Bariatric Surgery Practice Research Articles

Result of a National Audit of Bariatric Surgery Performed at Academic Centers

Bariatric surgery performed at US academic centers is safe and associated with low mortality. Multi-institutional consecutive cohort study. Academic medical centers. We audited the medical records from 40 consecutive bariatric surgery cases performed between October 1, 2003, and March 31, 2004, at each of the 29 institutions participating in the University HealthSystem Consortium Bariatric Surgery Benchmarking Project. All medical records that met inclusion criteria (patient age, >17 and <65 years; and body mass index [calculated as weight in kilograms divided by the square of height in meters], 35-70) and exclusion criteria (previous bariatric surgery) were reviewed and data were collected on a standardized form. Demographic data, operative time, blood loss, transfusion requirement, complications, readmission, reoperation, and in-hospital and 30-day mortality. Data from 1144 bariatric surgery cases were reviewed from 29 University HealthSystem Consortium institutions. The specific bariatric procedures included gastric bypass (91.7%), gastroplasty or gastric banding (8.2%), and biliopancreatic diversion (0.1%). For gastric bypass procedures (n = 1049), the mean patient age was 43 years and mean body mass index was 49; 76% of procedures were performed laparoscopically, with a conversion rate of 2.2%; the overall complication rate was 16%, with an anastomotic leakage rate of 1.6%; the 30-day readmission rate was 6.6%; and the 30-day mortality rate was 0.4%. For restrictive procedures (n = 94), the mean patient age was 45 years and mean body mass index was 45; 92% of procedures were performed laparoscopically with no conversion; the overall complication rate was 3.2%; the 30-day readmission rate was 4.3%; and the 30-day mortality rate was 0%. Within the context of the 2004 University HealthSystem Consortium Bariatric Surgery Benchmarking Project, the risk for death within 30 days after bariatric surgery at academic centers is less than 1%. In addition, the practice of bariatric surgery at these centers has shifted from open surgery to predominately laparoscopic surgery. These quality-controlled outcome data can be used as a benchmark for the practice of bariatric surgery at most US hospitals.

The Practice of Bariatric Surgery at Academic Medical Centers

The Practice of Bariatric Surgery at Academic Medical Centers

Propuesta y fundamentos para una norma de manejo quirúrgico del paciente obeso: Año 2004

Obesity is a chronic disease with an increasing prevalence in all groups of age, and is associated to increased general mortality and cardiovascular risk. The multidisciplinary non surgical approach must be the treatment of choice for obese subjects. However, the results of such approach among subjects with severe or morbid obesity, are unsatisfactory. In this group of patients, bariatric surgery and specifically gastric bypass achieves good long term results, maintaining a low body mass index, reducing complications and improving quality of life. Considering the widespread practice of bariatric surgery in Chile, the Nutrition Unit of the Ministry of Health formed a task force to propose update guidelines for the surgical treatment of obesity. These guidelines were proposed after a thorough literature review and discussion with groups that practice bariatric surgery using defined protocols. This document provides a summarized version of the guidelines. The first section discusses the background for bariatric surgery and the second part give specific recommendations for patient management and the formation of reference centers for surgical management of obesity.

Article Commentary: Bariatric Surgery: Malpractice Risks and Risk Management Guidelines

Providing appropriate medical care to bariatric surgery patients is the primary goal of every surgeon. However, with the expected growth of bariatric surgery in the future, the number of claims in this area are certain to grow. Therefore, it is important for surgeons who are engaged in the practice of bariatric surgery or who are contemplating entering the practice of bariatric surgery to consider risk management guidelines and principles very carefully. It is important to follow the available guidelines and criteria like those established by the American Society of Bariatric Surgery to help reduce the risk of liability. Despite appropriate care and treatment, unfortunately, these patients will continue to suffer complications, some of which are life-threatening. The importance of establishing and maintaining a solid physician-patient relationship by using appropriate interpersonal skills cannot be overemphasized. Indeed, a good relationship with the patient and family remains the most effective way of reducing the risk of being sued when there is an unfortunate complication, as well as increasing the chances of a successful defense in the event of suit.

La chirurgie de l'obésité en France : résultats d'une enquête prospective nationale

Aim. – To compare the actual practice of Bairatric surgery in France with the guidelines of scientific societies regarding surgical indications and followup. Methods. – This a prospective descriptive transversal study performed within a two month period (December 2002 – January 2003) in all patients for which a consent demand has been sent to the Medical Insurance Services (examined by an administrative consultant) and/or patients operated on for morbid obesity (with or without administrative sonsent). Results. – One thousand (and) three patients have been examined by an administrative consultant before obesity surgery and 1238 patients have been operated in 263 centres including 79 public (non-profit) centres and 184 private centres. In 16.7 % of the cases, there were wrong indications according to recognized criteria (BMI < 35 kg/m 2 or lack of comorbidities for BMI between 35 and 39) or even contraindications because of other diseases. Patient informed consent was retrieved in only 54 % of medical files and follow up protocol was done in only 47 % of the cases. Because of several missing data, the practice of bariatric surgery followed the guidelines in only 34 % of cases. In hospital morbidity rate was 5 %. Two patients died postoperatively (mortality rate 0.2 %). Conclusions. – This study demonstrates that the practice of bariatric surgery needs to be improved in France.

