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Study Roundup

Published in September Issue             

Association of Centers for Medicare & Medicaid Services Overall Hospital Quality Star Rating With Outcomes in Advanced Laparoscopic Abdominal Surgery   (JAMA Surgery)

Observational study examined whether CMS high-star (4-5 stars) hospitals (HSHs) have improved patient outcomes and resource utilization in advanced laparoscopic abdominal surgery, including bariatric surgery, compared with low-star (1-2 stars) hospitals (LSHs). Findings reveal HSHs have similar outcomes to LSHs for advanced laparoscopic abdominal operations. However, HSHs may represent hospitals with improved resource use and cost. The University HealthSystem Consortium database was used to compare outcomes of 72,662 advanced laparoscopic abdominal operations from
January 1, 2013, through December 31, 2015 between HSHs and LSHs [66 HSHs (n = 38,299);
78 LSHs (n = 34,363). Patients who underwent advanced laparoscopic abdominal surgery, including sleeve gastrectomy, gastric bypass, colorectal surgery or hiatal hernia surgery, were included. The HSHs were observed to have fewer intensive care unit admissions (1007 [2.6%] vs 1711 [5.0%]) and lower mean cost ($7866 vs $8708). No significant difference was found in mortality between HSHs and LSHs for any advanced laparoscopic abdominal surgery. No significant difference was found in serious morbidity between HSHs and LSHs for bariatric surgery. However, HSHs may represent hospitals with improved resource use and cost.

Ten-year Outcomes of a Prospective Randomized Trial of Laparoscopic Gastric Bypass Versus Laparoscopic Gastric Banding (Annals of Surgery)

Study examined long-term weight loss, morbidity, and changes in comorbidities and quality of life after bariatric surgery. Between 2002 and 2007, 111 patients with a BMI of 35 to 60 kg/m2 were randomly assigned to undergo laparoscopic gastric bypass or laparoscopic gastric banding. At 10-year follow-up, the mean total body weight loss for the entire cohort was -37.5 kg, -42.4 kg for gastric bypass and -27.4 kg for gastric banding. Late reoperation was significantly higher after gastric banding compared with the gastric bypass group
(31.4% vs. 8.1%, respectively). For the entire cohort, improvement or remission of diabetes occurred in 68%; 61% for hypertension; and 57% for dyslipidemia. The long-term mortality for the entire cohort was 1.0% at a mean follow-up of 9.5 years. Factors predictive of improved weight loss included the type of operation (i.e. gastric bypass), sex (i.e. female) and the absence of diabetes at the time of surgery. Quality of life continued to be improved from the time of surgery for both the groups. Compared with gastric banding, the findings show that gastric bypass was associated with better long-term weight loss, lower rate of late reoperation, and improved remission of comorbidities.

All-Cause and Specific-Cause Mortality Risk After Roux-en-Y Gastric Bypass in Patients With and Without Diabetes (Diabetes Care)

Study compared all-cause and specific-cause mortality after Roux-en-Y gastric bypass in 3,242 patient to 2,428 matched control subjects (n = 625 with diabetes and n = 1,803 without diabetes). Patients were identified using data from electronic health records from January 2004 to December 2015 and stratified by diabetes status (with vs. without). Median postoperative follow-up was 5.8 years for patients with diabetes and 6.7 years for patients without diabetes. All-cause mortality was reduced in gastric bypass patients compared with control subjects only for those with diabetes at the time of surgery. Mortality was not significantly improved in RYGB patients without diabetes compared with control subjects without diabetes. Deaths from cardiovascular diseases, respiratory conditions, and diabetes were more frequent in control subjects with diabetes than in gastric bypass patients with diabetes. Gastric bypass patients without diabetes were less likely to die of cancer and respiratory diseases than control subjects without diabetes, but were at higher risk of death from external causes, including intentional self-harm, than control subjects without diabetes.

Reduced Risk of Acute Exacerbation of COPD After Bariatric Surgery (Chest)

Using a population-based emergency department (ED) and inpatient sample from three US states (California, Florida, and Nebraska), a self-controlled case series study of 481 adults with obesity and COPD who underwent bariatric surgery examined the impact of weight reduction on COPD-related outcomes finding the risk of an ED visit or hospitalization for acute exacerbation of COPD (AECOPD) substantially decreased after bariatric surgery. Each patient’s risk of an ED visit or hospitalization for AECOPD was compared during a sequential 12-month period before and after surgery as well as pre-surgery and post-surgery months
13 through 24. During the 13 to 24 months before bariatric surgery, 28% of patients had an ED visit or hospitalization for AECOPD. In the subsequent 12-month pre-surgery period, the risk did not change substantially (31%). By contrast, during the first 12 months after bariatric surgery, the risk declined significantly (12%). Likewise, in the subsequent period of 13 to 24 months after bariatric surgery, the risk remained significantly low (13%).

Outcomes of Two-Step Revisional Bariatric Surgery: Reasons for the Gastric Banding Explantation Matter (Obesity Surgery)

Retrospective cohort study examined whether the reason for gastric band explantation would influence percentage excess weight loss (%EWL) at 10 months then 1 and 2 years following revisional Roux-en-Y gastric bypass or sleeve gastrectomy. Revisional surgeries were performed from January 2012 to March 2017 in a two-step manner (first surgery gastric band explantation and second surgery gastric bypass or sleeve gastrectomy). Cohort included 171 patients—146 women (85.4%) and 25 men, median age 51 years. Band-related complications accounted for 55% of explantations and 45% related to failed weight loss. Overall, 95 patients (56%) underwent a revisional gastric bypass, and 76 patients underwent a revisional sleeve gastrectomy. There was no difference in morbidity between the two groups (sleeve 2.6% vs. bypass 4.2%). Patients undergoing revisional gastric bypass for failed weight loss had a significantly lower %EWL at 2 years compared to patients undergoing a sleeve gastrectomy for failed weight loss or a gastric bypass for band-related complications. Patients undergoing revisional gastric bypass following band explantation for failed weight loss had a significantly lower %EWL at 2 years compared to patients undergoing a sleeve gastrectomy for failed weight loss or a gastric bypass for band-related complications.

