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Operative Time as a Marker of Quality in Bariatric Surgery
S16
Scientific Forum Abstracts
Laparoscopic Approach to Abdominal Surgery Has Favorable Impact on Postoperative Respiratory Complications Independent of Surgeon Experience Thomas H Shin, PhD, Maira I Rudolph, Vicki Sein, MD, Sara M Burns, Megan B Zhang, Timothy Houle, PhD, Matthias Eikermann, MD, PhD Massachusetts General Hospital, Boston, MA INTRODUCTION: Use of laparoscopic surgery has significantly expanded over recent years, given its reduced rates of surgical trauma, postoperative pain, and recovery times. Although many studies have examined the potential association of pulmonary complications with pneumoperitoneum during laparoscopy, there are limited data investigating this relationship while accounting for surgical provider familiarity with laparoscopy. METHODS: There were 11,589 adult abdominal operations at a tertiary care hospital and 2 affiliated community hospitals analyzed using logistic regression or truncated negative binominal regression, respectively, to evaluate the effect of laparoscopic approach on patientcentered outcomes. To ascertain the robustness of these findings, we performed stratification analysis adjusted for a propensity score generated by an a priori set of covariates covering demographics, patient comorbidities, provider variables, and intraoperative complications. RESULTS: Adjusted analysis revealed lower rates of postoperative respiratory complications (OR 0.74, 95% CI 0.58e0.95, p ¼ 0.017), 30-day readmissions (OR 0.70, 95% CI 0.56e0.88, p ¼ 0.002), length of hospital stay (IRR 0.76, CI 0.73e0.79, p < 0.001), and medical cost (IRR 0.87, 95% CI 0.85e0.89, p < 0.001) in laparoscopic vs open abdominal procedures. Propensity score-based analysis revealed, while a surgeon’s previous number of laparoscopy influences one’s probability of receiving laparoscopic surgery, laparoscopic approaches have lesser odds of postoperative respiratory complications (OR 0.76, 95% CI 0.60e0.97, p ¼ 0.026) after controlling for variability of surgeon laparoscopy experience. These reduced odds are successively less with each subsequent propensity score quintile. CONCLUSIONS: Our findings revealed that although surgical provider familiarity may affect the likelihood of laparoscopy, laparoscopic abdominal surgery is associated with favorable postoperative respiratory outcomes compared with open surgery. Lower Utilization of Bariatric Surgery by Hispanic Americans in the United States Christina Koh, MD, Colette S Inaba, MD, Sarath Sujatha-Bhaskar, MD, Ninh T Nguyen, MD, FACS, FASMBS University of California, Irvine, Orange, CA INTRODUCTION: The objective of this study was to examine the regional variation in utilization of bariatric surgery for minorities at academic centers. METHODS: Patients with a primary diagnosis of obesity, who underwent laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y
J Am Coll Surg
gastric bypass, or laparoscopic adjustable gastric banding were selected from the University HealthSystem Consortium database (2013e2015). The 4 regional divisions, as defined by the U.S. Census Bureau, were used. The Center for Disease Control and Prevention data were utilized to estimate obesity rates for each region by race. RESULTS: There were 73,119 laparoscopic bariatric surgery procedures performed. During the study period, the number of procedures performed per 1,000 obese patients was highest in the Northeast (2.21), followed by the Midwest (0.73), the South (0.5), and the West (0.33). Blacks had higher utilization of bariatric surgery in each of the 4 regions compared with the proportion of obese blacks within each region. Whites had lower utilization of bariatric surgery compared with the proportion of obese whites in the Northeast (by 8.9%) and Midwest (by 6.1%). Hispanics had lower utilization of bariatric surgery compared with the proportion of obese Hispanics in each of the 4 regions by 21.3% in the Northeast, 55.1% in the Midwest, 79.1% in the South, and 57% in the West. CONCLUSIONS: There is regional variation in utilization of bariatric surgery at academic centers, with the highest utilization in the Northeast and lowest in the West. There is also a racial disparity in delivery of bariatric surgery with Hispanics having the lowest utilization in all regions.
