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Alcohol use, abuse rise after bariatric surgery
ORLANDO –
Following any of several methods of bariatric surgery, patients showed a statistically significant 8% higher rate of new onset alcohol abuse, and a relative 50% increased rate of significant alcohol use, compared with rates before surgery, Prandeet Wander, MD, said at the World Congress of Gastroenterology at ACG 2017.
Her meta-analysis identified prospective, retrospective, and cross-sectional studies of alcohol use that included more than 100 bariatric surgery patients and that had follow-up beyond 1 year. Patients could have undergone Roux-en-Y gastric bypass, sleeve gastrectomy, or laparoscopic adjustable gastric banding. Comparator populations had to be either the surgery patients prior to the procedure or the controls matched by age and body mass index.
The 28 included studies enrolled 15,714 patients who averaged 43 years old, with more than three quarters women. Follow-up averaged 2.6 years. The most common surgery was Roux-en-Y, used in 23 studies, followed by banding in 12 studies, and sleeves in 8 studies (some studies used more than one type of surgery).
Nineteen of the studies examined the prevalence of “significant alcohol abuse” following surgery in a total of 4,552 patients, with 23% of patients overall showing this behavior. Five studies, involving 2,698 patients, documented the rate of new-onset alcohol abuse after surgery, with an overall rate of 8% that was statistically significant. All five studies individually showed increased incidence of alcohol abuse, with rates that ranged from 4% to 8%.
The analysis that showed a relative 50% higher rate of “significant” alcohol use after surgery, compared with the same patients before their surgery used data from 11 studies with 3,370 patients. Five of these 11 studies individually showed a statistically significant increase in alcohol use, 1 showed a significant, 34% relative decrease, and the remaining 5 studies did not show statistically significant changes, with 3 studies trending toward an increased rate and two trending toward a decreased rate after surgery.
None of the 28 included studies had a randomized control arm, and the studies collectively ran in six countries, including the United States, and hence involved different societal norms of alcohol use. Changes in alcohol absorption and metabolism following bariatric surgery may play roles in the observed effects, as might undiagnosed depression or substance use by patients who undergo this surgery, Dr. Wander suggested.
SOURCE: Wander P et al. World Congress of Gastroenterology, abstract 10.
ORLANDO –
Following any of several methods of bariatric surgery, patients showed a statistically significant 8% higher rate of new onset alcohol abuse, and a relative 50% increased rate of significant alcohol use, compared with rates before surgery, Prandeet Wander, MD, said at the World Congress of Gastroenterology at ACG 2017.
Her meta-analysis identified prospective, retrospective, and cross-sectional studies of alcohol use that included more than 100 bariatric surgery patients and that had follow-up beyond 1 year. Patients could have undergone Roux-en-Y gastric bypass, sleeve gastrectomy, or laparoscopic adjustable gastric banding. Comparator populations had to be either the surgery patients prior to the procedure or the controls matched by age and body mass index.
The 28 included studies enrolled 15,714 patients who averaged 43 years old, with more than three quarters women. Follow-up averaged 2.6 years. The most common surgery was Roux-en-Y, used in 23 studies, followed by banding in 12 studies, and sleeves in 8 studies (some studies used more than one type of surgery).
Nineteen of the studies examined the prevalence of “significant alcohol abuse” following surgery in a total of 4,552 patients, with 23% of patients overall showing this behavior. Five studies, involving 2,698 patients, documented the rate of new-onset alcohol abuse after surgery, with an overall rate of 8% that was statistically significant. All five studies individually showed increased incidence of alcohol abuse, with rates that ranged from 4% to 8%.
The analysis that showed a relative 50% higher rate of “significant” alcohol use after surgery, compared with the same patients before their surgery used data from 11 studies with 3,370 patients. Five of these 11 studies individually showed a statistically significant increase in alcohol use, 1 showed a significant, 34% relative decrease, and the remaining 5 studies did not show statistically significant changes, with 3 studies trending toward an increased rate and two trending toward a decreased rate after surgery.
None of the 28 included studies had a randomized control arm, and the studies collectively ran in six countries, including the United States, and hence involved different societal norms of alcohol use. Changes in alcohol absorption and metabolism following bariatric surgery may play roles in the observed effects, as might undiagnosed depression or substance use by patients who undergo this surgery, Dr. Wander suggested.
SOURCE: Wander P et al. World Congress of Gastroenterology, abstract 10.
ORLANDO –
Following any of several methods of bariatric surgery, patients showed a statistically significant 8% higher rate of new onset alcohol abuse, and a relative 50% increased rate of significant alcohol use, compared with rates before surgery, Prandeet Wander, MD, said at the World Congress of Gastroenterology at ACG 2017.
Her meta-analysis identified prospective, retrospective, and cross-sectional studies of alcohol use that included more than 100 bariatric surgery patients and that had follow-up beyond 1 year. Patients could have undergone Roux-en-Y gastric bypass, sleeve gastrectomy, or laparoscopic adjustable gastric banding. Comparator populations had to be either the surgery patients prior to the procedure or the controls matched by age and body mass index.
The 28 included studies enrolled 15,714 patients who averaged 43 years old, with more than three quarters women. Follow-up averaged 2.6 years. The most common surgery was Roux-en-Y, used in 23 studies, followed by banding in 12 studies, and sleeves in 8 studies (some studies used more than one type of surgery).
Nineteen of the studies examined the prevalence of “significant alcohol abuse” following surgery in a total of 4,552 patients, with 23% of patients overall showing this behavior. Five studies, involving 2,698 patients, documented the rate of new-onset alcohol abuse after surgery, with an overall rate of 8% that was statistically significant. All five studies individually showed increased incidence of alcohol abuse, with rates that ranged from 4% to 8%.
The analysis that showed a relative 50% higher rate of “significant” alcohol use after surgery, compared with the same patients before their surgery used data from 11 studies with 3,370 patients. Five of these 11 studies individually showed a statistically significant increase in alcohol use, 1 showed a significant, 34% relative decrease, and the remaining 5 studies did not show statistically significant changes, with 3 studies trending toward an increased rate and two trending toward a decreased rate after surgery.
None of the 28 included studies had a randomized control arm, and the studies collectively ran in six countries, including the United States, and hence involved different societal norms of alcohol use. Changes in alcohol absorption and metabolism following bariatric surgery may play roles in the observed effects, as might undiagnosed depression or substance use by patients who undergo this surgery, Dr. Wander suggested.
SOURCE: Wander P et al. World Congress of Gastroenterology, abstract 10.
REPORTING FROM WORLD CONGRESS OF GASTROENTEROLOGY
Key clinical point: Following bariatric surgery patients have increased alcohol use and abuse.
Major finding: Alcohol abuse rose by 8%; significant alcohol use rose by a relative 50%.
Study details: Meta-analysis of 28 reports with 15,714 patients
Disclosures: Dr. Wander had no disclosures.
Source: Wander P et al. World Congress of Gastroenterology, abstract 10.
Hispanics trail blacks, whites in bariatric surgery rates
SAN DIEGO – A study of procedures at academic centers provides evidence that obese Hispanics in the United States undergo bariatric surgery at a much lower rate than whites and blacks. It also reveals marked regional variations in overall weight-loss surgery.
“Our findings do suggest that severely obese Hispanics are utilizing bariatric surgery much lower than other ethnic groups,” said study coauthor Ninh T. Nguyen, MD, FACS, chair of the department of surgery at the University of California Irvine Medical Center, in an interview. “Our research does not specifically address the reasons for this gap in the delivery of care. Further research will need to be done to understand the reasons and the ways to close this gap.”
According to Dr. Nguyen, the researchers undertook the study to better understand how bariatric surgery is delivered across ethnicities and geographic regions in the United States.
The researchers analyzed statistics from the Vizient health care performance database for the years 2013-2015. They focused on patients at about 120 academic centers who underwent 73,119 laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and laparoscopic adjustable gastric banding procedures. The patients were stratified by race and region.
Researchers found that bariatric procedures were performed at a much higher rate in the Northeast academic centers (2.21 per 1,000 obese persons), compared with the Midwest (0.73), South (0.50), and West (0.33).
In regard to race, the rates for blacks and whites were fairly similar in the Northwest (2.02 and 2.35 bariatric procedures per 1,000 obese persons, respectively), the South (0.59 and 0.63, respectively) and the West (0.45 and 0.43, respectively). There was a wider gap in the Midwest, with whites at 0.69 and blacks at 1.07.
Across the country, however, obese Hispanics were less likely than persons of the other two races to undergo weight-loss surgery. The gap was fairly small in the Northeast, where 1.74 per 1,000 obese Hispanics underwent weight-loss surgery, compared with rates of 2.02 and 2.35 among whites and blacks, respectively. But the disparity was much larger in the other parts of the country, with rates at 0.14 in the West, 0.11 in the South and 0.33 in the Midwest, compared with rates from 0.43 to 1.07 among blacks and whites.