The practice of bariatric surgery at academic medical centers

The growing demand for laparoscopic bariatric surgery has led to an increase in the development of new bariatric surgical practices. Proper hospital facilities and an experienced bariatric surgical team are necessary to ensure optimal patient results. We surveyed academic centers participating in the University HealthSystem Consortium to examine the current practice of bariatric surgery. The survey questioned (1) availability of resources and equipment designed for the morbidly obese, (2) accidents, equipment problems, and workers' compensation relating to the care of bariatric surgical patients, (3) credentialing of bariatric surgeons, and (4) suggestions for improvements in the bariatric surgery program. Twenty-five institutions that perform bariatric surgery responded. Although the majority of institutions noted that they had basic bariatric equipment, some organizations did not have facility resources such as high-weight operating room tables and computed tomography scanners or transfer devices. Twenty-eight percent of institutions reported having accidents or equipment problems and 40% of institutions had workers' compensation claims relating to the care of bariatric patients. With regard to credentialing, 60% of institutions required the surgeons to have performed a minimum number of procedures prior to granting privileges. Suggested improvements included the need for more specialized bariatric equipment, enhancement of the education of all members of the bariatric surgical team, and designation of a bariatric physician who would coordinate care. This survey of bariatric surgery practices at academic medical centers demonstrates that the practice of bariatric surgery could be improved with regard to availability of bariatric equipment and resources and credentialing of surgeons.

Who should be doing laparoscopic bariatric surgery?

The training and credentialing of surgeons for laparoscopic bariatric surgery is controversial. We sought to determine if there is an association between surgeons' practice and choice of open or laparoscopic bariatric surgery. Members of the ASBS were surveyed via email. Associations were tested with Cochran-Mantel-Haenszel or Pearson's chi-square. 104/472 members responded; 65% were in private practice; 47% did 1-5 operations/week, 48% offered open procedures only, and 76% undertook gastric bypass. Respondents believe that laparoscopic procedures: should mimic open ones (77%), are safe (63%), should be evaluated by clinical trials (48%), and that expertise in bariatric surgery is more important than laparoscopic experience. 75% believe that courses and preceptorships are important. Regarding laparoscopic operations, surgeons doing only open procedures believe that: 1) the ASBS should be the main credentialing body; 2) surgeons should do > 25 open before laparoscopic ones; and 3) clinical trials are needed (P < 0.02, all). Surgeons with laparoscopic training or practices believe that laparoscopic surgery is safe and effective (P < 0.002). Both laparoscopic and open surgeons believe bariatric surgeons should be the only surgeons doing laparoscopic bariatric procedures (P < 0.008). There is consensus that laparoscopic bariatric surgery should be undertaken only by surgeons with strong interest in bariatric surgery. Laparoscopic bariatric surgeons should incorporate lessons learned from open surgery. Both laparoscopic and open bariatric surgeons should seek added expertise via courses and preceptorships. The skepticism of surgeons with 'open' practices could be addressed by clinical trials. The ASBS should maintain its leadership position and foster emerging technologies.

Is Bariatric Surgery Safe in Academic Centers?

Contemporary outcomes of bariatric surgery are not well defined. Our aim was to document the outcomes of bariatric surgery on the basis of surgeon caseload and affiliation. We analyzed prospectively collected Florida-wide hospital discharge data. Forty-four surgeons undertook bariatric surgery in 933 patients during 1999. The ten surgeons who averaged more than two operations/month undertook 764 operations; 162 (17%) were done by academic surgeons. Complications [14% vs 7% (P = 0.008, chi-square)], length of stay (5 +/- 0.7 vs 4 +/- 0.1 days), and hospital charges (in thousands) ($31 +/- 4.0 vs $24 +/- 0.4) were greater in academic than in community-based centers (P < 0.05, Wilcoxon rank-sum). However, 36 per cent of patients operated upon by academic surgeons had a high Severity Index compared with only 16 per cent of patients operated upon by community-based surgeons (P < 0.001, chi-square). In high-risk patients complications (40% vs 46%), length of stay (7 +/- 1.0 vs 6 +/- 0.4 days), and hospital charges (in thousands) ($42 +/- 6 vs $35 +/- 2) were similar between academic and community-based surgeons. We conclude that outcomes of bariatric surgery in high-risk patients are similar among academic and community-based surgeons. Academic surgeons undertake bariatric surgery in high-risk patients more frequently than community-based surgeons, which underlies their increased complication rate. These prospectively collected data reflect surgical outcomes more accurately than clinical series and will impact our practice of bariatric surgery.

Bariatric Re-operations: Are They Preventable?

