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Readmissions after bariatric surgery: Open versus laparoscopic
Abstracts: Plenary Session/Surgery for Obesity and Related Diseases / 1 (2005) 222–283
Purpose: Gastric bypass is used to successfully treat the medical complications of morbid obesity. During the extensive preoperative evaluation and risk assessment, new medical conditions are often diagnosed. A four-year retrospective review of a single surgeon’s experience was used to determine the incidence of previously unidentified medical conditions and their relative frequencies. Methods: Between February 7, 2001 and October 31, 2004 the charts of 360 patients were reviewed. The presenting diagnoses were made by the primary care physicians and documented by the bariatric dietitians. These diagnoses were compared with those identified during the standard preoperative risk assessment. Sleep studies, cardiac, or pulmonary evaluations were conducted based on clinical indications. Results: On review of 360 charts, new medical diagnoses were obtained in 134 (37%) patients. Some patients had more than one new medical diagnosis. Obstructive sleep apnea was identified in 117 (32.5%) patients, hypertension in 7 (1.9%), diabetes mellitus in 7 (1.9%), cardiac disease in 4 (1.1%), thyroid disease in 7 (1.9%), gallstones in 3 (0.8%), hypercholesterolemia in 2 (0.6%), and GERD in 2 (0.6%). Conclusions: Previously undiagnosed medical conditions are commonly revealed in the extensive preoperative risk assessment for bariatric surgical candidates. Even diagnoses that are prevalent in the morbidly obese population are often not diagnosed by primary care physicians. This has a great health impact on whether or not patients undergo surgery. PII: S1550-7289(05)00225-X POSTOP
P38.
PREOPERATIVE RADIOLOGIC DIAGNOSIS OF INTERNAL HERNIA AFTER LAPAROSCOPIC ROUXEN-Y GASTRIC BYPASS Alexander Onopchenko, M.D., The Center for Surgical Weight Loss and Wellness at Atlantic City Medical Center, Atlantic City, NJ. Purpose: Internal hernia ia a known complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). Preoperative diagnosis may be difficult on the basis of history and physical examination. CT scanning is often performed as a diagnostic tool for patients with symptoms after LRYGB but is often read by the radiologist as non-specific or normal. Preoperative review of the study by the bariatric surgeon familiar with the neoanatomy can identify the internal hernia and its location. Methods: We retrospectively reviewed our first 205 patients undergoing LRYGB to identify all patients that developed an internal hernia. The patient’s symptoms, physical findings and CT scan fidings were reviewed. Time to presentation with the internal hernia was noted. Radiologic interpretation of the scans was recorded as well as the bariatric surgeon’s preoperative impression after review of the scans. Results: In our initial experience of 205 patients undergoing LRYGB, 5 patients presented at various times in their postoperative course with an internal hernia for an incidence of 2.4%. All patients underwent preoperative CT scanning. Radiological interpretation of the scans identified one internal hernia of the five
259
preoperatively. Preoperative review of the scans by the bariatric surgeon was not only highly suggestive of the diagnosis but of the location as well in all 5 cases. Conclusions: Preoperative diagnosis of an internal hernia in patients after LRYGB is often difficult. CT scanning has been found to be a very helpful diagnostic tool especially when reviewed preoperatively by the bariatric surgeon. PII: S1550-7289(05)00226-1
P39.