The reasons for the surgery gap are unknown. Dr. Nguyen pointed to several possible explanations: “lack of education of obesity as a disease by the primary care providers and the need for referral to a bariatric surgeon for patients with body mass index greater than 40 kg/m2 or 35 kg/m2 with obesity-related comorbidities; poor understanding of the benefits of bariatric surgery and its low risk; lack of understanding of the urgency for treatment by the patient and provider; and hurdles in obtaining coverage for the operation by insurers.”
John Magaña Morton, MD, FACS, chief of bariatric and minimally invasive surgery at Stanford (Calif.) University School of Medicine and past president of the American Society for Metabolic and Bariatric Surgery, doesn’t think discrimination is causing the disparity.
“It’s probably a reflection of insurance status – Hispanics tend to be less insured than Caucasian or African American patients – as well as preference for patients to go to nonacademic centers,” he said.
Indeed, a Kaiser Family Foundation analysis found that 21% of the 52 million Hispanics younger than 65 years in the United States were uninsured in 2015, compared with 9% of whites and 13% of blacks. Only Native Americans/Alaska Natives had an uninsured rate as high as Hispanics.
“In terms of need [for weight-loss features], it’s certainly there for Hispanics,” said Dr. Morton. “[Hispanic patients] have high rates of obesity and diabetes, both of which are helped by bariatric surgery.”
He said about 40% of patients in his Palo Alto, Calif., practice are Hispanic, reflecting the high number in the local population.
It helps that Dr. Morton and several of his partners speak Spanish. “If you have a welcoming environment,” he said, “that can make a difference.”
The study authors and Dr. Morton report no relevant disclosures. No specific study funding is reported.
SAN DIEGO – A study of procedures at academic centers provides evidence that obese Hispanics in the United States undergo bariatric surgery at a much lower rate than whites and blacks. It also reveals marked regional variations in overall weight-loss surgery.
“Our findings do suggest that severely obese Hispanics are utilizing bariatric surgery much lower than other ethnic groups,” said study coauthor Ninh T. Nguyen, MD, FACS, chair of the department of surgery at the University of California Irvine Medical Center, in an interview. “Our research does not specifically address the reasons for this gap in the delivery of care. Further research will need to be done to understand the reasons and the ways to close this gap.”
According to Dr. Nguyen, the researchers undertook the study to better understand how bariatric surgery is delivered across ethnicities and geographic regions in the United States.
The researchers analyzed statistics from the Vizient health care performance database for the years 2013-2015. They focused on patients at about 120 academic centers who underwent 73,119 laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and laparoscopic adjustable gastric banding procedures. The patients were stratified by race and region.
Researchers found that bariatric procedures were performed at a much higher rate in the Northeast academic centers (2.21 per 1,000 obese persons), compared with the Midwest (0.73), South (0.50), and West (0.33).
In regard to race, the rates for blacks and whites were fairly similar in the Northwest (2.02 and 2.35 bariatric procedures per 1,000 obese persons, respectively), the South (0.59 and 0.63, respectively) and the West (0.45 and 0.43, respectively). There was a wider gap in the Midwest, with whites at 0.69 and blacks at 1.07.
Across the country, however, obese Hispanics were less likely than persons of the other two races to undergo weight-loss surgery. The gap was fairly small in the Northeast, where 1.74 per 1,000 obese Hispanics underwent weight-loss surgery, compared with rates of 2.02 and 2.35 among whites and blacks, respectively. But the disparity was much larger in the other parts of the country, with rates at 0.14 in the West, 0.11 in the South and 0.33 in the Midwest, compared with rates from 0.43 to 1.07 among blacks and whites.
The reasons for the surgery gap are unknown. Dr. Nguyen pointed to several possible explanations: “lack of education of obesity as a disease by the primary care providers and the need for referral to a bariatric surgeon for patients with body mass index greater than 40 kg/m2 or 35 kg/m2 with obesity-related comorbidities; poor understanding of the benefits of bariatric surgery and its low risk; lack of understanding of the urgency for treatment by the patient and provider; and hurdles in obtaining coverage for the operation by insurers.”
John Magaña Morton, MD, FACS, chief of bariatric and minimally invasive surgery at Stanford (Calif.) University School of Medicine and past president of the American Society for Metabolic and Bariatric Surgery, doesn’t think discrimination is causing the disparity.
“It’s probably a reflection of insurance status – Hispanics tend to be less insured than Caucasian or African American patients – as well as preference for patients to go to nonacademic centers,” he said.
Indeed, a Kaiser Family Foundation analysis found that 21% of the 52 million Hispanics younger than 65 years in the United States were uninsured in 2015, compared with 9% of whites and 13% of blacks. Only Native Americans/Alaska Natives had an uninsured rate as high as Hispanics.
“In terms of need [for weight-loss features], it’s certainly there for Hispanics,” said Dr. Morton. “[Hispanic patients] have high rates of obesity and diabetes, both of which are helped by bariatric surgery.”
He said about 40% of patients in his Palo Alto, Calif., practice are Hispanic, reflecting the high number in the local population.
It helps that Dr. Morton and several of his partners speak Spanish. “If you have a welcoming environment,” he said, “that can make a difference.”
The study authors and Dr. Morton report no relevant disclosures. No specific study funding is reported.
SAN DIEGO – A study of procedures at academic centers provides evidence that obese Hispanics in the United States undergo bariatric surgery at a much lower rate than whites and blacks. It also reveals marked regional variations in overall weight-loss surgery.
“Our findings do suggest that severely obese Hispanics are utilizing bariatric surgery much lower than other ethnic groups,” said study coauthor Ninh T. Nguyen, MD, FACS, chair of the department of surgery at the University of California Irvine Medical Center, in an interview. “Our research does not specifically address the reasons for this gap in the delivery of care. Further research will need to be done to understand the reasons and the ways to close this gap.”
According to Dr. Nguyen, the researchers undertook the study to better understand how bariatric surgery is delivered across ethnicities and geographic regions in the United States.
The researchers analyzed statistics from the Vizient health care performance database for the years 2013-2015. They focused on patients at about 120 academic centers who underwent 73,119 laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and laparoscopic adjustable gastric banding procedures. The patients were stratified by race and region.
Researchers found that bariatric procedures were performed at a much higher rate in the Northeast academic centers (2.21 per 1,000 obese persons), compared with the Midwest (0.73), South (0.50), and West (0.33).
In regard to race, the rates for blacks and whites were fairly similar in the Northwest (2.02 and 2.35 bariatric procedures per 1,000 obese persons, respectively), the South (0.59 and 0.63, respectively) and the West (0.45 and 0.43, respectively). There was a wider gap in the Midwest, with whites at 0.69 and blacks at 1.07.
Across the country, however, obese Hispanics were less likely than persons of the other two races to undergo weight-loss surgery. The gap was fairly small in the Northeast, where 1.74 per 1,000 obese Hispanics underwent weight-loss surgery, compared with rates of 2.02 and 2.35 among whites and blacks, respectively. But the disparity was much larger in the other parts of the country, with rates at 0.14 in the West, 0.11 in the South and 0.33 in the Midwest, compared with rates from 0.43 to 1.07 among blacks and whites.
The reasons for the surgery gap are unknown. Dr. Nguyen pointed to several possible explanations: “lack of education of obesity as a disease by the primary care providers and the need for referral to a bariatric surgeon for patients with body mass index greater than 40 kg/m2 or 35 kg/m2 with obesity-related comorbidities; poor understanding of the benefits of bariatric surgery and its low risk; lack of understanding of the urgency for treatment by the patient and provider; and hurdles in obtaining coverage for the operation by insurers.”
John Magaña Morton, MD, FACS, chief of bariatric and minimally invasive surgery at Stanford (Calif.) University School of Medicine and past president of the American Society for Metabolic and Bariatric Surgery, doesn’t think discrimination is causing the disparity.
“It’s probably a reflection of insurance status – Hispanics tend to be less insured than Caucasian or African American patients – as well as preference for patients to go to nonacademic centers,” he said.
Indeed, a Kaiser Family Foundation analysis found that 21% of the 52 million Hispanics younger than 65 years in the United States were uninsured in 2015, compared with 9% of whites and 13% of blacks. Only Native Americans/Alaska Natives had an uninsured rate as high as Hispanics.
“In terms of need [for weight-loss features], it’s certainly there for Hispanics,” said Dr. Morton. “[Hispanic patients] have high rates of obesity and diabetes, both of which are helped by bariatric surgery.”
He said about 40% of patients in his Palo Alto, Calif., practice are Hispanic, reflecting the high number in the local population.
