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Strategies to decrease readmission after gastric bypass, in the long-term
Author’s Accepted Manuscript Strategies to decrease re-admission after gastric bypass, in the long-term Michel Gagner
www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S1550-7289(17)30034-5 http://dx.doi.org/10.1016/j.soard.2017.01.020 SOARD2899
To appear in: Surgery for Obesity and Related Diseases Cite this article as: Michel Gagner, Strategies to decrease re-admission after gastric bypass, in the long-term, Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2017.01.020 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Strategies to decrease re-admission after Gastric bypass, in the long-term.
Michel Gagner, M.D. FRCSC, FACS, FASMBS Herbert Wertheim College of Medicine, Florida International University, Miami, FL and Hopital du Sacre Coeur, Montreal , QC, Canada
Everybody is focused on decreasing short-term re-admission (30 days), especially as many are now using Enhanced Recovery After Bariatric Surgery (ERABS) programs. We have recently heard about the quality improvement program, known as DROP, for Decreasing Readmissions through Opportunities Provided, developed by the American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (ACS-MBSAQIP). With this program, for example, 30 day re-admissions after laparoscopic sleeve gastrectomy (SG) decreased from 4.02% to 3.54%, a 12% reduction.
But what about long-term? Would this decrease the overall costs in a major way? I read with interest the manuscript entitled Hospital admission after gastric bypass: A nationwide cohort study with up to 6 year follow-up by Bruze et al. from Sweden.1 A longitudinal study of more than 28, 331 patients have been followed in a country that has a national healthcare system, similarly to many OECD countries (Organisation for Economic Cooperation and Development), who underwent a Roux-en-Y gastric bypass (RYGB) between 2007 and 2012. Using the Scandinavian Obesity Surgery registry (SOreg); these were compared to a matched population during the same period (274, 759 patients), excluding plastic surgeries and child deliveries. A Hospital Readmission rate (HR) of 2.6 and 2.7 demonstrated an increased risk
of later hospital admissions at 1 and 6 years (by then 65% of patients had been re-admitted) for RYGB patients and especially for a gastrointestinal surgical procedure (HR 7.7).
What stands out are hospitalizations needed for gallstone problems, internal herniation, and gastro-intestinal surgeries in general. One would perhaps decrease dramatically the incidence of gallstones with the use of routine oral ursodeoxycholic acid postoperatively for 6 months, something not in routine use in Sweden.2 Would prophylactic cholecystectomy for asymptomatic gallstones at the time of RYGB decrease this possibility? The University of California in San Diego is favoring this, based on the California Office of Statewide Health Planning and Development longitudinal database, which queried patients who underwent RYGB with or without cholecystectomy between 1995 and 2009. Of 134,584 RYGB patients, 21,022 underwent concomitant cholecystectomy. It improved both survival (HR 0.51) and long-term outcomes (HR 0.84). The incidence of gallbladder disease following RYGB alone was 6.8 and 15.2 % at 1 and 5 years. Cholecystectomy after RYGB was associated with higher risk of conversion to an open procedure (HR 1.58), post-operative complications (HR 1.47) and deaths (HR 1.32).3 However, old open surgical data is less applicable to today’s reality with laparoscopic approaches. The debate is still on. I tend not to favor this approach as there is a higher risk of bile duct injury in a morbidly obese patient, and the increased operating time would be a negative aspect of this approach. Dorman et al. have found, using the ACS-NSQIP database, that of 32,946 patients who underwent RYGB, 1,731 (5.2%) also had a cholecystectomy, which was a risk factor for major adverse events following a laparoscopic, but not an open procedure. Regardless of approach, prolonged length of stay was more common among those with a concomitant cholecystectomy.4
An advantage provided by SG is the direct access to the biliary tree via endoscopic retrograde cholangio-pancreatogrphy (ERCP), without the need for a general anesthetic. Performing a transgastric ERCP, a considerable complex procedure, which adds co-morbidity.5 CBD stones or pancreatitis can still occur after cholecystectomy, complicating ERCP’s.