IS ROUTINE PROPHYLACTIC CHOLECYSTECTOMY NECESSARY AT TIME OF ROUX-EN-Y GASTRIC BYPASS FOR MORBID OBESITY? Jerome D. Taylor, M.D., I. Michael Leitman, M.D., Peter K. Hon, B.S., Michael Horowitz, M.D., Lenox Hill Hospital, New York, NY. Purpose: Morbid obesity is associated with an increased incidence of gallstones. Rapid weight loss, such that occurs after gastric bypass surgery may also increase the incidence of gallstone development. Standard surgical treatments for gallbladder disease and its complications might be more difficult after gastric bypass surgery. Controversy exists whether prophylactic cholecystectomy is necessary at the time of Roux-en-Y gastric bypass (RGB). Methods: Retrospective analysis was performed on a database of 535 patients undergoing Roux-en-Y gastric bypass surgery for morbid obesity during a 5.5-year period. Patients were followed and medical records were reviewed. Ursodeoxycholic acid (Actigall) was not prescribed for any patient after surgery. Results: Eight percent of patients had cholecystectomy before RGB. 75 of 492 patients (15%) were found the have gallstones at RGB and cholecystectomy was performed at the same time. Three of these patients had bile leaks but only one required further intervention (percutaneous transhepatic drainage for 3 weeks). After RGB, 14 patients (3%) required cholecystectomy for symptomatic cholelithiasis in the postoperative period. All were performed laparoscopically and without complication. Conclusions: Gallbladder disease after gastric bypass surgery does occur but is not frequent. Prophylactic cholecystectomy for a normal gallbladder is not necessary at the time of gastric bypass surgery. Patients without biliary tract symptoms may not require routine preoperative sonogram. If an abnormal gallbladder or gallstones are found at the time of gastric bypass surgery, then prophylactic cholecystectomy should be considered. PII: S1550-7289(05)00227-3
P40.
READMISSIONS AFTER BARIATRIC SURGERY: OPEN VERSUS LAPAROSCOPIC Pratibha Vemulapalli, M.D., Glenn J. Forrester, M.D., Larry F. Griffith, M.D., Babak Moeinolmolki, M.D., Karen E. Gibbs, M.D., Julio Teixeira, M.D., Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY. Purpose: Emergency room visits and early readmission after bariatric surgery (⬍30 days) occur at an unknown frequency. We sought to determine how often patients returned to the emergency department (ED) after undergoing bariatric surgery for the treatment of morbid obesity.
260
Abstracts: Plenary Session/Surgery for Obesity and Related Diseases / 1 (2005) 222–283
Methods: Between January 1 and December 31, 2003, 450 procedures (laparoscopic gastric banding, Roux-en-Y open and laparoscopic gastric bypass) for the treatment of morbid obesity were performed in our institution. Retrospectively, hospital and ED admissions were then reviewed to determine which of these patients presented within 1 year of surgery. Results: Twenty percent of the total population (92 patients) treated surgically for morbid obesity (16% open procedures and 4% laparoscopic procedures) presented to the ED. Overall, 41% of laparoscopic and 43% of open procedure emergency visits resulted in patient discharge. The average number of ED visits for open bypass and laparoscopic procedures were 1.78 and 1.3, respectively (p ⫽ 0.04). The average hospital length of stay from these visits was 4.2 days for the open procedure and 3.6 for the laparoscopic procedure (p ⬎0.5). The most common causes of readmission were abdominal pain, nausea, vomiting, and wound complications for the open procedure. Meanwhile, nausea and vomiting were the most common causes of readmission for the laparoscopic cases. Conclusions: Emergency room visit rates are higher after open bariatric procedures than with laparoscopic procedures. However, nearly half of all ED visits after both open and laparoscopic procedures combined resulted in no hospital admission. PII: S1550-7289(05)00228-5
P41.