It helps that Dr. Morton and several of his partners speak Spanish. “If you have a welcoming environment,” he said, “that can make a difference.”
The study authors and Dr. Morton report no relevant disclosures. No specific study funding is reported.
AT THE ACS CLINICAL CONGRESS
Key clinical point: At academic centers, obese Hispanics undergo bariatric surgery at a much lower rate than blacks and whites. U.S. regions outside the Northeast have lower rates of weight-loss procedures overall.
Major finding: Outside the Northeast, the bariatric surgery rate per 1,000 obese people is much lower for Hispanics (range, 0.11-0.33) than for blacks and whites (range, 0.43-1.07).
Data source: Analysis of 73,119 bariatric procedures from 2013-2015 at about 120 academic centers.
Disclosures: The study authors report no relevant disclosures. No specific study funding is reported.
In bariatric surgery, leak test may backfire
SCOTTSDALE, ARIZ. – A test used to detect anastomotic leaks during bariatric surgery may in fact be a potential cause of leaks, since performance of the test was associated with double the frequency of 30-day postoperative leaks, a study showed.
Based on this finding from an analysis of the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, the researchers suggested that the use of an endoscope could lead to fewer complications.
The test itself is valuable, since surgeons hope to find and repair a leak immediately, but Dr. Nguyen said the wrong method is being used. “The technique of doing the test should be endoscopy rather than the use of an orogastric tube,” he said. The database did not indicate which technique was being used, but Dr. Nguyen said that use of endoscopy is rare. Surgeons “don’t want to break scrub to go around and perform the endoscopy. It’s easier to ask the anesthesiologist to put a tube down,” said Dr. Nguyen, who is chair of surgery at University of California Irvine Medical Center.
The study, which was presented at the annual meeting of the Western Surgical Association, is the first to look at intraoperative and postoperative procedures and risk of leaks during bariatric surgery, and was possible only because of the recent availability of the MBSAQIP database. The study cannot prove causation between performance of the provocative test and heightened leak risk, and one audience member suggested the possibility that the tests were ordered when a surgeon believed the patient was at higher risk. If so, the association wouldn’t be causative.
However, the provocation test was performed 82% of the time, suggesting that the test was being carried out routinely, said Dr. Nguyen.
By contrast, when the surgeon inserted a surgical drain, the risk of leak was nearly four times higher. “It is most likely that the surgeon only decided to place the drain because they were worried about that particular operation, since it was only done a small percentage of the time. Our results suggest that they were right [to be concerned]. We believe it’s a reflection of the knowledge of the surgeon for that particular case,” said Dr. Nguyen.
If indeed there is a risk associated with the provocation test, the use of endoscopy could reduce that risk. Dr. Nguyen also pointed out that endoscopy provides anatomical detail that can help guide revision surgery, and it’s a useful training exercise for residents. “This is an important skill that you need when you graduate from general surgery,” said Dr. Nguyen.
The researchers analyzed data from 133,478 patients who underwent laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB), excluding emergent and revisional cases; 69.3% of patients underwent LSG, while 30.7% underwent LRYGB. The researchers looked at the association between leak frequency and the presence of the provocative test, surgical drain, and swallow study.
The 30-day leak rate was 0.7% overall, and 0.5% in LSG and 1.2% in LRYGB (adjusted odds ratio for LSG, 0.52; 95% confidence interval, 0.44-0.61; P less than .001). The rate was higher in the 81.9% of patients who received the provocative test than in those who did not (0.8% vs. 0.4%; aOR, 1.41; 95% CI, 1.14-1.76; P = .02). The leak risk was also higher in the 24.5% of patients who had a drain placed (1.6% vs. 0.4%; aOR, 3.46; 95% CI, 3.01-3.98; P less than .001).
A total of 41.1% of patients received a swallow study, but their leak rate (0.7%) was identical to that of those who did not have a swallow study.
The study received no outside funding. Dr. Nguyen reported having no relevant financial disclosures.
SCOTTSDALE, ARIZ. – A test used to detect anastomotic leaks during bariatric surgery may in fact be a potential cause of leaks, since performance of the test was associated with double the frequency of 30-day postoperative leaks, a study showed.
Based on this finding from an analysis of the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, the researchers suggested that the use of an endoscope could lead to fewer complications.
The test itself is valuable, since surgeons hope to find and repair a leak immediately, but Dr. Nguyen said the wrong method is being used. “The technique of doing the test should be endoscopy rather than the use of an orogastric tube,” he said. The database did not indicate which technique was being used, but Dr. Nguyen said that use of endoscopy is rare. Surgeons “don’t want to break scrub to go around and perform the endoscopy. It’s easier to ask the anesthesiologist to put a tube down,” said Dr. Nguyen, who is chair of surgery at University of California Irvine Medical Center.
The study, which was presented at the annual meeting of the Western Surgical Association, is the first to look at intraoperative and postoperative procedures and risk of leaks during bariatric surgery, and was possible only because of the recent availability of the MBSAQIP database. The study cannot prove causation between performance of the provocative test and heightened leak risk, and one audience member suggested the possibility that the tests were ordered when a surgeon believed the patient was at higher risk. If so, the association wouldn’t be causative.
However, the provocation test was performed 82% of the time, suggesting that the test was being carried out routinely, said Dr. Nguyen.
By contrast, when the surgeon inserted a surgical drain, the risk of leak was nearly four times higher. “It is most likely that the surgeon only decided to place the drain because they were worried about that particular operation, since it was only done a small percentage of the time. Our results suggest that they were right [to be concerned]. We believe it’s a reflection of the knowledge of the surgeon for that particular case,” said Dr. Nguyen.
If indeed there is a risk associated with the provocation test, the use of endoscopy could reduce that risk. Dr. Nguyen also pointed out that endoscopy provides anatomical detail that can help guide revision surgery, and it’s a useful training exercise for residents. “This is an important skill that you need when you graduate from general surgery,” said Dr. Nguyen.
The researchers analyzed data from 133,478 patients who underwent laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB), excluding emergent and revisional cases; 69.3% of patients underwent LSG, while 30.7% underwent LRYGB. The researchers looked at the association between leak frequency and the presence of the provocative test, surgical drain, and swallow study.
The 30-day leak rate was 0.7% overall, and 0.5% in LSG and 1.2% in LRYGB (adjusted odds ratio for LSG, 0.52; 95% confidence interval, 0.44-0.61; P less than .001). The rate was higher in the 81.9% of patients who received the provocative test than in those who did not (0.8% vs. 0.4%; aOR, 1.41; 95% CI, 1.14-1.76; P = .02). The leak risk was also higher in the 24.5% of patients who had a drain placed (1.6% vs. 0.4%; aOR, 3.46; 95% CI, 3.01-3.98; P less than .001).
A total of 41.1% of patients received a swallow study, but their leak rate (0.7%) was identical to that of those who did not have a swallow study.
The study received no outside funding. Dr. Nguyen reported having no relevant financial disclosures.
SCOTTSDALE, ARIZ. – A test used to detect anastomotic leaks during bariatric surgery may in fact be a potential cause of leaks, since performance of the test was associated with double the frequency of 30-day postoperative leaks, a study showed.
Based on this finding from an analysis of the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, the researchers suggested that the use of an endoscope could lead to fewer complications.
The test itself is valuable, since surgeons hope to find and repair a leak immediately, but Dr. Nguyen said the wrong method is being used. “The technique of doing the test should be endoscopy rather than the use of an orogastric tube,” he said. The database did not indicate which technique was being used, but Dr. Nguyen said that use of endoscopy is rare. Surgeons “don’t want to break scrub to go around and perform the endoscopy. It’s easier to ask the anesthesiologist to put a tube down,” said Dr. Nguyen, who is chair of surgery at University of California Irvine Medical Center.
The study, which was presented at the annual meeting of the Western Surgical Association, is the first to look at intraoperative and postoperative procedures and risk of leaks during bariatric surgery, and was possible only because of the recent availability of the MBSAQIP database. The study cannot prove causation between performance of the provocative test and heightened leak risk, and one audience member suggested the possibility that the tests were ordered when a surgeon believed the patient was at higher risk. If so, the association wouldn’t be causative.
However, the provocation test was performed 82% of the time, suggesting that the test was being carried out routinely, said Dr. Nguyen.
By contrast, when the surgeon inserted a surgical drain, the risk of leak was nearly four times higher. “It is most likely that the surgeon only decided to place the drain because they were worried about that particular operation, since it was only done a small percentage of the time. Our results suggest that they were right [to be concerned]. We believe it’s a reflection of the knowledge of the surgeon for that particular case,” said Dr. Nguyen.