Operative Time as a Marker of Quality in Bariatric Surgery Colette S Inaba, MD, Christina Koh, MD, Sarath Sujatha-Bhaskar, MD, Shea Gallagher, Yanjun Chen, Ninh T Nguyen, MD, FACS, FASMBS University of California, Irvine, Orange, CA INTRODUCTION: Prolonged operative time (OT) has been associated with increased morbidity, but no study has assessed the effect of OT on outcomes up to a year after bariatric surgery. The purpose of this study was to determine the effect of OT on morbidity and mortality up to 1 year after laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). METHODS: Using the American Society of Metabolic and Bariatric Surgery (ASMBS) Database, data were analyzed for LRYGB and LSG cases from 2008 to 2012. Cases with concurrent procedures were excluded. Multivariate logistic regression was used to assess the association between OT and morbidity and mortality after LRYBG and LSG, adjusting for preoperative demographic and clinical characteristics. RESULTS: We examined 93,051 cases, including 74,745 LRYGB (80.3%) and 18,306 LSG (19.7%). For LRYGB, median OT was 102 (IQR 75e135) minutes. Every additional 30 minutes of OT was associated with increased odds of 30-day leak (AOR 1.26, p < 0.0001), 1-year leak (AOR 1.24, p < 0.0001), 30-day mortality (AOR 1.15, p ¼ 0.0326), and 1-year mortality (AOR 1.12, p ¼ 0.0279). For LSG, median OT was 86 (IQR 58e103) minutes. Every additional 30 minutes of OT was associated with increased
Vol. 225, No. 4S1, October 2017
CONCLUSIONS: Increased OT is associated with a significantly increased risk of leak and mortality after LRYGB, and increased risk of leak after LSG. Operative time may be used as a marker for quality in bariatric surgery. Pathologic High-Resolution Manometry Findings Are Not Necessarily Associated with Inferior Outcomes after Paraesophageal Hernia Repair Andrea Wirsching, MD, Qing Zhang, MD, PhD, Susan E McCormick, Michal Hubka, Donald E Low Virginia Mason Medical Center, Seattle, WA INTRODUCTION: Pathologic esophageal pressure topography (pEPT), diagnosed during high-resolution manometry, is found frequently as part of the preoperative evaluation of paraesophageal hernia (PEH) patients. The clinical relevance of these findings is currently largely unknown. METHODS: From 2008 to 2016, 297 patients undergoing PEH repair were prospectively recorded in an IRB-approved database. Preoperative EPT was evaluated by a single, specialized gastroenterologist according to the Chicago classification. Outcomes in patients with pEPT were compared with those from patients with normal motility (NM). RESULTS: pEPT was documented in 108 patients (36.4%). Sex, BMI, comorbidities, size, and orientation of the PEH were similar between pEPT and NM patients. pEPT patients were older (71 vs 68 years, p ¼ 0.03) and had higher American Society of Anesthesiologists (ASA) scores. Partial fundoplication was more commonly done in pEPT patients (9% vs 1%, p ¼ 0.001). Overall complications were similar between pEPT and NM patients, as were the incidence of complications of Clavien-Dindo grade 3A (1% vs 3%). One patient died (0.3%), and readmissions occurred in 1 pEPT and 6 NM patients. In patients with a minimum of 3 months follow-up, incidence of pre- vs postoperative dysphagia in pEPT vs NM patients went from 61% to 4% vs 53% to 12%, regurgitation from 50% to 2% and 62% to 9%. Esophagograms done at a minimum of 3 months postoperatively showed delayed emptying in 2 pEPT and 9 NM patients. CONCLUSIONS: Patients found to have pEPT before surgical repair of PEH showed similar symptomatic improvement compared with patients with NM. Postoperative Disruption of Intestinal Microbiota Composition Attenuates the Metabolic Efficacy of Vertical Sleeve Gastrectomy Cyrus Jahansouz, MD*, Scott Kizy, MD, Christopher Staley, PhD, Daniel B Leslie, MD, FACS, Michael J Sadowsky, PhD, Alexander Khoruts, MD, Sayeed Ikramuddin, MD, FACS University of Minnesota, Minneapolis, MN
S17
INTRODUCTION: Intestinal microbiota play critical roles in energy production and bile acid metabolism. Vertical sleeve gastrectomy (VSG) is a procedure that is among the most successful treatments for obesity and glucose homeostasis, and it influences microbial and bile acid composition through Farnesoid X-receptor (FXR) and Takeda G-protein-coupled receptor (TGR5). It is unknown, however, whether metabolic outcomes after VSG can be altered by manipulating intestinal microbiota. METHODS: Diet-induced obese mice were randomized to VSG or sham operation, with or without antibiotics (fidaxomicin or streptomycin) in drinking water on postoperative days 1 to 4. Fecal samples were collected and characterized before surgery and on postoperative days 7 and 28. Mice were metabolically characterized 4 to 5 weeks after surgery. RESULTS: VSG resulted in weight loss and shifts in intestinal microbiota relative to sham-operated mice. Fidaxomicin or streptomycin exposure after VSG altered intestinal microbiota composition, reduced the relative abundance of known FXR antagonist tauromuricholic acid in portal venous blood, and increased FXR activity in the liver. These alterations were associated with increased adiposity and impaired glucose homeostasis in VSG operated mice that were comparable to those in sham-operated mice (Figure). Importantly, antibiotic exposure did not alter food intake relative to control VSG mice. % Preoperative Weight 120 110
% Preop Weight
odds of 30-day leak (AOR 1.22, p ¼ 0.0002) and 1-year leak (AOR 1.21, p ¼ 0.0002).