REDUCTION OF QT INTERVAL IN MORBIDLY OBESE PATIENTS UNDERGOING BILIOPANCREATIC DIVERSION IS INDEPENDENT OF WEIGHT LOSS Francesco S. Papadia1, M.D., Alice Scopinaro2, M.D., Gian Paolo Bezante2, M.D., Antonio Barsotti2, M.D., Nicola Scopinaro1, M.D., 1Department of Surgery, and 2Department of Cardiology, University of Genoa School of Medicine, Genoa, Italy. Purpose: Aim of this study was to evaluate the effect of BPD on QT interval (QTc) in a cohort of patients submitted to surgery. Methods: Data of 82 patients operated on between January 2001 and February 2004 were collected. Electrocardiograms were collected postoperatively at different follow-up intervals, and preoperative heart rate (HR) and QTc were compared with postoperative values. Relationship of HR and QTc with patients’ data was investigated with univariate and multivariate analysis. Results: Mean age at surgery was 38 years. Mean BW was 130 kg, BMI 48 kg/m2. Preoperatively, mean HR and QTc were 84 bpm and 412 msec. QTc and HR decreased significantly postoperatively, with normalization of QTc in all cases. Diabetes mellitus was associated with faster HR and longer QTc preoperatively. A linear correlation with HR and QTc was found for serum glucose, triglyceride and BMI values. No difference was found between postoperative QTc or ⌬QTc and follow-up interval. No association was found between QTc and BMI after surgery, but HR and BMI were still associated. No association was found between HR and QTc and IEW%L. Stepwise regression analysis identified diabetes mellitus as the most significant predictor of abnormal QTc preoperatively. Conclusions: BPD leads to significant decrease of QTc and HR. The close association between preoperative serum glucose and QTc and HR suggests that insulin resistance may play a role on
QTc and HR values. BPD might decrease the risk of cardiac arrhythmias in morbidly obese patients independently of postoperative weight loss. PII: S1550-7289(05)00229-7
P42.
COMPARISON OF METHODS FOR DETERMINING IDEAL BODY WEIGHT FOR BARIATRIC PATIENTS Debbie Daley, R.D., Robert T. Marema, M.D., Abbe Breiter, M.S., R.D., Justine Strauss, E.P., Cynthia K. Buffington, Ph.D., U.S. Bariatric, Fort Lauderdale, FL. Purpose: There exists no consensus on the best calculation to use for Ideal Body Weight (IBW) for obese patients. The IBW is important for use in calculations to determine % excess body weight, the standardized measure for weight loss success after bariatric surgery. In the present study, we examined two commonly used methods for estimating IBW and compared them to body weights obtained upon weight loss stabilization postoperatively. Methods: The study population included 118 morbidly obese gastric bypass patients (BMI ⱖ40). IBW was calculated using the Hamwi Method and Metropolitan (MET) Life Insurance Company’s 1983 charts. These calculations were then compared with patients’ postoperative weights upon weight loss stabilization at 1 year. Results: The data show that the average IBW weights females and males should obtain, according to the MET charts, are 56.47 ⫾ 0.41 (mean ⫾ SEM) and 73.05 ⫾ 0.63, respectively. Average female and male IBWs according to the Hamwi equation are 51.72 ⫾ 0.57 and 79.47 ⫾ 1.19. Actual postgastric bypass stabilization weights for females averaged 68.08 ⫾ 1.50, which are 16.91% and 24.02% higher (p ⬍0.0001) than estimated by the MET and Hamwi methods. Stabilization weights for males averaged 94.53 ⫾ 2.30 which are 22.72% and 15.93% above the MET and Hamwi estimates (p ⬍0.0001). Conclusions: The findings suggest that the MET life tables and Hamwi methods for assessing IBW are unrealistic for the postsurgical bariatric population. Clinicians must be cautious when utilizing these methods to avoid unrealistic patient expectations and disappointments that may lead to psychological distress, eating aberrations and weight regain. PII: S1550-7289(05)00230-3
P43.
