PL-103: The natural history and metabolic consequences of morbid obesity for patients denied coverage for bariatric surgery

Surgery for Obesity and Related Diseases 6 (2010) S1-S26

PLENARY SESSION 2010 PL-101

ARE LAPAROSCOPICC BARIATRIC PROCEDURES SAFE IN SUPER-OBESE PATIENTS? A NSQIP DATA ANALYSIS Venkata R. Kakarla, MD; Kalyana C. Nandipati, MD; Armando E. Castro, MD; Stephen Merola, MD; Department of Surgery, New York Hospital Queens, Flushing, NY Background: Safety of Laparoscopic Bariatric procedures (LBP) in super obese patients is still debatable Methods: Using the American College of Surgeons-National Surgical Quality Improvement Project’s (ACS-NSQIP) participantuser file, patients who underwent Laparoscopic Gastric Bypass (LGB) and Laparoscopic Adjustable Gastric Band (LAGB) procedures for morbid obesity were identified. Several peri-operative variables including 30-day morbidity and mortality were collected. Data were compared within each procedure after dividing the patients based on BMI (BMI ⬍50 kg/m2 and BMI ⬎50 kg/m2). Results: 29,323 patients who underwent LBPs between 2005 and 2008 were identified. Overall, when compared to BMI ⬍50 kg/m2 group, the BMI ⬎50 kg/m2 group had more males (3:2), younger patients, higher incidence of co-morbidities (HTN and Dyspnea), significantly increased risk adjusted probability of morbidity and mortality, length of stay and rate of mortality (0.26% vs. 0.07%, p⬍0.0001, OR 4.38). In LGB, the BMI ⬎50 kg/m2 group had significantly higher incidence of post-op complications including superficial wound infections (2.45%, p⬍0.0001, OR 1.68), reintubation (0.61%, p⫽0.003, OR 1.97), PE (0.30%, p⫽0.032, OR 2.13), MI (0.07%, p⫽0.017), DVT (0.49%, p⫽0.006, OR 2.06), septic shock (0.44%, p⫽0.04, OR 1.74) and mortality (0.28%, p⫽0.026,OR 2.26). In LAGB, the BMI ⬎50 kg/m2 group had significantly higher incidence of post-op complications including superficial (1.65%, p⫽0.001, OR 2.18) and deep (0.23%, p⫽0.035, OR 2.56) wound infections, sepsis, septic shock and mortality (0.17%, p⫽0.022, OR 13.4). Conclusion: LBPs in super-obese patients are associated with significantly increased complications and mortality when compared to patients with BMI ⬍50 kg/m2. However, overall they appear to be safe with low complication and mortality rates. PL-102

LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS VERSUS LAPAROSCOPIC SLEEVE GASTRECTOMY: A CASE AND CONTROL STUDY AND 3 YEAR FOLLOWUP Camilo Boza, MD; Eduardo O. Figueroa, MD; Cristian Gamboa; Alex Escalona; Jose Salinas, MD; Fernando Pimentel; Gustavo Perez; Fernando Crovari, MD; Pablo Achurra, Medical Student; Luis Ibanez, MD; Surgery, Pontificia Universidad Cato´lica de Chile, Santiago, CHILE

Background: Laparoscopic Sleeve Gastrectomy (LSG) has become a popular surgical procedure among bariatric surgeons. Few studies have compared the efficacy of the procedure to Roux-en-Y Gastric Bypass (RYGB). We performed a case control study to assess surgical results, weight progression and resolution of comorbid conditions. Methods: From January 2006 to September 2009 a total of 2,225 patients underwent bariatric Surgery. Age, BMI and gender matched patients submitted to RYGB (817) and LSG (807) were included. Complication rate, mortality, and Excess Weight Loss (EWL) after 1, 2 and 3 years were analyzed. Results: The mean age for RYGB and LSG was 37 ⫾ 10.3 and 36.6 ⫾ 11.7 years, respectively (p⫽0.5). Most of the patients were female (RYGB 76.5% vs. LSG 75.8%; p⫽0.8) Preoperative BMI was similar in both groups (RYGB 37.7 ⫾ 3.2 kg/m2 vs. LSG 37.4 ⫾ 3.8 kg/m2; p⫽ 0.1). Mean operative time was longer for RYGB (106.9 ⫾ 34.7 min vs. 77.2 ⫾ 30.6 min; p⬍0.01) and hospital stay was longer in RYGB (3.3 ⫾ 4.2 days vs. 2.9 ⫾ 3.5 in LSG; p⫽0.04). Early complications were 7.2% for RYGB and 3.6% for LSG (p⫽0.001); suture leak was 0.7% for RYGB and 0.6% for LSG (p⫽0.7). The %EWL for RYGB vs. LSG at 1 year was 100.4 ⫾ 30.4 vs. 86 ⫾ 28.6 (p⬍0.001), at year 2, 89.8 ⫾ 32 vs. 79.2 ⫾ 30.5 (p⫽0.09) and at year 3, 93 ⫾ 23.6 vs. 79 ⫾ 31 (p⫽0.07). Total cholesterol at year 1 for RYGB vs. LSG was 166.4 ⫾ 25.6 vs. 188 ⫾ 37 mg/dl, respectively (p⫽0.005), resolution or improvement of diabetes was similar in both groups. Conclusion: LSG has become an acceptable primary bariatric procedure for obesity with results comparable to RYGB. PL-103

