Mujjahid Abbas

Safety of laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass in elderly patients – analysis of the MBSAQIP

BACKGROUND An increase in the prevalence of obesity and longer life expectancy has resulted in an increased number of candidates over the age of 60 who are pursuing a bariatric procedure. OBJECTIVE The aim of this study was to assess the safety of laparoscopic Roux-Y gastric bypass (LRYGB) compared to laparoscopic sleeve gastrectomy (LSG) in patients aged 60 years or older. SETTING University Hospital, United States METHODS: Preoperative characteristics and 30-day outcomes from the MBSAQIP 2015 were selected for all patients aged 60 years or older who underwent a LSG or LRYGB. LRYGB cases were closely matched (1:1) with LSG patients by age (±1 year), BMI (±1 kg/m2), gender, preoperative steroid or immunosuppressant use, preoperative functional health status and comorbidities including: diabetes, gastroesophageal reflux disease, hypertension, hyperlipidemia, venous stasis, sleep apnea and history of severe chronic obstructive pulmonary disease. RESULTS A 3371 matched pairs were included in the study. The mean operative time in LRYGB was significantly longer in comparison to LSG patients (122 vs 84 min., P<0.001). Patients after LRYGB had a significantly increased anastomotic leakage rate (1.01% vs 0.47 %, p = 0.011), 30-day readmission rate (6.08% vs 3.74%, p < 0.001) and 30-day reoperation rate (2.49% vs 0.89%, p < 0.001) The length of hospital stay was longer in LRYGB. Mortality and bleed rate was comparable. CONCLUSIONS LRYGB and LSG in patients aged 60 years or older are relatively safe in the short term with an acceptable complication rate and low mortality. However, LRYGB is more challenging and is associated with significantly increased rates of leakage events, 30-day reoperation, 30-day readmission, longer operative time and longer hospital stay.

The educating enigma: Does training level impact postoperative outcome in bariatric surgery?

Background: Bariatric procedures are complex, and the acceptance of complications by the general public is exceedingly low. Using the database of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, outcomes in bariatric surgery were evaluated to determine the effect of trainees. Methods: The following data on postoperative complications for patients undergoing bariatric surgery in 2015 were collected: surgical site infections, sepsis, urinary tract infection, duration of hospital stay, operative time, renal failure, pulmonary embolus, deep vein thrombosis, pneumonia, and re‐operation. These were analyzed against presence and level of trainees, using analysis of variance after normalizing the data. Results: Of 168,093 procedures, 125,078 were performed without trainees, 14,883 were performed with a fellow, and 28,132 were performed with a resident. Cases without trainees were 25% Roux‐en‐Y gastric bypass, 59% sleeve gastrectomy, and 16% other. Cases with fellows were 35% Roux‐en‐Y gastric bypass, 51% sleeve gastrectomy, and 13% other; cases with residents were 27% Roux‐en‐Y gastric bypass, 59% sleeve gastrectomy, and 15% other. Patient demographics were similar. Average operative time differed between groups as follows: without trainees, 85 minutes; with residents, 105 minutes; and with fellows, 117 minutes (P < .001). Although not dramatically so, infections tended to be a bit more likely with fellows (2% vs 1%; P < .001), and the rate of urinary tract infection and hospital stay tended to be greater with either fellows or residents (1% vs 0%; P < .001; 2.0 days vs 2.1 days vs 1.8 days; P < .001, respectively). Conclusion: Fellow involvement resulted in the greatest operative times, and the rate of infections, urinary tract infections, and prolonged hospital stay, although statistically greater, were only mildly increased and of questionable clinical importance. These mild increases in postoperative complications may be attributed to prolonged operating room time.

Application of HARM Score to Measure Surgical Quality and Outcomes in Bariatric Patients

BackgroundThe HospitAl stay, Readmission, and Mortality rates (HARM) score is a quality indicator that is easily determined from routine administrative data. However, the HARM score has not yet been applied to patients undergoing bariatric surgery.ObjectiveThe aims of the present study were to adjust the HARM score to the bariatric population and to validate the ability of the modified HARM score to serve as an inexpensive tool to measure the quality of bariatric surgery.MethodsA MBSAQIP 2015 PUF database was reviewed. For each discharge, a 1 to 10 score was calculated on the basis of length of stay (LOS), discharge status, and 30-day readmissions. We adjusted the LOS categories to the distribution of LOS in the MBSQIP database. The new LOS categories were used to calculate the modified HARM score, referred to as the BARiatric HARM (BAR-HARM) score. The association between HARM and BAR-HARM scores and complication rate was assessed.ResultsA total of 197,141 cases were evaluated: 98.8% were elective and 1.2% were emergent admissions. The mean individual patient BAR-HARM score was 1.75 ± 1.04 for elective cases, and 2.02 ± 1.45 for emergency cases. The complication rates for the respective BAR-HARM categories ≤ 2, > 2 to 3, > 3 to 4, and > 4 were 3.95, 27.53, 40.14, and 79.97% (p < 0.001).ConclusionsThe quality of bariatric surgery can be reliably and validly assessed using the BAR-HARM score, which is a modification of the HARM score.

Internal Hernia and Small Bowel Obstruction After Roux-en-Y Gastric Bypass

Gastric bypass (RYGB) is considered the gold standard for bariatric surgical procedures. Small bowel obstruction (SBO) after gastric bypass is not uncommon; the internal hernia is the most common etiology followed by adhesions.