Mesenteric defects should be closed routinely, whatever the procedure and approach, when it involves a connection of the small bowel. The recent multicenter randomized trial with a twoarm, parallel design done at 12 centers for bariatric surgery in Sweden demonstrated clearly a reduction in the incidence of bowel obstruction when mesenteric defects were closed routinely as opposed to none. At 3 years after surgery, the cumulative incidence of reoperation because of small bowel obstruction was significantly reduced in the closure group (cumulative probability 0·055 for closure vs. 0·102 for non-closure, hazard ratio 0·56, 95% CI 0·41-0·76, p=0·0002).6 There is a learning curve to do this properly: one has to use the right suture, appropriate bites in the mesentery, distance and tension, as well as anchoring to the serosa These steps are undoubtedly key factors that could decrease occurrence of an internal hernia with its associated symptoms.
In terms of reducing other gastro-intestinal problems like strictures, ulcers, and hiatal hernia/reflux, one could use a longer period of proton-pump inhibitors (PPI), as it has been demonstrated that the incidence of marginal ulceration after RYGB decreased significantly (P<.05) among patients receiving daily PPI for 90 days (n = 26, 6.5%) compared with those
receiving PPI for 30 days (n = 76, 12.4%).7 Also creating a smaller gastric pouch will likely decrease the incidence of ulcers, and a wider anastomosis decrease the incidence of strictures. For hiatal hernias, better detection preoperatvely may guide the surgeon to perform a routine hiatal hernia closure at the time of RYGB.8
Other risk factors for readmission in the long-term have been identified: female sex, psychiatric disease and low educational level.1 Is there a role for SG in these higher risk groups? The Swedish authors believe that re-admission is higher in SG patients.1 They have quoted a study linked to a high risk for readmission (>30%)!, but this study was taken from an administrative database from New York (not a clinical one), more specifically the New York Statewide Planning and Research Cooperative System (SPARCS) administrative database, in 2006 to 2008, where this surgery was during the procedure’s learning curve,. There was also a major administrative error in this paper, where the code ICD-9 43.89 was utilized (open and other partial gastrectomy) and is not a bariatric surgery code, while the new code ICD-9 43.82 began to be used in October 2011. This means that many “open and partial gastrectomies” may have been indeed done for tumors or ulcers and not specifically SG for obesity, known for a higher readmission rate. Hence this data is to be found unreliable.9
The study by Sippey at al. was more accurate; clinical data came from the ACS-NSQIP participating facilities. A total of 34,983 patients underwent bariatric surgery with an adequate mix (46.0% SG, 54.0% RYGB). Readmission was reported in 1773 (5.1%) patients, and was more
common after RYGB compared with SG (6.1% versus 3.8%, P<.001, adjusted OR 1.59). Postoperative pain, bleeding, intestinal obstructions, and wound occurrences were more commonly a readmission cause for RYGB compared with SG.10
A single institution review by the Massachusetts General Hospital has demonstrated that a higher percentage of RYGB patients required cholecystectomy as compared to SG patients (5 vs. 2 %, p < 0.01).11 There was also a significant difference in the proportion of patients requiring reoperation for other reasons following RYGB as compared to SG (6.9 vs. 0.9 %, p < 0.01). A total of 32.8 % of these bypass patients underwent more than one re-operation, with a relative risk of 11.5 (95 % CI 4.69-28.5) as compared to those undergoing SG. Other re-operations occurred without an identifiable abdominal source in 22.2 %: adhesions/obstructions in 17.6 %, internal hernias in 15.7 %, ulcers 3.7% and intussusceptions 2.8%. SG was associated with a much lower rate of re-operations, while patients after RYGB were at a significant long-term risk for multiple re-operations.11
And this has been recently confirmed in a study by Berger et al., although only short term, where a total of 130,007 patients who underwent primary bariatric surgery were identified.12 A total of 4.4% of patients were readmitted within 30 days, with patients undergoing SG having a readmission rate of 2.8% vs. 4.9% for RYGB. Causes of readmissions were nausea, vomiting, fluid and electrolyte issues, nutritional depletion (35.4%), abdominal pain (13.5%), anastomotic leak (6.4%), and bleeding (5.8%), accounting for 61% of readmissions. Higher rates of readmission were seen with RYGB than SG, odds ratio 3.06; 95% confidence interval 2.46-3.81).12
Reoperations for weight regain, diabetes recurrence after RYGB were not discussed in the Bruze et al. study, perhaps because no such clear strategies exist in Sweden for these patients? These may be the highest costs in the long-term (after 10 years). Finally, since Sweden is not performing laparoscopic SG in as large a scale as other countries, we should wait for the results of a multicenter randomized trial comparing RYGB and SG, to find out if readmission will be decreased in the long-term with this intervention.