If indeed there is a risk associated with the provocation test, the use of endoscopy could reduce that risk. Dr. Nguyen also pointed out that endoscopy provides anatomical detail that can help guide revision surgery, and it’s a useful training exercise for residents. “This is an important skill that you need when you graduate from general surgery,” said Dr. Nguyen.
The researchers analyzed data from 133,478 patients who underwent laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB), excluding emergent and revisional cases; 69.3% of patients underwent LSG, while 30.7% underwent LRYGB. The researchers looked at the association between leak frequency and the presence of the provocative test, surgical drain, and swallow study.
The 30-day leak rate was 0.7% overall, and 0.5% in LSG and 1.2% in LRYGB (adjusted odds ratio for LSG, 0.52; 95% confidence interval, 0.44-0.61; P less than .001). The rate was higher in the 81.9% of patients who received the provocative test than in those who did not (0.8% vs. 0.4%; aOR, 1.41; 95% CI, 1.14-1.76; P = .02). The leak risk was also higher in the 24.5% of patients who had a drain placed (1.6% vs. 0.4%; aOR, 3.46; 95% CI, 3.01-3.98; P less than .001).
A total of 41.1% of patients received a swallow study, but their leak rate (0.7%) was identical to that of those who did not have a swallow study.
The study received no outside funding. Dr. Nguyen reported having no relevant financial disclosures.
AT WSA 2017
Key clinical point: Use of endoscopy to perform the provocative test may reduce the incidence of anastomotic leaks.
Major finding: The rate of leaks was 0.8% in patients who had the provocative test, compared with 0.4% in patients who didn’t have the test.
Data source: A retrospective analysis of 133,478 procedures.
Disclosures: The study received no outside funding. Dr. Nguyen reported having no relevant financial disclosures.
VIDEO: Bariatric experts discuss recent experience with gastric balloon devices
Two experts on bariatric surgery spoke at the Minimally Invasive Surgery Symposium, held in Las Vegas. Jaime Ponce, MD, FACS, and John Morton, MD, FACS, discussed several different types of gastric balloon devices and the factors guiding their use for patients. Dr. Morton suggested that the balloon devices could serve as an intermediate treatment between medications and surgery.
Two experts on bariatric surgery spoke at the Minimally Invasive Surgery Symposium, held in Las Vegas. Jaime Ponce, MD, FACS, and John Morton, MD, FACS, discussed several different types of gastric balloon devices and the factors guiding their use for patients. Dr. Morton suggested that the balloon devices could serve as an intermediate treatment between medications and surgery.
Two experts on bariatric surgery spoke at the Minimally Invasive Surgery Symposium, held in Las Vegas. Jaime Ponce, MD, FACS, and John Morton, MD, FACS, discussed several different types of gastric balloon devices and the factors guiding their use for patients. Dr. Morton suggested that the balloon devices could serve as an intermediate treatment between medications and surgery.
Large database analysis suggests safety of bariatric surgery in seniors
NATIONAL HARBOR, MD. – despite a slight increase in unadjusted mortality rates, according to an analysis of data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).
Based on data that was collected in 2015 and submitted to MBSAQIP, “bariatric surgery is safe in the elderly, even in those 70 years old and older,” reported Tallal Zeni, MD, director of the Michigan Bariatric Institute in Livonia.
There were 16,568 patients older than age 60 years entered into the MBSAQIP database in 2015. When those were compared with the 117,443 younger patients, the unadjusted rates of morbidity (6.5% vs. 6.0%) and mortality (0.3% vs. 0.1%) were higher for the older patients, but “they are close,” according to Dr. Zeni. Both rates reached significance by the conventional definition (P < .05), but he suggested that they are lower in this study than those in prior studies of MBSAQIP datasets and that they are acceptable relative to the anticipated health benefits.
Above the age of 60 years, no correlation could be made between increasing age and increasing risk of morbidity, mortality, or rate of reoperations, according to Dr. Zeni.
Why should bariatric surgery be considered in older patients? He cited data from a study that showed the life expectancy in a 70-year-old without functional limitations is 13 years. As a result, he added, “it behooves us to provide them with the best quality of life we can.”
Relative to prior MBSAQIP evaluations of bariatric surgery in the elderly, the proportion of patients undergoing sleeve gastrectomy relative to gastric bypass has been increasing, Dr. Zeni reported. In the analysis, approximately two-thirds of the bariatric procedures were performed with sleeve gastrectomy, which is higher relative to what previous MBSAQIP analyses have shown.
Based on rates of morbidity for those two surgical approaches in the analysis, that trend makes sense. While the higher 30-day mortality for gastric bypass, compared with sleeve gastrectomy, was not significant (0.38% vs. 0.26%; P = .221), all-cause morbidity was almost two times greater for those undergoing gastric bypass than it was for those undergoing sleeve gastrectomy (10.61% vs. 5.81%; P < .001), Dr. Zeni reported.
However, some of that difference may be explained by baseline disparities between the two groups. In the gastric bypass group, there were higher rates of preoperative diabetes (54% vs. 40%; P < .001), sleep apnea (57% vs. 50%; P < .001) and hyperlipidemia (59% vs. 54%; P < .001). Also, gastric bypass patients were more likely to have a history of a previous bariatric procedure (11% vs. 8.5%; P < .001) and to be in the American Society of Anesthesiologists Physical Status score of 3 (84% vs. 80%; P < .001), according to Dr. Zeni.
The specific complications more common in the gastric bypass group than the sleeve gastrectomy group included anastomotic leak (0.56% vs. 0.3%; P = .017), surgical site infection (1.74% vs. 0.61%; P < .001), pneumonia (0.87% vs. 0.32%; P < .001), and bleeding (1.14% vs. 0.5%; P = .024). Although the average operating time was 40 minutes longer in the bypass group, there were no significant differences in thromboembolic complications.
Overall, despite a modest increase in the risk of complications for bariatric surgery in elderly patients, that risk can be considered acceptable in relation to the potential health benefits, according to Dr. Zeni. He suggested that the data might encourage further growth in the rates of bariatric procedures among patients older than 60 years.
Dr. Zeni reports no relevant financial relationships.
NATIONAL HARBOR, MD. – despite a slight increase in unadjusted mortality rates, according to an analysis of data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).
Based on data that was collected in 2015 and submitted to MBSAQIP, “bariatric surgery is safe in the elderly, even in those 70 years old and older,” reported Tallal Zeni, MD, director of the Michigan Bariatric Institute in Livonia.
There were 16,568 patients older than age 60 years entered into the MBSAQIP database in 2015. When those were compared with the 117,443 younger patients, the unadjusted rates of morbidity (6.5% vs. 6.0%) and mortality (0.3% vs. 0.1%) were higher for the older patients, but “they are close,” according to Dr. Zeni. Both rates reached significance by the conventional definition (P < .05), but he suggested that they are lower in this study than those in prior studies of MBSAQIP datasets and that they are acceptable relative to the anticipated health benefits.
Above the age of 60 years, no correlation could be made between increasing age and increasing risk of morbidity, mortality, or rate of reoperations, according to Dr. Zeni.
Why should bariatric surgery be considered in older patients? He cited data from a study that showed the life expectancy in a 70-year-old without functional limitations is 13 years. As a result, he added, “it behooves us to provide them with the best quality of life we can.”
Relative to prior MBSAQIP evaluations of bariatric surgery in the elderly, the proportion of patients undergoing sleeve gastrectomy relative to gastric bypass has been increasing, Dr. Zeni reported. In the analysis, approximately two-thirds of the bariatric procedures were performed with sleeve gastrectomy, which is higher relative to what previous MBSAQIP analyses have shown.
Based on rates of morbidity for those two surgical approaches in the analysis, that trend makes sense. While the higher 30-day mortality for gastric bypass, compared with sleeve gastrectomy, was not significant (0.38% vs. 0.26%; P = .221), all-cause morbidity was almost two times greater for those undergoing gastric bypass than it was for those undergoing sleeve gastrectomy (10.61% vs. 5.81%; P < .001), Dr. Zeni reported.
However, some of that difference may be explained by baseline disparities between the two groups. In the gastric bypass group, there were higher rates of preoperative diabetes (54% vs. 40%; P < .001), sleep apnea (57% vs. 50%; P < .001) and hyperlipidemia (59% vs. 54%; P < .001). Also, gastric bypass patients were more likely to have a history of a previous bariatric procedure (11% vs. 8.5%; P < .001) and to be in the American Society of Anesthesiologists Physical Status score of 3 (84% vs. 80%; P < .001), according to Dr. Zeni.
The specific complications more common in the gastric bypass group than the sleeve gastrectomy group included anastomotic leak (0.56% vs. 0.3%; P = .017), surgical site infection (1.74% vs. 0.61%; P < .001), pneumonia (0.87% vs. 0.32%; P < .001), and bleeding (1.14% vs. 0.5%; P = .024). Although the average operating time was 40 minutes longer in the bypass group, there were no significant differences in thromboembolic complications.