DUODENAL SWITCH AND NUTRITIONAL SUPPORT Keith Kim, M.D., Robert T. Marema, M.D., Cynthia K. Buffington, Ph.D., U.S. Bariatric, Fort Lauderdale, FL. Purpose: Nutrient malabsorption plays a major role in the massive weight loss of the duodenal switch (DS). Studies have found that malabsorption with DS tends to be greatest for protein, fat-soluble vitamins, and calcium. There is presently wide variation in the nutritional guidelines provided to DS patients and in postoperative nutritional parameters measured by surgeons performing the procedure. We conducted a survey of DS surgeons to see if there are
Purpose: Gastric bypass is used to successfully treat the medical complications of morbid obesity. During the extensive preoperative evaluation and risk assessment, new medical conditions are often diagnosed. A four-year retrospective review of a single surgeon’s experience was used to determine the incidence of previously unidentified medical conditions and their relative frequencies. Methods: Between February 7, 2001 and October 31, 2004 the charts of 360 patients were reviewed. The presenting diagnoses were made by the primary care physicians and documented by the bariatric dietitians. These diagnoses were compared with those identified during the standard preoperative risk assessment. Sleep studies, cardiac, or pulmonary evaluations were conducted based on clinical indications. Results: On review of 360 charts, new medical diagnoses were obtained in 134 (37%) patients. Some patients had more than one new medical diagnosis. Obstructive sleep apnea was identified in 117 (32.5%) patients, hypertension in 7 (1.9%), diabetes mellitus in 7 (1.9%), cardiac disease in 4 (1.1%), thyroid disease in 7 (1.9%), gallstones in 3 (0.8%), hypercholesterolemia in 2 (0.6%), and GERD in 2 (0.6%). Conclusions: Previously undiagnosed medical conditions are commonly revealed in the extensive preoperative risk assessment for bariatric surgical candidates. Even diagnoses that are prevalent in the morbidly obese population are often not diagnosed by primary care physicians. This has a great health impact on whether or not patients undergo surgery. PII: S1550-7289(05)00225-X POSTOP
P38.
PREOPERATIVE RADIOLOGIC DIAGNOSIS OF INTERNAL HERNIA AFTER LAPAROSCOPIC ROUXEN-Y GASTRIC BYPASS Alexander Onopchenko, M.D., The Center for Surgical Weight Loss and Wellness at Atlantic City Medical Center, Atlantic City, NJ. Purpose: Internal hernia ia a known complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). Preoperative diagnosis may be difficult on the basis of history and physical examination. CT scanning is often performed as a diagnostic tool for patients with symptoms after LRYGB but is often read by the radiologist as non-specific or normal. Preoperative review of the study by the bariatric surgeon familiar with the neoanatomy can identify the internal hernia and its location. Methods: We retrospectively reviewed our first 205 patients undergoing LRYGB to identify all patients that developed an internal hernia. The patient’s symptoms, physical findings and CT scan fidings were reviewed. Time to presentation with the internal hernia was noted. Radiologic interpretation of the scans was recorded as well as the bariatric surgeon’s preoperative impression after review of the scans. Results: In our initial experience of 205 patients undergoing LRYGB, 5 patients presented at various times in their postoperative course with an internal hernia for an incidence of 2.4%. All patients underwent preoperative CT scanning. Radiological interpretation of the scans identified one internal hernia of the five
259
preoperatively. Preoperative review of the scans by the bariatric surgeon was not only highly suggestive of the diagnosis but of the location as well in all 5 cases. Conclusions: Preoperative diagnosis of an internal hernia in patients after LRYGB is often difficult. CT scanning has been found to be a very helpful diagnostic tool especially when reviewed preoperatively by the bariatric surgeon. PII: S1550-7289(05)00226-1
P39.