References
1-Bruze G, Ottosson J, Neovius M, Naslund I, Marsk R. Hospital admission after gastric bypass: A nationwide cohort study with up to 6 years follow-up. SOARD 2017, in press.
2-Sugerman HJ, Brewer WH, Shiffman ML, Brolin RE, Fobi MA, Linner JH, MacDonald KG, MacGregor AM, Martin LF, Oram-Smith JC, et al. A multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid weight loss. Am J Surg. 1995 Jan;169(1):91-6.
3-Weiss AC, Inui T, Parina R, Coker AM, Jacobsen G, Horgan S, Talamini M, Chang DC, Sandler B. Concomitant cholecystectomy should be routinely performed with laparoscopic Roux-en-Y gastric bypass. Surg Endosc. 2015 Nov;29(11):3106-11.
4-Dorman RB, Zhong W, Abraham AA, Ikramuddin S, Al-Refaie WB, Leslie DB, Habermann EB. Does concomitant cholecystectomy at time of Roux-en-Y gastric bypass impact adverse operative outcomes? Obes Surg. 2013 Nov;23(11):1718-26.
5-Manassa E, Assalia A, Mahajna A.Laparoscopic intraoperative ERCP through a transgastric approach after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2016 May;12(4):e43-5.
6-Stenberg E, Szabo E, Ågren G, Ottosson J, Marsk R, Lönroth H, Boman L, Magnuson A, Thorell A, Näslund I. Closure of mesenteric defects in laparoscopic gastric bypass: a multicentre, randomised, parallel, open-label trial. Lancet. 2016 Apr 2;387(10026):1397-404.
7-Kang X, Zurita-Macias L, Hong D, Cadeddu M, Anvari M, Gmora S. A comparison of 30-day versus 90-day proton pump inhibitor therapy in prevention of marginal ulcers after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2016 Jun;12(5):1003-7.
8- Mohammed R, Fei P, Phu J, Asai M, Antanavicius G. Efficiency of preoperative esophagogastroduodenoscopy in identifying operable hiatal hernia for bariatric surgery patients. Surg Obes Relat Dis. 2016 Aug 17. pii: S1550-7289(16)30187-3.
9-Telem DA, Talamini M, Gesten F, Patterson W, Peoples B, Gracia G, Yang J, Zhang Q, Altieri M, Pryor AD. Hospital admissions greater than 30 days following bariatric surgery: patient and procedure matter. Surg Endosc. 2015 Jun;29(6):1310-5.
10-Sippey M, Kasten KR, Chapman WH, Pories WJ, Spaniolas K. 30-day readmissions after sleeve gastrectomy versus Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2016 Jun;12(5):991-6.
11-Zak Y, Petrusa E, Gee DW. Laparoscopic Roux-en-Y gastric bypass patients have an increased lifetime risk of repeat operations when compared to laparoscopic sleeve gastrectomy patients. Surg Endosc. 2016 May;30(5):1833-8.