Overall, despite a modest increase in the risk of complications for bariatric surgery in elderly patients, that risk can be considered acceptable in relation to the potential health benefits, according to Dr. Zeni. He suggested that the data might encourage further growth in the rates of bariatric procedures among patients older than 60 years.
Dr. Zeni reports no relevant financial relationships.
NATIONAL HARBOR, MD. – despite a slight increase in unadjusted mortality rates, according to an analysis of data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).
Based on data that was collected in 2015 and submitted to MBSAQIP, “bariatric surgery is safe in the elderly, even in those 70 years old and older,” reported Tallal Zeni, MD, director of the Michigan Bariatric Institute in Livonia.
There were 16,568 patients older than age 60 years entered into the MBSAQIP database in 2015. When those were compared with the 117,443 younger patients, the unadjusted rates of morbidity (6.5% vs. 6.0%) and mortality (0.3% vs. 0.1%) were higher for the older patients, but “they are close,” according to Dr. Zeni. Both rates reached significance by the conventional definition (P < .05), but he suggested that they are lower in this study than those in prior studies of MBSAQIP datasets and that they are acceptable relative to the anticipated health benefits.
Above the age of 60 years, no correlation could be made between increasing age and increasing risk of morbidity, mortality, or rate of reoperations, according to Dr. Zeni.
Why should bariatric surgery be considered in older patients? He cited data from a study that showed the life expectancy in a 70-year-old without functional limitations is 13 years. As a result, he added, “it behooves us to provide them with the best quality of life we can.”
Relative to prior MBSAQIP evaluations of bariatric surgery in the elderly, the proportion of patients undergoing sleeve gastrectomy relative to gastric bypass has been increasing, Dr. Zeni reported. In the analysis, approximately two-thirds of the bariatric procedures were performed with sleeve gastrectomy, which is higher relative to what previous MBSAQIP analyses have shown.
Based on rates of morbidity for those two surgical approaches in the analysis, that trend makes sense. While the higher 30-day mortality for gastric bypass, compared with sleeve gastrectomy, was not significant (0.38% vs. 0.26%; P = .221), all-cause morbidity was almost two times greater for those undergoing gastric bypass than it was for those undergoing sleeve gastrectomy (10.61% vs. 5.81%; P < .001), Dr. Zeni reported.
However, some of that difference may be explained by baseline disparities between the two groups. In the gastric bypass group, there were higher rates of preoperative diabetes (54% vs. 40%; P < .001), sleep apnea (57% vs. 50%; P < .001) and hyperlipidemia (59% vs. 54%; P < .001). Also, gastric bypass patients were more likely to have a history of a previous bariatric procedure (11% vs. 8.5%; P < .001) and to be in the American Society of Anesthesiologists Physical Status score of 3 (84% vs. 80%; P < .001), according to Dr. Zeni.
The specific complications more common in the gastric bypass group than the sleeve gastrectomy group included anastomotic leak (0.56% vs. 0.3%; P = .017), surgical site infection (1.74% vs. 0.61%; P < .001), pneumonia (0.87% vs. 0.32%; P < .001), and bleeding (1.14% vs. 0.5%; P = .024). Although the average operating time was 40 minutes longer in the bypass group, there were no significant differences in thromboembolic complications.
Overall, despite a modest increase in the risk of complications for bariatric surgery in elderly patients, that risk can be considered acceptable in relation to the potential health benefits, according to Dr. Zeni. He suggested that the data might encourage further growth in the rates of bariatric procedures among patients older than 60 years.
Dr. Zeni reports no relevant financial relationships.
AT OBESITY WEEK 2017
Key clinical point: Based on mortality and morbidity rates, bariatric surgery is acceptably safe in patients older than 60 years of age.
Major finding: Compared with patients younger than 60 years, older patients had only modestly increased rates of morbidity (6.5% vs. 6.0%) and mortality (0.3% vs. 0.1%).
Data source: A retrospective database analysis.
Disclosures: Dr. Zeni reports no relevant financial relationships.
VIDEO: MBSAQIP data looks at sleeve gastrectomy outcomes
Surgeon Matthew A. Hutter, MD, FACS, discusses the first report from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) focused on laparoscopic sleeve gastrectomy. The study (Ann Surg. 2016;264[3]:464-73) looked at outcomes, methods, and complications of this procedure based on a database of nearly 190,000 patients, more than 1,600 surgeons, and 720 centers. Dr. Hutter said that is high-quality data that offers surgeons good information on the procedure.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Surgeon Matthew A. Hutter, MD, FACS, discusses the first report from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) focused on laparoscopic sleeve gastrectomy. The study (Ann Surg. 2016;264[3]:464-73) looked at outcomes, methods, and complications of this procedure based on a database of nearly 190,000 patients, more than 1,600 surgeons, and 720 centers. Dr. Hutter said that is high-quality data that offers surgeons good information on the procedure.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Surgeon Matthew A. Hutter, MD, FACS, discusses the first report from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) focused on laparoscopic sleeve gastrectomy. The study (Ann Surg. 2016;264[3]:464-73) looked at outcomes, methods, and complications of this procedure based on a database of nearly 190,000 patients, more than 1,600 surgeons, and 720 centers. Dr. Hutter said that is high-quality data that offers surgeons good information on the procedure.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Gastrectomy mortality risk increased fivefold with same-day discharge
NATIONAL HARBOR, MD. – Laparoscopic sleeve gastrectomy has been associated with low mortality, but the mortality is even lower when it includes overnight observation, according to a national database evaluation.
Among patients discharged on the same day, 30-day mortality was 0.1%, but it fell to 0.02% among patients discharged the following day, according to Colette Inaba, MD, a surgery resident at the University of California, Irvine.*
“Surgeons who are considering same-day discharge in sleeve gastrectomy patients should have a low threshold to admit these patients for overnight observation given our findings,” Dr. Inaba reported at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.
Same-day discharge has been associated with an increased mortality risk in previously published descriptive institutional reviews, but this is the first study to evaluate this question through analysis of a national database, according to Dr. Inaba. It was based on 37,301 laparoscopic sleeve gastrectomy cases performed in 2015 and submitted to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. All participants in this database are accredited bariatric centers.
There were baseline differences between same-day and next-day discharges, but many of these differences conferred the next-day group with higher risk. In particular, the next-day group had significantly higher rates of hypertension, diabetes mellitus, hypercholesterolemia, chronic obstructive pulmonary disease, and sleep apnea. On average, the procedure time was 13 minutes longer in the next-day versus the same-day discharge groups.
In addition to mortality, 30-day morbidity and need for revisions were compared between the two groups, but there were no significant differences between groups in the rates of these outcomes.
Overall, the baseline demographics of the patients in same-day and next-day groups were comparable, according to Dr. Inaba. She described the population as predominantly female and white with an average body mass index of 45 kg/m2. In this analysis, only primary procedures (excluding redos and revisions) were included.
Relative to the next-day discharge cases, a significantly higher percentage of same-day discharge procedures were performed with a surgical tech or another provider rather than a designated first-assist surgeon, according to Dr. Inaba. For next-day cases, a higher percentage was performed with the participation of fellows or surgical residents. There were fewer swallow studies performed before discharge in the same-day discharge group.
Very similar results were generated by a study evaluating same-day discharge after laparoscopic Roux-en-Y gastric bypass, according to John M. Morton, MD, chief of bariatric and minimally invasive surgery, Stanford (Calif.) University. Dr. Morton, first author of the study and moderator of the session in which Dr. Inaba presented the LSG data, reported that same-day discharge in that study was also associated with a trend for an increased risk of serious complications (Ann Surg. 2014;259:286-92).
“Same-day discharge is often reimbursed at a lower rate, so there is less pay and patients are at greater risk of harm,” Dr. Morton said.
The reasons that same-day discharge is associated with higher mortality cannot be derived from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, but, Dr. Inaba said, “Our thought is it is a function of failure to rescue patients from respiratory complications.” She acknowledged that this is a speculative assessment not supported by data, but she suggested that history of sleep apnea might be a particular indication to consider next-day discharge.
Dr. Inaba reports no financial relationships relevant to this topic.
Correction, 12/4/17: An earlier version of this article misstated the 30-day mortality among patients discharged the next day.
NATIONAL HARBOR, MD. – Laparoscopic sleeve gastrectomy has been associated with low mortality, but the mortality is even lower when it includes overnight observation, according to a national database evaluation.