IS ROUTINE PROPHYLACTIC CHOLECYSTECTOMY NECESSARY AT TIME OF ROUX-EN-Y GASTRIC BYPASS FOR MORBID OBESITY? Jerome D. Taylor, M.D., I. Michael Leitman, M.D., Peter K. Hon, B.S., Michael Horowitz, M.D., Lenox Hill Hospital, New York, NY. Purpose: Morbid obesity is associated with an increased incidence of gallstones. Rapid weight loss, such that occurs after gastric bypass surgery may also increase the incidence of gallstone development. Standard surgical treatments for gallbladder disease and its complications might be more difficult after gastric bypass surgery. Controversy exists whether prophylactic cholecystectomy is necessary at the time of Roux-en-Y gastric bypass (RGB). Methods: Retrospective analysis was performed on a database of 535 patients undergoing Roux-en-Y gastric bypass surgery for morbid obesity during a 5.5-year period. Patients were followed and medical records were reviewed. Ursodeoxycholic acid (Actigall) was not prescribed for any patient after surgery. Results: Eight percent of patients had cholecystectomy before RGB. 75 of 492 patients (15%) were found the have gallstones at RGB and cholecystectomy was performed at the same time. Three of these patients had bile leaks but only one required further intervention (percutaneous transhepatic drainage for 3 weeks). After RGB, 14 patients (3%) required cholecystectomy for symptomatic cholelithiasis in the postoperative period. All were performed laparoscopically and without complication. Conclusions: Gallbladder disease after gastric bypass surgery does occur but is not frequent. Prophylactic cholecystectomy for a normal gallbladder is not necessary at the time of gastric bypass surgery. Patients without biliary tract symptoms may not require routine preoperative sonogram. If an abnormal gallbladder or gallstones are found at the time of gastric bypass surgery, then prophylactic cholecystectomy should be considered. PII: S1550-7289(05)00227-3
P40.
READMISSIONS AFTER BARIATRIC SURGERY: OPEN VERSUS LAPAROSCOPIC Pratibha Vemulapalli, M.D., Glenn J. Forrester, M.D., Larry F. Griffith, M.D., Babak Moeinolmolki, M.D., Karen E. Gibbs, M.D., Julio Teixeira, M.D., Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY. Purpose: Emergency room visits and early readmission after bariatric surgery (⬍30 days) occur at an unknown frequency. We sought to determine how often patients returned to the emergency department (ED) after undergoing bariatric surgery for the treatment of morbid obesity.
260
Abstracts: Plenary Session/Surgery for Obesity and Related Diseases / 1 (2005) 222–283
Methods: Between January 1 and December 31, 2003, 450 procedures (laparoscopic gastric banding, Roux-en-Y open and laparoscopic gastric bypass) for the treatment of morbid obesity were performed in our institution. Retrospectively, hospital and ED admissions were then reviewed to determine which of these patients presented within 1 year of surgery. Results: Twenty percent of the total population (92 patients) treated surgically for morbid obesity (16% open procedures and 4% laparoscopic procedures) presented to the ED. Overall, 41% of laparoscopic and 43% of open procedure emergency visits resulted in patient discharge. The average number of ED visits for open bypass and laparoscopic procedures were 1.78 and 1.3, respectively (p ⫽ 0.04). The average hospital length of stay from these visits was 4.2 days for the open procedure and 3.6 for the laparoscopic procedure (p ⬎0.5). The most common causes of readmission were abdominal pain, nausea, vomiting, and wound complications for the open procedure. Meanwhile, nausea and vomiting were the most common causes of readmission for the laparoscopic cases. Conclusions: Emergency room visit rates are higher after open bariatric procedures than with laparoscopic procedures. However, nearly half of all ED visits after both open and laparoscopic procedures combined resulted in no hospital admission. PII: S1550-7289(05)00228-5
P41.