Scientific Forum Abstracts
^ *
100
^ *#
^ *#
^ *
90
* p<0.05 b/w controls # p<0.05 b/w Fidaxo ^ p<0.05 b/w VSG @ p<0.05 b/w Sham
80 70 60
VSG Sham Fidaxo VSG Fidaxo Sham
0
7
14
21
28
Days Post-op
CONCLUSIONS: Disruption of postoperative shifts in intestinal microbial composition that affect bile acid metabolism attenuate weight loss and metabolic improvement after VSG. Once disrupted, the microbial composition remains altered and distinct from antibiotic-naı¨ve control VSG mice. Our results implicate intestinal microbiota as an important contributor to metabolic homeostasis and a potentially modifiable target affecting metabolic outcomes after VSG. Racial Disparities in Bariatric Surgery Patients Adam C Sheka, MD, Scott Kizy, MD, Cyrus Jahansouz, MD, Keith Wirth, MD, Jayleen Grams, MD, PhD, Monica Baskin, PhD, Daniel B Leslie, MD, FACS, Sayeed Ikramuddin, MD, FACS University of Minnesota, Minneapolis, MN; University of Alabama, Birmingham, AL INTRODUCTION: The obesity epidemic in the United States disproportionately affects African Americans (AA); AA have a
Scientific Forum Abstracts
Laparoscopic Approach to Abdominal Surgery Has Favorable Impact on Postoperative Respiratory Complications Independent of Surgeon Experience Thomas H Shin, PhD, Maira I Rudolph, Vicki Sein, MD, Sara M Burns, Megan B Zhang, Timothy Houle, PhD, Matthias Eikermann, MD, PhD Massachusetts General Hospital, Boston, MA INTRODUCTION: Use of laparoscopic surgery has significantly expanded over recent years, given its reduced rates of surgical trauma, postoperative pain, and recovery times. Although many studies have examined the potential association of pulmonary complications with pneumoperitoneum during laparoscopy, there are limited data investigating this relationship while accounting for surgical provider familiarity with laparoscopy. METHODS: There were 11,589 adult abdominal operations at a tertiary care hospital and 2 affiliated community hospitals analyzed using logistic regression or truncated negative binominal regression, respectively, to evaluate the effect of laparoscopic approach on patientcentered outcomes. To ascertain the robustness of these findings, we performed stratification analysis adjusted for a propensity score generated by an a priori set of covariates covering demographics, patient comorbidities, provider variables, and intraoperative complications. RESULTS: Adjusted analysis revealed lower rates of postoperative respiratory complications (OR 0.74, 95% CI 0.58e0.95, p ¼ 0.017), 30-day readmissions (OR 0.70, 95% CI 0.56e0.88, p ¼ 0.002), length of hospital stay (IRR 0.76, CI 0.73e0.79, p < 0.001), and medical cost (IRR 0.87, 95% CI 0.85e0.89, p < 0.001) in laparoscopic vs open abdominal procedures. Propensity score-based analysis revealed, while a surgeon’s previous number of laparoscopy influences one’s probability of receiving laparoscopic surgery, laparoscopic approaches have lesser odds of postoperative respiratory complications (OR 0.76, 95% CI 0.60e0.97, p ¼ 0.026) after controlling for variability of surgeon laparoscopy experience. These reduced odds are successively less with each subsequent propensity score quintile. CONCLUSIONS: Our findings revealed that although surgical provider familiarity may affect the likelihood of laparoscopy, laparoscopic abdominal surgery is associated with favorable postoperative respiratory outcomes compared with open surgery. Lower Utilization of Bariatric Surgery by Hispanic Americans in the United States Christina Koh, MD, Colette S Inaba, MD, Sarath Sujatha-Bhaskar, MD, Ninh T Nguyen, MD, FACS, FASMBS University of California, Irvine, Orange, CA INTRODUCTION: The objective of this study was to examine the regional variation in utilization of bariatric surgery for minorities at academic centers. METHODS: Patients with a primary diagnosis of obesity, who underwent laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y
J Am Coll Surg