Many operations are currently used for morbid obesity, and every procedure appears to have advantages, drawbacks and failures. Re-operation is a part of bariatric surgery practice that is necessary in the event of failure. We analyzed the reasons for failure in the bariatric re-operation group. From June 1998 to April 2000, 17 morbidly obese patients had a bariatric re-operation. Of 203 bariatric operations performed in our institution, 12 patients had a re-operation (5.9%), and 5 patients had their primary procedure performed elsewhere. Mean age was 36.5 +/- 11 years, mean original weight 151.3 +/- 44.3 kg, mean BMI 58.4 +/- 16.9 kg/m2 and mean excess body weight (EBW) 94.4 +/- 43.5 kg. Mean height was 161 +/- 7.7 cm, and 15 patients were female (88.2%). The primary bariatric operation was vertical banded gastroplasty (VBG) in 15 patients (88.2%), Roux-en-Y gastric bypass (RYGBP) in 1 patient (5.9%), and gastric banding in 1 patient (5.9%). Duration since the primary surgery was a mean of 15.6 months (range 1-72 months). Reasons for re-operation were inadequate weight loss (47%) or food intolerance (53%). 11 patients had VBG converted to RYGBP, 1 patient had a gastric banding converted to a BPD, 4 patients had their VBG converted to a gastro-gastrostomy, and 1 patient had a RYGBP staple dehiscence re-stapled. Incidence of bariatric re-operations may be decreased if super-obese patients, older patients, and sweets-consuming individuals undergo RYGBP or BPD as the primary operation rather than VBG or gastric banding. The use of staplers transecting and separating the gastric pouch from the remaining stomach can decrease staple dehiscence.

Resectional gastric bypass in the bariatric surgery practice of a small community hospital

PurposeA bariatric surgery program was initiated at Winn Army Community Hospital using the resectional gastric bypass. This program includes a clinical pathway and obesity support group. We evaluated the bariatric surgery results utilizing the resectional gastric bypass. MethodsWe report the early results on 27 patients with mean age of 34 years (22 to 53), mean weight of 308 lb (245 to 438), and mean body mass index of 50.4 (40 to 61) over 26 months. Patient comorbidities included obesity arthropathy (44%), hypertension (33%), diabetes (22%), and obesity hypoventilation syndrome (7%). Patients were prospectively followed for complications, weight loss, and comorbidities. ResultsEarly minor complication rate was 37%. One early death occurred in a patient with severe comorbidities. Late complications included one case of retained sponge and unsatisfactory weight loss. The mean weight loss is 89.2 pounds (24-175) at ten months mean follow up. This correlates to a mean BMI of 33.5 (22.6-51.5). Patient comorbidities have diminished by 75% for obesity arthropathy, 66% for hypertension, 83% for diabetes, and 100% for obesity hypoventilation syndrome. ConclusionsA military community hospital can develop a successful bariatric surgery program. Appropriately selected patients can expect a significant decrease in body mass index and resolution of comorbidities.

Meralgia paresthetica following bariatric surgery.

Two papers in the literature have described meralgia paresthetica following bariatric surgery. One author ascribed the cause of the condition to pressure from an abdominal retractor. We encountered 11 similar cases in our bariatric surgery practice, but do not use the retractor previously invoked as the cause of the problem. It seems likely that some other factor is involved. Retrospective chart review. 11 patients were identified whose symptoms and clinical findings were consistent with meralgia paresthetica. There were 6 men and 5 women. Symptoms developed immediately following surgery in 8 cases, and resolved spontaneously within 3 months in 6 of these. Multiple causes have been described for meralgia paresthetica. It appears to be more common in obese patients. While extrinsic pressure from an abdominal retractor may play a role in some cases, other factors are clearly involved in the cases reported here.

Controversies in bariatric surgery — An overview

Background: Bariatric surgery, like many other fields of surgery, is developmental. As each field matures, certain practitioners have developed different combinations and permutations of existing procedures. With time, these may be adopted, excluded or, in turn, become subject to additional development. Methods: A selection of 15 of the many controversies which currently exist in bariatric surgery are stated, followed by a brief description of the different positions taken on each issue. Results and Conclusions: We conclude that an important part of the future of the practice of bariatric surgery lies within the types of resolutions, if any which may be found for these controversies.

Folate Status Following Gastric Bypass Surgery (The Great Folate Mystery).

Several previous investigators have reported an incidence of folic acid deficiency following gastric bypass surgery of up to 38%. Failure to encounter any folic acid deficiencies in our postoperative patients led us to discontinue follow-up folate studies for several years. However, due to repeated references to this deficiency in the literature, we re-instituted folate studies as part of the routine follow-up of our patients. Preoperative serum folate levels were obtained in 1,067 patients and preexisting deficiencies found in 63, an incidence of 6%. Of the 588 folate levels determined 1 to 10 years following gastric bypass, only six were less than 3.0 ng/di, an incidence of 1%. All patients were instructed preoperatively and postoperatively to take multivitamin/mineral supplements after gastric restrictive surgery, and were continually educated on their importance. In a bariatric surgery practice in which patients are instructed, reminded, encouraged and even badgered into taking postoperative vitamin/mineral supplements, folate deficiency should be a rarity. In such circumstances, folate deficiency may well act as a sensitive marker of non-compliance.