REDUCTION OF QT INTERVAL IN MORBIDLY OBESE PATIENTS UNDERGOING BILIOPANCREATIC DIVERSION IS INDEPENDENT OF WEIGHT LOSS Francesco S. Papadia1, M.D., Alice Scopinaro2, M.D., Gian Paolo Bezante2, M.D., Antonio Barsotti2, M.D., Nicola Scopinaro1, M.D., 1Department of Surgery, and 2Department of Cardiology, University of Genoa School of Medicine, Genoa, Italy. Purpose: Aim of this study was to evaluate the effect of BPD on QT interval (QTc) in a cohort of patients submitted to surgery. Methods: Data of 82 patients operated on between January 2001 and February 2004 were collected. Electrocardiograms were collected postoperatively at different follow-up intervals, and preoperative heart rate (HR) and QTc were compared with postoperative values. Relationship of HR and QTc with patients’ data was investigated with univariate and multivariate analysis. Results: Mean age at surgery was 38 years. Mean BW was 130 kg, BMI 48 kg/m2. Preoperatively, mean HR and QTc were 84 bpm and 412 msec. QTc and HR decreased significantly postoperatively, with normalization of QTc in all cases. Diabetes mellitus was associated with faster HR and longer QTc preoperatively. A linear correlation with HR and QTc was found for serum glucose, triglyceride and BMI values. No difference was found between postoperative QTc or ⌬QTc and follow-up interval. No association was found between QTc and BMI after surgery, but HR and BMI were still associated. No association was found between HR and QTc and IEW%L. Stepwise regression analysis identified diabetes mellitus as the most significant predictor of abnormal QTc preoperatively. Conclusions: BPD leads to significant decrease of QTc and HR. The close association between preoperative serum glucose and QTc and HR suggests that insulin resistance may play a role on
QTc and HR values. BPD might decrease the risk of cardiac arrhythmias in morbidly obese patients independently of postoperative weight loss. PII: S1550-7289(05)00229-7
P42.
COMPARISON OF METHODS FOR DETERMINING IDEAL BODY WEIGHT FOR BARIATRIC PATIENTS Debbie Daley, R.D., Robert T. Marema, M.D., Abbe Breiter, M.S., R.D., Justine Strauss, E.P., Cynthia K. Buffington, Ph.D., U.S. Bariatric, Fort Lauderdale, FL. Purpose: There exists no consensus on the best calculation to use for Ideal Body Weight (IBW) for obese patients. The IBW is important for use in calculations to determine % excess body weight, the standardized measure for weight loss success after bariatric surgery. In the present study, we examined two commonly used methods for estimating IBW and compared them to body weights obtained upon weight loss stabilization postoperatively. Methods: The study population included 118 morbidly obese gastric bypass patients (BMI ⱖ40). IBW was calculated using the Hamwi Method and Metropolitan (MET) Life Insurance Company’s 1983 charts. These calculations were then compared with patients’ postoperative weights upon weight loss stabilization at 1 year. Results: The data show that the average IBW weights females and males should obtain, according to the MET charts, are 56.47 ⫾ 0.41 (mean ⫾ SEM) and 73.05 ⫾ 0.63, respectively. Average female and male IBWs according to the Hamwi equation are 51.72 ⫾ 0.57 and 79.47 ⫾ 1.19. Actual postgastric bypass stabilization weights for females averaged 68.08 ⫾ 1.50, which are 16.91% and 24.02% higher (p ⬍0.0001) than estimated by the MET and Hamwi methods. Stabilization weights for males averaged 94.53 ⫾ 2.30 which are 22.72% and 15.93% above the MET and Hamwi estimates (p ⬍0.0001). Conclusions: The findings suggest that the MET life tables and Hamwi methods for assessing IBW are unrealistic for the postsurgical bariatric population. Clinicians must be cautious when utilizing these methods to avoid unrealistic patient expectations and disappointments that may lead to psychological distress, eating aberrations and weight regain. PII: S1550-7289(05)00230-3
P43.
DUODENAL SWITCH AND NUTRITIONAL SUPPORT Keith Kim, M.D., Robert T. Marema, M.D., Cynthia K. Buffington, Ph.D., U.S. Bariatric, Fort Lauderdale, FL. Purpose: Nutrient malabsorption plays a major role in the massive weight loss of the duodenal switch (DS). Studies have found that malabsorption with DS tends to be greatest for protein, fat-soluble vitamins, and calcium. There is presently wide variation in the nutritional guidelines provided to DS patients and in postoperative nutritional parameters measured by surgeons performing the procedure. We conducted a survey of DS surgeons to see if there are