Roux-En-Y Gastric Bypass in Type 2 Diabetes Patients with Mild Obesity: a Systematic Review and Meta-Analysis (Obesity Surgery)

Study evaluates the effectiveness of only Roux-en-Y gastric bypass in patients with type 2 diabetes and BMI of 30–40 kg/m2 using a literature search for randomized clinical trials, which resulted in identification of five studies. The main outcome was diabetes remission. Secondary outcomes were metabolic effect of gastric bypass, such as hypertension and dyslipidemia. The studies included a larger proportion of women, and the average time of diabetes duration ranged between 6 and 10 years with 43.3% of the patients having a BMI below 35 kg/m2. Baseline demographics such as age, HbA1c and duration of diabetes were less favorable in the surgical group. At the longest follow-up, gastric bypass significantly improves total and partial type 2 remission (OR 17.48 and OR 20.71, respectively). HbA1c also reduces at longest follow-up in the surgery group (- 1.83). Strong evidence suggests gastric bypass improves metabolic outcomes for at least 5 years in patients with class I obesity.

Predictors of Long-Term Remission and Relapse of Type 2 Diabetes Mellitus Following Gastric Bypass in Severely Obese Patients (Obesity Surgery)

Study investigated factors associated with long-term (>=3 years) remission and relapse of type 2 diabetes after bariatric surgery. Retrospective analysis of data from 254 patients with type 2 diabetes who had undergone Roux-en-Y gastric bypass from May 2000 to November 2011 and had at least 3 years of follow-up. The criteria for remission and relapse of type 2 diabetes followed the current American Diabetes Association recommendations. Remission was achieved in almost 82% of participants (69.7% complete, 12.2% partial). Of these,
12% relapsed within a mean follow-up of 5.1 years after surgery. Predictors of complete remission were younger age, better preoperative glycemic control, and shorter diabetes duration. Preoperative insulin use was associated with a ninefold increase in the relapse hazard. Use of two or more oral anti-diabetic agents increased the relapse hazard sixfold. Proportion of patients that did not achieve any remission during follow-up was 18.1%, however, these patients still exhibited significant improvements in glycemic control. Data suggests gastric bypass should not be delayed when remission of type 2 diabetes is a therapeutic goal, and best possible metabolic control should be sought in patients with obesity who may eventually be candidates for gastric bypass.

Clinical Significance of Failure to Lose Weight 10 Years Following Roux-en-Y Gastric Bypass (SOARD)

Study identified clinical implications of 10-year weight-loss failure, defined as <=0% reduction in excess BMI (%REBMI), following Roux-en-Y gastric bypass (1985-2004). Analyses also compared comorbidity rates and resolution by weight-loss classification. Of the 1,087 patients included, complete follow-up was available for 617 (57%) with a 10-year median %REBMI of 57.1% and 10.2% of patients had weight-loss failure. Prevalence of all comorbidities decreased, even in patients with weight loss failure. Compared to patients with successful weight loss, patients with weight loss failure had similar rates of resolution of preexisting comorbidities, except for reduced resolution of apnea and cardiac comorbidities. Risk factors for weight loss failure included lower BMI, non-governmental insurance, longer travel time to hospital, and year of surgery. Non-governmental insurance conferred the highest adjusted odds of weight loss failure. Data suggests the vast majority of patients experience dramatic health improvement 10 years after gastric bypass, even though some patients fail to maintain their weight loss.

Long-Term Weight Loss in Laparoscopic Sleeve Gastrectomy (SOARD)

A retrospective series of patients who underwent LSG between 2008 and 2011 was examined to determine weight loss results of sleeve gastrectomy up to 7 years following surgery. Of the 148 patients included, 76.3% were female and mean preoperative BMI for all patients was 36 kg/m2. Follow-up at 5, 6, and 7 years was 77.7%, 83.3%, and 82.2%, respectively. Mean percentage of excess weight loss (%EWL) and percentage of total weight loss (%TWL) at
1, 3, 5, and 7 years was 93.2%, 80.7%, 70.6%, and 51.7%, and 27.2%, 23.3%, 20.4%, and 16.3%, respectively. The failure rate was 30.4% at the fifth year and 51.4% at the seventh year. High preoperative BMI was related to worse %EWL, but not to %TWL. Preoperative BMI less than 35 kg/m2 was associated with better %EWL, but not with %TWL.

Single Stage Conversion from Adjustable Gastric Banding to Sleeve Gastrectomy or
Roux-en-Y Gastric Bypass

Study compared early safety of sleeve gastrectomy and gastric bypass when performed as single-stage conversion procedures at the time of adjustable gastric banding (AGB) removal. Using the Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program, 4,865 patients were identified that had undergone a single-stage AGB conversion to sleeve gastrectomy (69.1%) or gastric bypass (30.9%). The 30-day reoperation (1.6% vs. 2.7%), readmission (4% vs. 5.7%), reintervention (1.7% vs. 2.7%) and overall morbidity (2.9% vs. 6.5%) were significantly less common in the sleeve gastrectomy group. After controlling for baseline characteristics, gastric bypass was independently associated with higher overall
30-day reoperation (OR 1.81), readmission (OR 1.42), reintervention (OR 1.59) and overall morbidity (OR 2.17). Findings show patients undergoing gastric bypass as a single-stage conversion experience higher complication rates and the need for additional early procedures compared with sleeve gastrectomy.