Among patients discharged on the same day, 30-day mortality was 0.1%, but it fell to 0.02% among patients discharged the following day, according to Colette Inaba, MD, a surgery resident at the University of California, Irvine.*
“Surgeons who are considering same-day discharge in sleeve gastrectomy patients should have a low threshold to admit these patients for overnight observation given our findings,” Dr. Inaba reported at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.
Same-day discharge has been associated with an increased mortality risk in previously published descriptive institutional reviews, but this is the first study to evaluate this question through analysis of a national database, according to Dr. Inaba. It was based on 37,301 laparoscopic sleeve gastrectomy cases performed in 2015 and submitted to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. All participants in this database are accredited bariatric centers.
There were baseline differences between same-day and next-day discharges, but many of these differences conferred the next-day group with higher risk. In particular, the next-day group had significantly higher rates of hypertension, diabetes mellitus, hypercholesterolemia, chronic obstructive pulmonary disease, and sleep apnea. On average, the procedure time was 13 minutes longer in the next-day versus the same-day discharge groups.
In addition to mortality, 30-day morbidity and need for revisions were compared between the two groups, but there were no significant differences between groups in the rates of these outcomes.
Overall, the baseline demographics of the patients in same-day and next-day groups were comparable, according to Dr. Inaba. She described the population as predominantly female and white with an average body mass index of 45 kg/m2. In this analysis, only primary procedures (excluding redos and revisions) were included.
Relative to the next-day discharge cases, a significantly higher percentage of same-day discharge procedures were performed with a surgical tech or another provider rather than a designated first-assist surgeon, according to Dr. Inaba. For next-day cases, a higher percentage was performed with the participation of fellows or surgical residents. There were fewer swallow studies performed before discharge in the same-day discharge group.
Very similar results were generated by a study evaluating same-day discharge after laparoscopic Roux-en-Y gastric bypass, according to John M. Morton, MD, chief of bariatric and minimally invasive surgery, Stanford (Calif.) University. Dr. Morton, first author of the study and moderator of the session in which Dr. Inaba presented the LSG data, reported that same-day discharge in that study was also associated with a trend for an increased risk of serious complications (Ann Surg. 2014;259:286-92).
“Same-day discharge is often reimbursed at a lower rate, so there is less pay and patients are at greater risk of harm,” Dr. Morton said.
The reasons that same-day discharge is associated with higher mortality cannot be derived from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, but, Dr. Inaba said, “Our thought is it is a function of failure to rescue patients from respiratory complications.” She acknowledged that this is a speculative assessment not supported by data, but she suggested that history of sleep apnea might be a particular indication to consider next-day discharge.
Dr. Inaba reports no financial relationships relevant to this topic.
Correction, 12/4/17: An earlier version of this article misstated the 30-day mortality among patients discharged the next day.
NATIONAL HARBOR, MD. – Laparoscopic sleeve gastrectomy has been associated with low mortality, but the mortality is even lower when it includes overnight observation, according to a national database evaluation.
Among patients discharged on the same day, 30-day mortality was 0.1%, but it fell to 0.02% among patients discharged the following day, according to Colette Inaba, MD, a surgery resident at the University of California, Irvine.*
“Surgeons who are considering same-day discharge in sleeve gastrectomy patients should have a low threshold to admit these patients for overnight observation given our findings,” Dr. Inaba reported at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.
Same-day discharge has been associated with an increased mortality risk in previously published descriptive institutional reviews, but this is the first study to evaluate this question through analysis of a national database, according to Dr. Inaba. It was based on 37,301 laparoscopic sleeve gastrectomy cases performed in 2015 and submitted to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. All participants in this database are accredited bariatric centers.
There were baseline differences between same-day and next-day discharges, but many of these differences conferred the next-day group with higher risk. In particular, the next-day group had significantly higher rates of hypertension, diabetes mellitus, hypercholesterolemia, chronic obstructive pulmonary disease, and sleep apnea. On average, the procedure time was 13 minutes longer in the next-day versus the same-day discharge groups.
In addition to mortality, 30-day morbidity and need for revisions were compared between the two groups, but there were no significant differences between groups in the rates of these outcomes.
Overall, the baseline demographics of the patients in same-day and next-day groups were comparable, according to Dr. Inaba. She described the population as predominantly female and white with an average body mass index of 45 kg/m2. In this analysis, only primary procedures (excluding redos and revisions) were included.
Relative to the next-day discharge cases, a significantly higher percentage of same-day discharge procedures were performed with a surgical tech or another provider rather than a designated first-assist surgeon, according to Dr. Inaba. For next-day cases, a higher percentage was performed with the participation of fellows or surgical residents. There were fewer swallow studies performed before discharge in the same-day discharge group.
Very similar results were generated by a study evaluating same-day discharge after laparoscopic Roux-en-Y gastric bypass, according to John M. Morton, MD, chief of bariatric and minimally invasive surgery, Stanford (Calif.) University. Dr. Morton, first author of the study and moderator of the session in which Dr. Inaba presented the LSG data, reported that same-day discharge in that study was also associated with a trend for an increased risk of serious complications (Ann Surg. 2014;259:286-92).
“Same-day discharge is often reimbursed at a lower rate, so there is less pay and patients are at greater risk of harm,” Dr. Morton said.
The reasons that same-day discharge is associated with higher mortality cannot be derived from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, but, Dr. Inaba said, “Our thought is it is a function of failure to rescue patients from respiratory complications.” She acknowledged that this is a speculative assessment not supported by data, but she suggested that history of sleep apnea might be a particular indication to consider next-day discharge.
Dr. Inaba reports no financial relationships relevant to this topic.
Correction, 12/4/17: An earlier version of this article misstated the 30-day mortality among patients discharged the next day.
AT OBESITY WEEK 2017
Key clinical point: Thirty-day mortality after laparoscopic sleeve gastrectomy is several times higher with same-day discharge relative to an overnight stay.
Major finding: In an analysis of a national database with more than 35,000 cases, the mortality odds ratio for same-day discharge was 5.7 (P = .032) relative to next-day discharge.
Data source: Retrospective database analysis.
Disclosures: Dr. Inaba reports no financial relationships relevant to this topic.
ED visits after bariatric surgery may be difficult to reduce
NATIONAL HARBOR, MD. – In an evaluation of 633 emergency department visits following bariatric surgery in Michigan over a 1-year period, the vast majority were for complaints amenable to a phone call consultation or treatment in a lower-acuity setting, but few patients would have been satisfied with this type of management, according to an evaluation based on patient interviews presented at Obesity Week 2017.
“Unfortunately, 91% of the patients said that there was nothing the surgical team could have done that would have helped avoid the ED visit,” reported Haley Stevens, quality improvement coordinator at the Michigan Bariatric Surgery Collaborative, University of Michigan, Ann Arbor.
The 633 ED visits followed 7,617 bariatric surgeries for a rate of 8.3%. According to Ms. Stevens, this is consistent with the rates of 5%-11% reported previously. Based on clinically abstracted data and patient interviews conducted by trained nurses in a sample of patients involved in these ED visits, it was estimated that 62% were made without any attempt to first contact the surgical team, she reported at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.
In the interviews, a variety of reasons were offered for not first contacting the surgical team, according to Ms. Stevens. Most commonly, patients reported that a sense of urgency drove them to the ED. In 18% of cases, the complaint occurred after office hours, leading the patient to believe that the ED was the only option. Another 16% of patients reported that calling the surgeon simply did not occur to them.
“When interviewed, many patients considered the visit necessary and unavoidable even after learning subsequently that the symptoms were not serious,” Ms. Stevens reported.
The primary reasons for the ED visit were nausea, vomiting, or abdominal pain, which accounted for 50% of the visits. The next most common reasons were chest pain (8%) and concerns regarding the incision (7%). Only 30% of the ED visits ultimately resulted in a hospital admission, but 60% of the visits resulted in administration of intravenous fluids. Thirty-eight percent of ED visits resulted in oral or intravenous therapy for pain.
Based on the interviews, most patients reported that they visited the ED because they wanted an immediate evaluation of their symptoms, according to Ms. Stevens. She said that the goal in most cases was simply obtaining reassurance. While better patient education about symptoms and recovery might have circumvented patient concerns about nonurgent complaints, Ms. Stevens also suggested that visits to a lower-acuity center, such as an urgent care facility, might provide a lower-cost alternative for reassurance or simple treatments.
As this study represents the first in a series to guide a quality improvement initiative, Ms. Stevens acknowledged that the best solution to reducing unnecessary ED visits is unclear, but she did suggest that multiple strategies might be needed. Based on this and previously published studies evaluating this issue “there is no silver bullet” for reducing ED visits, Ms. Stevens said.
In an animated discussion that followed presentation of these results, others recounting efforts to reduce ED visits following bariatric surgery emphasized the importance of follow-up phone calls or home visits within 2 or 3 days of surgery. According to several of those who commented, these steps allow early identification of problems while providing the type of reassurance that can prevent unnecessary ED visits.