THE NATURAL HISTORY AND METABOLIC CONSEQUENCES OF MORBID OBESITY FOR PATIENTS DENIED COVERAGE FOR BARIATRIC SURGERY Ayman B. Al Harakeh, MD; Kyle J. Burkhamer; Kara J. Kallies, BA; Michelle A. Mathiason, MS; Shanu N. Kothari; MD; Department of Medical Education, Gundersen Lutheran Medical Foundation, La Crosse, WI; Department of Research, Gundersen Lutheran Medical Foundation, La Crosse, WI; Department of Surgery, Gundersen Lutheran Health System, La Crosse, WI; Background: Patients satisfying NIH criteria and deemed appropriate candidates often do not undergo bariatric surgery due to insurance denials. Our objective was to explore the natural history of these patients compared to those that underwent Laparoscopic Roux-en-Y Gastric Bypass (LRYGB).

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Abstracts: 2010 Plenary Session / Surgery for Obesity and Related Diseases 6 (2010) S1-S26

6Methods: Medical records of patients evaluated for LRYGB from 2001-2007 were retrospectively reviewed. Presence of major co-morbidities was assessed at the initial evaluation and within a 3-year follow-up for patients who underwent LRYGB and those denied LRYGB. Statistical analysis included chi square test. Results: There were 189 patients in the denials cohort and 587 patients in the LRYGB cohort. Age and gender were similar between the cohorts. Percentage of patients with prior diagnoses of co-morbidities in the denials and LRYGB cohorts at the initial evaluation were: diabetes⫽20% and 25%; HTN⫽51% and 43%; obstructive sleep apnea (OSA)⫽20% and 22%; lipid disorders⫽34% and 24%; and gastroesophageal reflux disease (GERD)⫽62% and 49%, respectively. BMI at initial evaluation and follow-up was 47.3 and 46.8 kg/m2 in the denials cohort (n⫽165, P⫽.236); 48.5 and 30.5 kg/m2 in the LRYGB cohort (n⫽544, P⬍.001). Conclusion: Patients denied LRYGB have a higher incidence of new co-morbidities diagnosed over a short follow-up despite no significant change in BMI. Table Percentage of new-onset co-morbidities after initial evaluation. Median Diabetes HTN Follow-up Mellitus (months) Denials Cohort 36 LRYGB Cohort Initial evaluation 7 to LRYGB Post-LRYGB 36 follow-up P-value