12-Berger ER, Huffman KM, Fraker T, Petrick AT, Brethauer SA, Hall BL, Ko CY, Morton JM. Prevalence and Risk Factors for Bariatric Surgery Readmissions: Findings From 130,007 Admissions in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Ann Surg. 2016 Nov 15. [Epub ahead of print]
www.elsevier.com/locate/buildenv
PII: DOI: Reference:
S1550-7289(17)30034-5 http://dx.doi.org/10.1016/j.soard.2017.01.020 SOARD2899
To appear in: Surgery for Obesity and Related Diseases Cite this article as: Michel Gagner, Strategies to decrease re-admission after gastric bypass, in the long-term, Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2017.01.020 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Strategies to decrease re-admission after Gastric bypass, in the long-term.
Michel Gagner, M.D. FRCSC, FACS, FASMBS Herbert Wertheim College of Medicine, Florida International University, Miami, FL and Hopital du Sacre Coeur, Montreal , QC, Canada
Everybody is focused on decreasing short-term re-admission (30 days), especially as many are now using Enhanced Recovery After Bariatric Surgery (ERABS) programs. We have recently heard about the quality improvement program, known as DROP, for Decreasing Readmissions through Opportunities Provided, developed by the American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (ACS-MBSAQIP). With this program, for example, 30 day re-admissions after laparoscopic sleeve gastrectomy (SG) decreased from 4.02% to 3.54%, a 12% reduction.
But what about long-term? Would this decrease the overall costs in a major way? I read with interest the manuscript entitled Hospital admission after gastric bypass: A nationwide cohort study with up to 6 year follow-up by Bruze et al. from Sweden.1 A longitudinal study of more than 28, 331 patients have been followed in a country that has a national healthcare system, similarly to many OECD countries (Organisation for Economic Cooperation and Development), who underwent a Roux-en-Y gastric bypass (RYGB) between 2007 and 2012. Using the Scandinavian Obesity Surgery registry (SOreg); these were compared to a matched population during the same period (274, 759 patients), excluding plastic surgeries and child deliveries. A Hospital Readmission rate (HR) of 2.6 and 2.7 demonstrated an increased risk
of later hospital admissions at 1 and 6 years (by then 65% of patients had been re-admitted) for RYGB patients and especially for a gastrointestinal surgical procedure (HR 7.7).
What stands out are hospitalizations needed for gallstone problems, internal herniation, and gastro-intestinal surgeries in general. One would perhaps decrease dramatically the incidence of gallstones with the use of routine oral ursodeoxycholic acid postoperatively for 6 months, something not in routine use in Sweden.2 Would prophylactic cholecystectomy for asymptomatic gallstones at the time of RYGB decrease this possibility? The University of California in San Diego is favoring this, based on the California Office of Statewide Health Planning and Development longitudinal database, which queried patients who underwent RYGB with or without cholecystectomy between 1995 and 2009. Of 134,584 RYGB patients, 21,022 underwent concomitant cholecystectomy. It improved both survival (HR 0.51) and long-term outcomes (HR 0.84). The incidence of gallbladder disease following RYGB alone was 6.8 and 15.2 % at 1 and 5 years. Cholecystectomy after RYGB was associated with higher risk of conversion to an open procedure (HR 1.58), post-operative complications (HR 1.47) and deaths (HR 1.32).3 However, old open surgical data is less applicable to today’s reality with laparoscopic approaches. The debate is still on. I tend not to favor this approach as there is a higher risk of bile duct injury in a morbidly obese patient, and the increased operating time would be a negative aspect of this approach. Dorman et al. have found, using the ACS-NSQIP database, that of 32,946 patients who underwent RYGB, 1,731 (5.2%) also had a cholecystectomy, which was a risk factor for major adverse events following a laparoscopic, but not an open procedure. Regardless of approach, prolonged length of stay was more common among those with a concomitant cholecystectomy.4
An advantage provided by SG is the direct access to the biliary tree via endoscopic retrograde cholangio-pancreatogrphy (ERCP), without the need for a general anesthetic. Performing a transgastric ERCP, a considerable complex procedure, which adds co-morbidity.5 CBD stones or pancreatitis can still occur after cholecystectomy, complicating ERCP’s.
