Lap Only, and Dual views, whereas paired t test compared recorded times of Lap Only vs Dual views, Live vs web ratings, and proctors' recorded times across the Lap Only and Dual views.

RESULTS

There were neither differences in ratings across Live, Lap Only, and Dual views (p = 0.49) nor in recorded times for performances viewed across Lap Only and Dual viewing options (p = 0.29 and 0.76, respectively). Mean summed performance ratings observed live (4.6) were higher than those observed via the web (4.0), although not significant (p = 0.051). There were no differences in recorded times for identical performances across Live and web observations (p = 0.18 and 0.69, respectively), although findings were limited by sample size for some tasks.

CONCLUSIONS

In spite of limitations, favorable results of this preliminary study supports use of videotaped FLS performances for streamlining training mechanisms for FLS proctors, and developing best practices in standard setting and long-term evaluation of the of FLS proctors.

Self-reported remission of obstructive sleep apnea following bariatric surgery: cohort study

BACKGROUND

Evidence on remission of obstructive sleep apnea (OSA) after bariatric surgery and its relation to weight loss is conflicting. We sought to identify factors associated with successful self-reported OSA remission in a large cohort of bariatric surgery patients.

METHODS

We analyzed data from the statewide, prospective clinical registry of the Michigan Bariatric Surgery Collaborative and identified 3,550 patients with OSA who underwent a primary bariatric procedure between June 2006 and October 2011 and had at least 1 year of follow-up data. We used multivariate logistic regression to identify preoperative factors associated with successful self-reported OSA remission, defined as discontinuation of continuous positive airway pressure or bilevel positive airway pressure at 1 year. Our regression model also included procedure type and weight loss at 1 year, divided into equal quintiles, as covariates.

RESULTS

The overall 1-year self-reported OSA remission rate was 60%. Significant predictors of remission included age category (per 10 yr) (OR .73, CI .69-.78), body mass index category (per 10 units) (OR .57, CI .54-.62), male gender (OR .58, CI .52-.69), hypertension (OR .83, CI .74-.99), depression (OR .78, CI .69-.88), pulmonary disease (OR .88, CI .78-.98), and baseline Health and Activities Limitations Index score (OR 1.70, CI 1.32-2.23). Relative to gastric banding, the adjusted odds of OSA remission were greater with gastric bypass (OR 2.38, CI 1.89-3.08), sleeve gastrectomy (OR 2.01, CI 1.44-2.55), and duodenal switch (OR 2.57, CI 1.02-7.26). The odds ratio of OSA remission increased stepwise through quintiles of 1-year weight loss. Relative to the lowest quintile, the odds ratios of remission in the 2(nd) through 5(th) quintiles were 1.44 (CI 1.11-1.84), 2.03 (CI 1.48-2.57), 2.47 (1.85-3.40), and 3.53 (CI 2.56-4.85).

CONCLUSIONS

Weight loss is an important predictor of self-reported OSA remission after bariatric surgery. However, independent of weight loss, there remain significant differences in the likelihood of remission between gastric banding and other bariatric procedures. This suggests that there may be metabolic, weight-independent effects of procedure type on self-reported OSA remission.

Profiling hospitals on bariatric surgery quality: which outcomes are most reliable?

BACKGROUND

Under the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, hospitals will receive risk-adjusted outcomes feedback for peer comparisons and benchmarking. It remains uncertain whether bariatric outcomes have adequate reliability to identify outlying performance, especially for hospitals with low caseloads that will be included in the program. We explored the ability of risk-adjusted outcomes to identify outlying hospital performance with bariatric surgery for a range of hospital caseloads.

STUDY DESIGN

We used the 2010 State Inpatient Databases for 12 states (N = 31,240 patients) to assess different outcomes (eg, complications, reoperation, and mortality) after bariatric stapling procedures. We first quantified outcomes reliability on a 0 (no reliability) to 1 (perfect reliability) scale. We then assessed whether risk- and reliability-adjusted outcomes could identify outlying performance among hospitals with different annual caseloads.

RESULTS

Overall and serious complications had the highest overall reliability, but this was heavily dependent on caseload. For example, among hospitals with the lowest caseloads (mean 56 cases/year), reliability for overall complications was 0.49 and 6.0% of hospitals had outlying performance. For hospitals with the highest caseloads (mean 298 cases/year), reliability for overall complications was 0.79 and 30.3% of hospitals had outlying performance. Reoperation had adequate reliability for hospitals with caseloads higher than 120 cases/year. Mortality had unacceptably low reliability regardless of hospital caseloads.

CONCLUSIONS

Overall complications and serious complications have adequate reliability for distinguishing outlying performance with bariatric surgery, even for hospitals with low annual caseloads. Rare outcomes, such as reoperations, have inadequate reliability to inform peer-based comparisons for hospitals with low annual caseloads, and mortality has unacceptably low reliability for bariatric performance profiling.

Variation in utilization of acid-reducing medication at 1 year following bariatric surgery: results from the Michigan Bariatric Surgery Collaborative

BACKGROUND

Morbidly obese patients undergoing bariatric surgery have high rates of gastroesophageal reflux and are often treated with acid-reducing medications (ARM) such as proton pump inhibitors or H2-blockers. The objective of this study was to evaluate the effect of bariatric procedures on the utilization of ARM. We analyzed data from the clinical registry of the Michigan Bariatric Surgery Collaborative on 35,477 patients undergoing bariatric surgery between January 2006 and October 2012 who completed both baseline and 1-year follow-up surveys. Procedures included laparoscopic adjustable gastric banding (LAGB, n=2,627), Roux-en-Y gastric bypass (RYGB, n=6,410), sleeve gastrectomy (SG, n=1,567), and biliopancreatic diversion with duodenal switch (BPD/DS, n=162).

METHODS

Rates of ARM at 1 year by procedure type were compared using logistic regression analysis. Models were adjusted for patient characteristics, baseline co-morbidities, weight loss, and hiatal hernia repair.

RESULTS

Overall ARM use at baseline was 37.7% and declined to 29.6% at 1 year after bariatric surgery. The proportion of patients starting an ARM at 1 year when they were not using one at baseline by procedure was LAGB (13.9%), RYGB (19.2%), SG (21.6%), and BPD/DS (26.7%). The proportion of patients discontinuing an ARM at 1 year when they were using one at baseline by procedure was LAGB (55.6%), RYGB (56.2%), SG (37.3%), and BPD/DS (42.1%). Compared with LAGB on multivariable analysis, the likelihood of ARM use at 1 year was higher for SG (OR 1.70, 95% CI 1.45-1.99) and BDP/DS (OR 1.53, CI .97-2.40) but not different for RYGB (OR 1.02, CI .90-1.16).

CONCLUSION

Overall ARM use decreases after bariatric surgery; however, it is not uniform and depends on procedure type. SG is a significant predictor for ARM use at 1 year.