The average cost of an ED visit following bariatric surgery is approximately $1,300, according to Ms. Stevens. For this and other reasons, strategies to reduce ED visits are needed, but Ms. Stevens cautioned that the solutions might not be simple. Based on data from this study, the key may be providing patients with a clear route to the reassurance they need to avoid seeking care for nonurgent issues.
Ms. Stevens reports no financial relationships relevant to this topic.
NATIONAL HARBOR, MD. – In an evaluation of 633 emergency department visits following bariatric surgery in Michigan over a 1-year period, the vast majority were for complaints amenable to a phone call consultation or treatment in a lower-acuity setting, but few patients would have been satisfied with this type of management, according to an evaluation based on patient interviews presented at Obesity Week 2017.
“Unfortunately, 91% of the patients said that there was nothing the surgical team could have done that would have helped avoid the ED visit,” reported Haley Stevens, quality improvement coordinator at the Michigan Bariatric Surgery Collaborative, University of Michigan, Ann Arbor.
The 633 ED visits followed 7,617 bariatric surgeries for a rate of 8.3%. According to Ms. Stevens, this is consistent with the rates of 5%-11% reported previously. Based on clinically abstracted data and patient interviews conducted by trained nurses in a sample of patients involved in these ED visits, it was estimated that 62% were made without any attempt to first contact the surgical team, she reported at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.
In the interviews, a variety of reasons were offered for not first contacting the surgical team, according to Ms. Stevens. Most commonly, patients reported that a sense of urgency drove them to the ED. In 18% of cases, the complaint occurred after office hours, leading the patient to believe that the ED was the only option. Another 16% of patients reported that calling the surgeon simply did not occur to them.
“When interviewed, many patients considered the visit necessary and unavoidable even after learning subsequently that the symptoms were not serious,” Ms. Stevens reported.
The primary reasons for the ED visit were nausea, vomiting, or abdominal pain, which accounted for 50% of the visits. The next most common reasons were chest pain (8%) and concerns regarding the incision (7%). Only 30% of the ED visits ultimately resulted in a hospital admission, but 60% of the visits resulted in administration of intravenous fluids. Thirty-eight percent of ED visits resulted in oral or intravenous therapy for pain.
Based on the interviews, most patients reported that they visited the ED because they wanted an immediate evaluation of their symptoms, according to Ms. Stevens. She said that the goal in most cases was simply obtaining reassurance. While better patient education about symptoms and recovery might have circumvented patient concerns about nonurgent complaints, Ms. Stevens also suggested that visits to a lower-acuity center, such as an urgent care facility, might provide a lower-cost alternative for reassurance or simple treatments.
As this study represents the first in a series to guide a quality improvement initiative, Ms. Stevens acknowledged that the best solution to reducing unnecessary ED visits is unclear, but she did suggest that multiple strategies might be needed. Based on this and previously published studies evaluating this issue “there is no silver bullet” for reducing ED visits, Ms. Stevens said.
In an animated discussion that followed presentation of these results, others recounting efforts to reduce ED visits following bariatric surgery emphasized the importance of follow-up phone calls or home visits within 2 or 3 days of surgery. According to several of those who commented, these steps allow early identification of problems while providing the type of reassurance that can prevent unnecessary ED visits.
The average cost of an ED visit following bariatric surgery is approximately $1,300, according to Ms. Stevens. For this and other reasons, strategies to reduce ED visits are needed, but Ms. Stevens cautioned that the solutions might not be simple. Based on data from this study, the key may be providing patients with a clear route to the reassurance they need to avoid seeking care for nonurgent issues.
Ms. Stevens reports no financial relationships relevant to this topic.
NATIONAL HARBOR, MD. – In an evaluation of 633 emergency department visits following bariatric surgery in Michigan over a 1-year period, the vast majority were for complaints amenable to a phone call consultation or treatment in a lower-acuity setting, but few patients would have been satisfied with this type of management, according to an evaluation based on patient interviews presented at Obesity Week 2017.
“Unfortunately, 91% of the patients said that there was nothing the surgical team could have done that would have helped avoid the ED visit,” reported Haley Stevens, quality improvement coordinator at the Michigan Bariatric Surgery Collaborative, University of Michigan, Ann Arbor.
The 633 ED visits followed 7,617 bariatric surgeries for a rate of 8.3%. According to Ms. Stevens, this is consistent with the rates of 5%-11% reported previously. Based on clinically abstracted data and patient interviews conducted by trained nurses in a sample of patients involved in these ED visits, it was estimated that 62% were made without any attempt to first contact the surgical team, she reported at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.
In the interviews, a variety of reasons were offered for not first contacting the surgical team, according to Ms. Stevens. Most commonly, patients reported that a sense of urgency drove them to the ED. In 18% of cases, the complaint occurred after office hours, leading the patient to believe that the ED was the only option. Another 16% of patients reported that calling the surgeon simply did not occur to them.
“When interviewed, many patients considered the visit necessary and unavoidable even after learning subsequently that the symptoms were not serious,” Ms. Stevens reported.
The primary reasons for the ED visit were nausea, vomiting, or abdominal pain, which accounted for 50% of the visits. The next most common reasons were chest pain (8%) and concerns regarding the incision (7%). Only 30% of the ED visits ultimately resulted in a hospital admission, but 60% of the visits resulted in administration of intravenous fluids. Thirty-eight percent of ED visits resulted in oral or intravenous therapy for pain.
Based on the interviews, most patients reported that they visited the ED because they wanted an immediate evaluation of their symptoms, according to Ms. Stevens. She said that the goal in most cases was simply obtaining reassurance. While better patient education about symptoms and recovery might have circumvented patient concerns about nonurgent complaints, Ms. Stevens also suggested that visits to a lower-acuity center, such as an urgent care facility, might provide a lower-cost alternative for reassurance or simple treatments.
As this study represents the first in a series to guide a quality improvement initiative, Ms. Stevens acknowledged that the best solution to reducing unnecessary ED visits is unclear, but she did suggest that multiple strategies might be needed. Based on this and previously published studies evaluating this issue “there is no silver bullet” for reducing ED visits, Ms. Stevens said.
In an animated discussion that followed presentation of these results, others recounting efforts to reduce ED visits following bariatric surgery emphasized the importance of follow-up phone calls or home visits within 2 or 3 days of surgery. According to several of those who commented, these steps allow early identification of problems while providing the type of reassurance that can prevent unnecessary ED visits.
The average cost of an ED visit following bariatric surgery is approximately $1,300, according to Ms. Stevens. For this and other reasons, strategies to reduce ED visits are needed, but Ms. Stevens cautioned that the solutions might not be simple. Based on data from this study, the key may be providing patients with a clear route to the reassurance they need to avoid seeking care for nonurgent issues.
Ms. Stevens reports no financial relationships relevant to this topic.
AT OBESITY WEEK 2017
Key clinical point:
Major finding: In interviews after their ED visit, 91% of bariatric patients insisted the visit was needed, even when informed it was nonurgent.
Data source: Retrospective review and patient interview.
Disclosures: Ms. Stevens reports no financial relationships relevant to this topic.
Psych evaluation identifies bariatric surgery patients who do less well
NATIONAL HARBOR, MD. – Psychological screening prior to bariatric surgery is not effective for identifying who will do poorly after the procedure, but it can identify patients who are at risk for less weight loss and likely to benefit from additional support, according to one of the largest studies designed to evaluate the predictive accuracy of this screening. The results were presented at Obesity Week 2017.
“Psychological evaluations should not be used to exclude patients, because we do not appear to be very good at predicting who does well,” said Nina E. Boulard, PhD, a psychologist who currently performs preoperative psychological screening of bariatric surgery candidates at Eastern Maine Medical Center, Bangor. Rather, “our evaluations identify those who need to be followed more closely so we can intervene early when patients struggle,” she said at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.
The two primary outcomes of interest were the ability to predict postsurgical mental health issues and the ability to predict difficulty in complying with behavioral changes. Percent excess weight loss (EWL) was also monitored. For mental health screening, the protocol included clinical interviews augmented with standardized testing, such as the Minnesota Multiphasic Personality Inventory-2-Restuctured Form (MMPI-2-RF). Patients were placed into five risk categories: low, low-moderate, moderate, moderate-high, and high.
For compliance, the patient evaluation was based primarily on interviews capturing self-reports of adherence to presurgical dietary and other lifestyle recommendations. Patients were also asked about eating behaviors, such as binge eating, and history of sexual abuse and attention-deficit/hyperactivity disorder and other neurodevelopmental issues.