Mesenteric defects should be closed routinely, whatever the procedure and approach, when it involves a connection of the small bowel. The recent multicenter randomized trial with a twoarm, parallel design done at 12 centers for bariatric surgery in Sweden demonstrated clearly a reduction in the incidence of bowel obstruction when mesenteric defects were closed routinely as opposed to none. At 3 years after surgery, the cumulative incidence of reoperation because of small bowel obstruction was significantly reduced in the closure group (cumulative probability 0·055 for closure vs. 0·102 for non-closure, hazard ratio 0·56, 95% CI 0·41-0·76, p=0·0002).6 There is a learning curve to do this properly: one has to use the right suture, appropriate bites in the mesentery, distance and tension, as well as anchoring to the serosa These steps are undoubtedly key factors that could decrease occurrence of an internal hernia with its associated symptoms.
In terms of reducing other gastro-intestinal problems like strictures, ulcers, and hiatal hernia/reflux, one could use a longer period of proton-pump inhibitors (PPI), as it has been demonstrated that the incidence of marginal ulceration after RYGB decreased significantly (P<.05) among patients receiving daily PPI for 90 days (n = 26, 6.5%) compared with those
receiving PPI for 30 days (n = 76, 12.4%).7 Also creating a smaller gastric pouch will likely decrease the incidence of ulcers, and a wider anastomosis decrease the incidence of strictures. For hiatal hernias, better detection preoperatvely may guide the surgeon to perform a routine hiatal hernia closure at the time of RYGB.8
Other risk factors for readmission in the long-term have been identified: female sex, psychiatric disease and low educational level.1 Is there a role for SG in these higher risk groups? The Swedish authors believe that re-admission is higher in SG patients.1 They have quoted a study linked to a high risk for readmission (>30%)!, but this study was taken from an administrative database from New York (not a clinical one), more specifically the New York Statewide Planning and Research Cooperative System (SPARCS) administrative database, in 2006 to 2008, where this surgery was during the procedure’s learning curve,. There was also a major administrative error in this paper, where the code ICD-9 43.89 was utilized (open and other partial gastrectomy) and is not a bariatric surgery code, while the new code ICD-9 43.82 began to be used in October 2011. This means that many “open and partial gastrectomies” may have been indeed done for tumors or ulcers and not specifically SG for obesity, known for a higher readmission rate. Hence this data is to be found unreliable.9
The study by Sippey at al. was more accurate; clinical data came from the ACS-NSQIP participating facilities. A total of 34,983 patients underwent bariatric surgery with an adequate mix (46.0% SG, 54.0% RYGB). Readmission was reported in 1773 (5.1%) patients, and was more
common after RYGB compared with SG (6.1% versus 3.8%, P<.001, adjusted OR 1.59). Postoperative pain, bleeding, intestinal obstructions, and wound occurrences were more commonly a readmission cause for RYGB compared with SG.10
A single institution review by the Massachusetts General Hospital has demonstrated that a higher percentage of RYGB patients required cholecystectomy as compared to SG patients (5 vs. 2 %, p < 0.01).11 There was also a significant difference in the proportion of patients requiring reoperation for other reasons following RYGB as compared to SG (6.9 vs. 0.9 %, p < 0.01). A total of 32.8 % of these bypass patients underwent more than one re-operation, with a relative risk of 11.5 (95 % CI 4.69-28.5) as compared to those undergoing SG. Other re-operations occurred without an identifiable abdominal source in 22.2 %: adhesions/obstructions in 17.6 %, internal hernias in 15.7 %, ulcers 3.7% and intussusceptions 2.8%. SG was associated with a much lower rate of re-operations, while patients after RYGB were at a significant long-term risk for multiple re-operations.11
And this has been recently confirmed in a study by Berger et al., although only short term, where a total of 130,007 patients who underwent primary bariatric surgery were identified.12 A total of 4.4% of patients were readmitted within 30 days, with patients undergoing SG having a readmission rate of 2.8% vs. 4.9% for RYGB. Causes of readmissions were nausea, vomiting, fluid and electrolyte issues, nutritional depletion (35.4%), abdominal pain (13.5%), anastomotic leak (6.4%), and bleeding (5.8%), accounting for 61% of readmissions. Higher rates of readmission were seen with RYGB than SG, odds ratio 3.06; 95% confidence interval 2.46-3.81).12
Reoperations for weight regain, diabetes recurrence after RYGB were not discussed in the Bruze et al. study, perhaps because no such clear strategies exist in Sweden for these patients? These may be the highest costs in the long-term (after 10 years). Finally, since Sweden is not performing laparoscopic SG in as large a scale as other countries, we should wait for the results of a multicenter randomized trial comparing RYGB and SG, to find out if readmission will be decreased in the long-term with this intervention.