gastric bypass, or laparoscopic adjustable gastric banding were selected from the University HealthSystem Consortium database (2013e2015). The 4 regional divisions, as defined by the U.S. Census Bureau, were used. The Center for Disease Control and Prevention data were utilized to estimate obesity rates for each region by race. RESULTS: There were 73,119 laparoscopic bariatric surgery procedures performed. During the study period, the number of procedures performed per 1,000 obese patients was highest in the Northeast (2.21), followed by the Midwest (0.73), the South (0.5), and the West (0.33). Blacks had higher utilization of bariatric surgery in each of the 4 regions compared with the proportion of obese blacks within each region. Whites had lower utilization of bariatric surgery compared with the proportion of obese whites in the Northeast (by 8.9%) and Midwest (by 6.1%). Hispanics had lower utilization of bariatric surgery compared with the proportion of obese Hispanics in each of the 4 regions by 21.3% in the Northeast, 55.1% in the Midwest, 79.1% in the South, and 57% in the West. CONCLUSIONS: There is regional variation in utilization of bariatric surgery at academic centers, with the highest utilization in the Northeast and lowest in the West. There is also a racial disparity in delivery of bariatric surgery with Hispanics having the lowest utilization in all regions.
Operative Time as a Marker of Quality in Bariatric Surgery Colette S Inaba, MD, Christina Koh, MD, Sarath Sujatha-Bhaskar, MD, Shea Gallagher, Yanjun Chen, Ninh T Nguyen, MD, FACS, FASMBS University of California, Irvine, Orange, CA INTRODUCTION: Prolonged operative time (OT) has been associated with increased morbidity, but no study has assessed the effect of OT on outcomes up to a year after bariatric surgery. The purpose of this study was to determine the effect of OT on morbidity and mortality up to 1 year after laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). METHODS: Using the American Society of Metabolic and Bariatric Surgery (ASMBS) Database, data were analyzed for LRYGB and LSG cases from 2008 to 2012. Cases with concurrent procedures were excluded. Multivariate logistic regression was used to assess the association between OT and morbidity and mortality after LRYBG and LSG, adjusting for preoperative demographic and clinical characteristics. RESULTS: We examined 93,051 cases, including 74,745 LRYGB (80.3%) and 18,306 LSG (19.7%). For LRYGB, median OT was 102 (IQR 75e135) minutes. Every additional 30 minutes of OT was associated with increased odds of 30-day leak (AOR 1.26, p < 0.0001), 1-year leak (AOR 1.24, p < 0.0001), 30-day mortality (AOR 1.15, p ¼ 0.0326), and 1-year mortality (AOR 1.12, p ¼ 0.0279). For LSG, median OT was 86 (IQR 58e103) minutes. Every additional 30 minutes of OT was associated with increased
Vol. 225, No. 4S1, October 2017
CONCLUSIONS: Increased OT is associated with a significantly increased risk of leak and mortality after LRYGB, and increased risk of leak after LSG. Operative time may be used as a marker for quality in bariatric surgery. Pathologic High-Resolution Manometry Findings Are Not Necessarily Associated with Inferior Outcomes after Paraesophageal Hernia Repair Andrea Wirsching, MD, Qing Zhang, MD, PhD, Susan E McCormick, Michal Hubka, Donald E Low Virginia Mason Medical Center, Seattle, WA INTRODUCTION: Pathologic esophageal pressure topography (pEPT), diagnosed during high-resolution manometry, is found frequently as part of the preoperative evaluation of paraesophageal hernia (PEH) patients. The clinical relevance of these findings is currently largely unknown. METHODS: From 2008 to 2016, 297 patients undergoing PEH repair were prospectively recorded in an IRB-approved database. Preoperative EPT was evaluated by a single, specialized gastroenterologist according to the Chicago classification. Outcomes in patients with pEPT were compared with those from patients with normal motility (NM). RESULTS: pEPT was