The psychological screening report is provided to the surgeon, who ultimately decides whether patients go on to surgery. In this analysis, relatively few high-risk patients were included because these patients, such as those with active psychosis, uncontrolled binge eating, or severe depression, were excluded from surgery and therefore did not generate postsurgical follow-up data.
As has been reported by others, Dr. Boulard reported that no single standardized test or clinical variable was an effective predictor of “who will and will not struggle” psychologically after surgery. However, after adjusting for age, gender, presurgery weight, diabetes history, and surgery type, several variables were associated with reduced proportion EWL. These included anxiety (P = .02), ADHD (P = .01), and prior hospitalization of a psychological indication (P less than .05). History of sexual abuse was predictive of reduced percentage EWL 1 year but not 2 years after surgery.
“So, what this tells us is the clinical interpretation of the big picture might be important,” Dr. Boulard commented.
The presurgical psychological screening was not predictive of compliance, a result that Dr. Boulard labeled as “surprising.” She speculated that because weight loss in the first 2 years after bariatric surgery is relatively uniform, longer follow-up, such as 5 years, might be needed to capture the impact of patients predicted to have poor compliance.
Importantly, percent EWL remained high even among patients with risk factors associated with mental health challenges after surgery, according to Dr. Boulard. She stressed that even those with less weight loss “did not do poorly.” Rather, the relative differences in postsurgical weight loss for those who were predicted to struggle versus those who were not was “a matter of degrees.”
While Dr. Boulard acknowledged a prospective study using a standardized psychological screening protocol would be appropriate to validate the findings of this study, the study results have already changed practice at her institution.
“We are following the at-risk patients more closely, so we can intervene quickly if there are issues after surgery,” Dr. Boulard explained. The question raised by this study is, “can we bring them [patients at higher risk] to a higher level of response so they are just as successful” as those without risk factors identified in psychological screening.
Dr. Boulard reports no financial relationships relevant to this topic.
NATIONAL HARBOR, MD. – Psychological screening prior to bariatric surgery is not effective for identifying who will do poorly after the procedure, but it can identify patients who are at risk for less weight loss and likely to benefit from additional support, according to one of the largest studies designed to evaluate the predictive accuracy of this screening. The results were presented at Obesity Week 2017.
“Psychological evaluations should not be used to exclude patients, because we do not appear to be very good at predicting who does well,” said Nina E. Boulard, PhD, a psychologist who currently performs preoperative psychological screening of bariatric surgery candidates at Eastern Maine Medical Center, Bangor. Rather, “our evaluations identify those who need to be followed more closely so we can intervene early when patients struggle,” she said at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.
The two primary outcomes of interest were the ability to predict postsurgical mental health issues and the ability to predict difficulty in complying with behavioral changes. Percent excess weight loss (EWL) was also monitored. For mental health screening, the protocol included clinical interviews augmented with standardized testing, such as the Minnesota Multiphasic Personality Inventory-2-Restuctured Form (MMPI-2-RF). Patients were placed into five risk categories: low, low-moderate, moderate, moderate-high, and high.
For compliance, the patient evaluation was based primarily on interviews capturing self-reports of adherence to presurgical dietary and other lifestyle recommendations. Patients were also asked about eating behaviors, such as binge eating, and history of sexual abuse and attention-deficit/hyperactivity disorder and other neurodevelopmental issues.
The psychological screening report is provided to the surgeon, who ultimately decides whether patients go on to surgery. In this analysis, relatively few high-risk patients were included because these patients, such as those with active psychosis, uncontrolled binge eating, or severe depression, were excluded from surgery and therefore did not generate postsurgical follow-up data.
As has been reported by others, Dr. Boulard reported that no single standardized test or clinical variable was an effective predictor of “who will and will not struggle” psychologically after surgery. However, after adjusting for age, gender, presurgery weight, diabetes history, and surgery type, several variables were associated with reduced proportion EWL. These included anxiety (P = .02), ADHD (P = .01), and prior hospitalization of a psychological indication (P less than .05). History of sexual abuse was predictive of reduced percentage EWL 1 year but not 2 years after surgery.
“So, what this tells us is the clinical interpretation of the big picture might be important,” Dr. Boulard commented.
The presurgical psychological screening was not predictive of compliance, a result that Dr. Boulard labeled as “surprising.” She speculated that because weight loss in the first 2 years after bariatric surgery is relatively uniform, longer follow-up, such as 5 years, might be needed to capture the impact of patients predicted to have poor compliance.
Importantly, percent EWL remained high even among patients with risk factors associated with mental health challenges after surgery, according to Dr. Boulard. She stressed that even those with less weight loss “did not do poorly.” Rather, the relative differences in postsurgical weight loss for those who were predicted to struggle versus those who were not was “a matter of degrees.”
While Dr. Boulard acknowledged a prospective study using a standardized psychological screening protocol would be appropriate to validate the findings of this study, the study results have already changed practice at her institution.
“We are following the at-risk patients more closely, so we can intervene quickly if there are issues after surgery,” Dr. Boulard explained. The question raised by this study is, “can we bring them [patients at higher risk] to a higher level of response so they are just as successful” as those without risk factors identified in psychological screening.
Dr. Boulard reports no financial relationships relevant to this topic.
NATIONAL HARBOR, MD. – Psychological screening prior to bariatric surgery is not effective for identifying who will do poorly after the procedure, but it can identify patients who are at risk for less weight loss and likely to benefit from additional support, according to one of the largest studies designed to evaluate the predictive accuracy of this screening. The results were presented at Obesity Week 2017.
“Psychological evaluations should not be used to exclude patients, because we do not appear to be very good at predicting who does well,” said Nina E. Boulard, PhD, a psychologist who currently performs preoperative psychological screening of bariatric surgery candidates at Eastern Maine Medical Center, Bangor. Rather, “our evaluations identify those who need to be followed more closely so we can intervene early when patients struggle,” she said at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.
The two primary outcomes of interest were the ability to predict postsurgical mental health issues and the ability to predict difficulty in complying with behavioral changes. Percent excess weight loss (EWL) was also monitored. For mental health screening, the protocol included clinical interviews augmented with standardized testing, such as the Minnesota Multiphasic Personality Inventory-2-Restuctured Form (MMPI-2-RF). Patients were placed into five risk categories: low, low-moderate, moderate, moderate-high, and high.
For compliance, the patient evaluation was based primarily on interviews capturing self-reports of adherence to presurgical dietary and other lifestyle recommendations. Patients were also asked about eating behaviors, such as binge eating, and history of sexual abuse and attention-deficit/hyperactivity disorder and other neurodevelopmental issues.
The psychological screening report is provided to the surgeon, who ultimately decides whether patients go on to surgery. In this analysis, relatively few high-risk patients were included because these patients, such as those with active psychosis, uncontrolled binge eating, or severe depression, were excluded from surgery and therefore did not generate postsurgical follow-up data.
As has been reported by others, Dr. Boulard reported that no single standardized test or clinical variable was an effective predictor of “who will and will not struggle” psychologically after surgery. However, after adjusting for age, gender, presurgery weight, diabetes history, and surgery type, several variables were associated with reduced proportion EWL. These included anxiety (P = .02), ADHD (P = .01), and prior hospitalization of a psychological indication (P less than .05). History of sexual abuse was predictive of reduced percentage EWL 1 year but not 2 years after surgery.
“So, what this tells us is the clinical interpretation of the big picture might be important,” Dr. Boulard commented.
The presurgical psychological screening was not predictive of compliance, a result that Dr. Boulard labeled as “surprising.” She speculated that because weight loss in the first 2 years after bariatric surgery is relatively uniform, longer follow-up, such as 5 years, might be needed to capture the impact of patients predicted to have poor compliance.
Importantly, percent EWL remained high even among patients with risk factors associated with mental health challenges after surgery, according to Dr. Boulard. She stressed that even those with less weight loss “did not do poorly.” Rather, the relative differences in postsurgical weight loss for those who were predicted to struggle versus those who were not was “a matter of degrees.”
While Dr. Boulard acknowledged a prospective study using a standardized psychological screening protocol would be appropriate to validate the findings of this study, the study results have already changed practice at her institution.
“We are following the at-risk patients more closely, so we can intervene quickly if there are issues after surgery,” Dr. Boulard explained. The question raised by this study is, “can we bring them [patients at higher risk] to a higher level of response so they are just as successful” as those without risk factors identified in psychological screening.
Dr. Boulard reports no financial relationships relevant to this topic.
AT OBESITY WEEK 2017
Key clinical point: Psychological screening prior to bariatric surgery selects patients at risk for reduced postoperative weight loss.
Major finding: Prior psychological hospitalization (P less than .05) and number of previous psychological diagnoses (P = .04) are among markers of less postop weight loss.
Data source: Retrospective analysis.
Disclosures: Dr. Boulard reports no financial relationships relevant to this topic.