References
1-Bruze G, Ottosson J, Neovius M, Naslund I, Marsk R. Hospital admission after gastric bypass: A nationwide cohort study with up to 6 years follow-up. SOARD 2017, in press.
2-Sugerman HJ, Brewer WH, Shiffman ML, Brolin RE, Fobi MA, Linner JH, MacDonald KG, MacGregor AM, Martin LF, Oram-Smith JC, et al. A multicenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid weight loss. Am J Surg. 1995 Jan;169(1):91-6.
3-Weiss AC, Inui T, Parina R, Coker AM, Jacobsen G, Horgan S, Talamini M, Chang DC, Sandler B. Concomitant cholecystectomy should be routinely performed with laparoscopic Roux-en-Y gastric bypass. Surg Endosc. 2015 Nov;29(11):3106-11.
4-Dorman RB, Zhong W, Abraham AA, Ikramuddin S, Al-Refaie WB, Leslie DB, Habermann EB. Does concomitant cholecystectomy at time of Roux-en-Y gastric bypass impact adverse operative outcomes? Obes Surg. 2013 Nov;23(11):1718-26.
5-Manassa E, Assalia A, Mahajna A.Laparoscopic intraoperative ERCP through a transgastric approach after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2016 May;12(4):e43-5.
6-Stenberg E, Szabo E, Ågren G, Ottosson J, Marsk R, Lönroth H, Boman L, Magnuson A, Thorell A, Näslund I. Closure of mesenteric defects in laparoscopic gastric bypass: a multicentre, randomised, parallel, open-label trial. Lancet. 2016 Apr 2;387(10026):1397-404.
7-Kang X, Zurita-Macias L, Hong D, Cadeddu M, Anvari M, Gmora S. A comparison of 30-day versus 90-day proton pump inhibitor therapy in prevention of marginal ulcers after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2016 Jun;12(5):1003-7.
8- Mohammed R, Fei P, Phu J, Asai M, Antanavicius G. Efficiency of preoperative esophagogastroduodenoscopy in identifying operable hiatal hernia for bariatric surgery patients. Surg Obes Relat Dis. 2016 Aug 17. pii: S1550-7289(16)30187-3.
9-Telem DA, Talamini M, Gesten F, Patterson W, Peoples B, Gracia G, Yang J, Zhang Q, Altieri M, Pryor AD. Hospital admissions greater than 30 days following bariatric surgery: patient and procedure matter. Surg Endosc. 2015 Jun;29(6):1310-5.
10-Sippey M, Kasten KR, Chapman WH, Pories WJ, Spaniolas K. 30-day readmissions after sleeve gastrectomy versus Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2016 Jun;12(5):991-6.
11-Zak Y, Petrusa E, Gee DW. Laparoscopic Roux-en-Y gastric bypass patients have an increased lifetime risk of repeat operations when compared to laparoscopic sleeve gastrectomy patients. Surg Endosc. 2016 May;30(5):1833-8.
12-Berger ER, Huffman KM, Fraker T, Petrick AT, Brethauer SA, Hall BL, Ko CY, Morton JM. Prevalence and Risk Factors for Bariatric Surgery Readmissions: Findings From 130,007 Admissions in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Ann Surg. 2016 Nov 15. [Epub ahead of print]