documented in 108 patients (36.4%). Sex, BMI, comorbidities, size, and orientation of the PEH were similar between pEPT and NM patients. pEPT patients were older (71 vs 68 years, p ¼ 0.03) and had higher American Society of Anesthesiologists (ASA) scores. Partial fundoplication was more commonly done in pEPT patients (9% vs 1%, p ¼ 0.001). Overall complications were similar between pEPT and NM patients, as were the incidence of complications of Clavien-Dindo grade 3A (1% vs 3%). One patient died (0.3%), and readmissions occurred in 1 pEPT and 6 NM patients. In patients with a minimum of 3 months follow-up, incidence of pre- vs postoperative dysphagia in pEPT vs NM patients went from 61% to 4% vs 53% to 12%, regurgitation from 50% to 2% and 62% to 9%. Esophagograms done at a minimum of 3 months postoperatively showed delayed emptying in 2 pEPT and 9 NM patients. CONCLUSIONS: Patients found to have pEPT before surgical repair of PEH showed similar symptomatic improvement compared with patients with NM. Postoperative Disruption of Intestinal Microbiota Composition Attenuates the Metabolic Efficacy of Vertical Sleeve Gastrectomy Cyrus Jahansouz, MD*, Scott Kizy, MD, Christopher Staley, PhD, Daniel B Leslie, MD, FACS, Michael J Sadowsky, PhD, Alexander Khoruts, MD, Sayeed Ikramuddin, MD, FACS University of Minnesota, Minneapolis, MN
S17
INTRODUCTION: Intestinal microbiota play critical roles in energy production and bile acid metabolism. Vertical sleeve gastrectomy (VSG) is a procedure that is among the most successful treatments for obesity and glucose homeostasis, and it influences microbial and bile acid composition through Farnesoid X-receptor (FXR) and Takeda G-protein-coupled receptor (TGR5). It is unknown, however, whether metabolic outcomes after VSG can be altered by manipulating intestinal microbiota. METHODS: Diet-induced obese mice were randomized to VSG or sham operation, with or without antibiotics (fidaxomicin or streptomycin) in drinking water on postoperative days 1 to 4. Fecal samples were collected and characterized before surgery and on postoperative days 7 and 28. Mice were metabolically characterized 4 to 5 weeks after surgery. RESULTS: VSG resulted in weight loss and shifts in intestinal microbiota relative to sham-operated mice. Fidaxomicin or streptomycin exposure after VSG altered intestinal microbiota composition, reduced the relative abundance of known FXR antagonist tauromuricholic acid in portal venous blood, and increased FXR activity in the liver. These alterations were associated with increased adiposity and impaired glucose homeostasis in VSG operated mice that were comparable to those in sham-operated mice (Figure). Importantly, antibiotic exposure did not alter food intake relative to control VSG mice. % Preoperative Weight 120 110
% Preop Weight
odds of 30-day leak (AOR 1.22, p ¼ 0.0002) and 1-year leak (AOR 1.21, p ¼ 0.0002).
Scientific Forum Abstracts
^ *
100
^ *#
^ *#
^ *
90
* p<0.05 b/w controls # p<0.05 b/w Fidaxo ^ p<0.05 b/w VSG @ p<0.05 b/w Sham
80 70 60
VSG Sham Fidaxo VSG Fidaxo Sham
0
7
14
21
28
Days Post-op
CONCLUSIONS: Disruption of postoperative shifts in intestinal microbial composition that affect bile acid metabolism attenuate weight loss and metabolic improvement after VSG. Once disrupted, the microbial composition remains altered and distinct from antibiotic-naı¨ve control VSG mice. Our results implicate intestinal microbiota as an important contributor to metabolic homeostasis and a potentially modifiable target affecting metabolic outcomes after VSG. Racial Disparities in Bariatric Surgery Patients Adam C Sheka, MD, Scott Kizy, MD, Cyrus Jahansouz, MD, Keith Wirth, MD, Jayleen Grams, MD, PhD, Monica Baskin, PhD, Daniel B Leslie, MD, FACS, Sayeed Ikramuddin, MD, FACS University of Minnesota, Minneapolis, MN; University of Alabama, Birmingham, AL INTRODUCTION: The obesity epidemic in the United States disproportionately affects African Americans (AA); AA have a