OSA

Lipid GERD Disorders

9.2%

41.9% 34.2% 11.2%

0.7%

20.1% 17.7%

0.3% ⬍.001

19.4%

0.3%

0.4%

0.3%

0.6%

⬍.001 ⬍.001 ⬍.001

⬍.001

0.9%

0.4%

PL-104

VENOUS THROMBOEMBOLISM (VTE) FOLLOWING BARIATRIC SURGERY PERFORMED IN BARIATRIC CENTERS OF EXCELLENCE® (BSCOE): ANALYSIS OF THE BARIATRIC OUTCOMES LONGITUDINAL DATABASESM (BOLDSM) Deborah Winegar; Virginia Pate, MS; Quinn Swanger, BS; Eric J. DeMaria, MD; Surgical Review Corporation, Raleigh, NC; Duke University, Durham, NC Background: VTE is an uncommon complication of bariatric surgery but a leading cause of postoperative mortality. The study of factors predictive of low-incidence complications requires the analysis of large cohorts. BOLD, the world’s largest prospective database for bariatric surgery, provides a suitable medium for analyzing low-frequency events. Methods: BOLD data from 80,157 research-consented patients treated at BSCOEs prior to September 22, 2009 were analyzed for VTE events following surgery. Results: The overall incidence of VTE was 0.31%. ⬎80% of these events occurred post-discharge, most within 30 days following surgery. The incidence of VTE was higher in patients undergoing gastric bypass (GB) vs. adjustable gastric banding (AGB) (0.35% vs. 0.11%*, OR⫽3.2). Among GB patients, VTE was more frequent when the procedure was performed by open vs. laparoscopic access (0.95% vs. 0.30%*, OR⫽3.2).

Patients with a VTE event were older (⫹3.5 years*), had a higher preoperative BMI (⫹3.2 kg/m2*), and a prior history of VTE (1.22% vs. 0.22%*, OR⫽5.6). Males were 1.7 times more likely to experience VTE (0.23% vs. 0.44%*). Most patients (93.5%) received some method of VTE prophylaxis therapy (VPX). All methods of VPX provided protection against 90-day VTE for AGB patients (0.09% vs. 0.43%*). In GB patients, VPX using anticoagulation methods was associated with a small increase in VTE (0.37 % vs. 0.29%*), which was significant even after controlling for the aforementioned risk factors (hazard ratio⫽1.9, p⫽0.0167). *p⬍0.0001. Conclusion: The overall incidence of VTE was low in the population treated at BSCOEs, where clinical pathways to prevent VTE are mandated. Analysis of this large study population allowed identification of patient characteristics correlating with increased risk for post-operative VTE and the variable effectiveness of VPX methods. PL-105

LONG-TERM OUTCOMES AND CONSEQUENCES OF DISTAL GASTRIC BYPASS (D-GB) IN SEVERE CLINICAL OBESITY John M. Kellum, M.D.; Silas M. Chikunguwo, MD; James W. Maher, MD; Luke G. Wolfe, MSci; Harvey J. Sugerman, MD; Surgery, Virginia Commonwealth University, Richmond, VA Background: Data on long-term outcomes after D-GB is limited in American patients. The purpose of this study was to evaluate the long-term weight loss and metabolic outcomes of D-GB with follow-up to 24 years. Methods: Between 1985-1989, 43 super-obese (BMI ⬎50 kg/m2) and six morbidly obese (BMI ⬎40 kg/m2) patients had a malabsorptive D-GB. All operations were done by open celiotomy and included a Roux-en-Y gastric bypass with a 30-50 mL proximal gastric pouch (stapled in continuity), a biliopancreatic limb extending from the ligament of Treitz to 250 cm from the ileocecal junction, and a common channel of 50-150 cm. Weight loss and nutritional parameters were assessed from our bariatric database and office visits. Results: The mean preop BMI (⫾SD) was 58.9⫾9.3 kg/m2. Age was 35.5⫾9.5 years. Women comprised 80% of patients. There was one perioperative death from a pulmonary embolus. Of the 48 remaining patients, 21 (43.7%) required limb-lengthening revisions for protein-calorie malnutrition, not ameliorated by intermittent TPN. In those with 50-cm common channels, 13/23 required revision, as compared with 8/25 with ⱖ100-cm common channels (p⬍0.05, ␹2). There were eight late deaths, six to 19 years after D-GB. Among those with no revision, 19 of 27 (70.4%) had ⬎5 yr follow-up. In these patients, the latest BMI was 34.2 kg/m2 at 10 ⫾6.1 years. Percent initial excess weight loss was 66.8 ⫾14%. The mean serum albumin was 3.6 ⫾0.5 g/dL (range 2.3-4.4) iron 24.4 ⫾15.5 ␮/dL, and 25-OH-Vit D was 14.6 ⫾ 11.3 ng/mL Conclusion: While patients had excellent long-term weight loss after D-GBP, there was an unacceptable incidence of proteincalorie malnutrition requiring revision, especially with 50-cm common channels. In patients not having revisions, late low albumin, iron and vitamin D levels were common. This operation should not be the primary operation for morbid or super-obesity.