Differences in open versus laparoscopic gastric bypass mortality risk using the Obesity Surgery Mortality Risk Score (OS-MRS).

BACKGROUND: The Obesity Surgery Mortality Risk Score (OS-MRS) was developed to ascertain preoperative mortality risk of patients having bariatric surgery. To date there has not been a comparison between open and laparoscopic operations using the OS-MRS. OBJECTIVE: To determine whether there are differences in mortality risk between open and laparoscopic Roux-en-Y Gastric Bypass (RYGB) using the OS-MRS. SETTING: Three university-affiliated hospitals. METHODS: The 90-day mortality of 2467 consecutive patients who had primary open (1574) or laparoscopic (893) RYGB performed by one surgeon was determined. Univariate and multivariate analysis using 5 OS-MRS risk factors including body mass index (BMI) gender, age>45, presence of hypertension and preoperative deep vein thrombosis (DVT) risk was performed in each group. Each patient was placed in 1 of 3 OS-MRS risk classes based on the number of risks: A (0-1), B (2-3), and C (4-5). RESULTS: Preoperative BMI and DVT risk factors were significantly greater in the open group (OG). Preoperative age was significantly greater in the laparoscopic group (LG). There were significantly more class B and C patients in LG. Ninety-day mortality rates for OG and LG patients were 1.0% and .9%, respectively. Pulmonary embolism was the most common cause of death. All deaths in LG occurred during first 4 years of that experience. Mortality rate by class was A = .1%; B = 1.5%; C = 2.3%. The difference in mortality between class B and C patients was not significant. Univariate analysis in the OG indicated that BMI, age, gender, and DVT risk were significant predictors of mortality. In the LG only BMI and DVT were significant predictors of death. Presence of hypertension was not a significant predictor in either group. Multivariate analysis excluding hypertension found that age was predictive of mortality in the OG while BMI (P = .057) and gender (P = .065) approached statistical significance. Conversely, only BMI was predictive of mortality in the LG with age approaching significance (P = .058). In multivariate analysis DVT risk was not predictive of mortality in either group. CONCLUSIONS: There are significant differences in the predictive value of the OS-MRS between open and laparoscopic RYGB. Although laparoscopic patients were significantly older versus the open patients, age was not predictive of mortality after laparoscopic RYGB. BMI trended toward increased mortality risk in both groups. Changes in technique and protocol likely contributed toward no mortality during the last 6 years of our laparoscopic experience.

Weight loss outcome of revisional bariatric operations varies according to the primary procedure.

BACKGROUND: Revisional bariatric operations performed for weight loss failure are frequently associated with inconsistent weight reduction and serious perioperative complications. METHODS: Outcomes of 151 consecutive revisional operations performed by one surgeon for unsatisfactory weight loss were compared to determine whether postoperative weight loss is influenced by the type of primary procedure. Minimum follow-up was 12 months. RESULTS: Primary operations included 14 jejunoileal bypass (JIB): one revised to gastroplasty, 13 to RY gastric bypass; 71 gastroplasty/banding (GP/B): all revised to Roux-en-Y gastric bypass (RYGB); and 66 gastric bypass: 49 revised to distal/malabsorptive RYGB, 12 restapled without malabsorption, and 5 loop bypasses revised to standard RYGB. Perioperative morbidity/mortality rates were 21.8% and 1.3%, respectively. Follow-up at 12 months was 93%. Mean weight/body mass index unit loss after revision of JIB was 90 pounds/17 units versus 113 pounds/16 units after revision of GP/B and 71 pounds/11 units after revision of gastric bypass (P < or = 0.05) with corresponding mean percent of excess weight loss of 51% for JIB, 56% for GP/B, and 48% for gastric bypass. Five of the JIB revisions (38%) lost > or = 50% excess weight loss versus 39 of the GP/B revisions (61%) and 28 of the gastric bypass revisions (48%). Comorbidities improved/resolved in 100% of those who lost > or = 50% of excess weight versus 89% who did not. CONCLUSIONS: Weight loss after revision of pure restrictive operations is significantly better than after revision of operations with malabsorptive components. Improvement of comorbidities in the great majority of patients justifies revision of all types of bariatric operations for unsatisfactory weight loss.

Impact of technological advances on complications of revisional bariatric operations.

BACKGROUND: Revisional bariatric operations are technically challenging and are associated with a high perioperative complication rate. Several parameters were analyzed to determine whether experience, coupled with technical innovation, reduced complications after these high-risk procedures. STUDY DESIGN: Outcomes of 215 consecutive revisional bariatric operations performed by 1 surgeon during the past 22 years were assessed before and after routine use of 6-row endostaplers and harmonic scalpel, which began in 2001. RESULTS: All but 3 operations were performed open, including 151 for weight loss failure (14 jejunoileal bypass, 71 gastroplasty or banding, 66 gastric bypass) and 64 for complications of the primary procedure (12 jejunoileal bypass, 11 gastroplasty or banding, 41 gastric bypass). Major perioperative complications occurred in 45 patients (21%): there were 15 leaks, 11 wound infections, 3 pulmonary embolisms, and 16 miscellaneous, including 3 deaths (1.4%). Morbidity after January 2001 was 6 of 73 (8.2%) versus 39 of 138 (28%) before 2001 (p < 0.0005). All deaths occurred before 2001. Complications occurred in 10 of 97 patients (10.3%) who had primary gastric restrictive operations (excluding banding) by the author versus 24 of 65 patients (36.9%) who had similar primary operations by other surgeons (p < 0.0001). Morbidity after second revisions was 70% versus 14.4% after first revisions (p < 0.0001). The 32 most recent patients were discharged in a mean of 3.0 days without complications. CONCLUSIONS: Incorporating the endostaplers and harmonic scalpel into open revisional operations significantly reduced postoperative complications. Because these 2 devices were introduced during the last 5 years of this study, it seems likely that cumulative experience also contributed to improved outcomes. Our results also suggest that surgeons perform their initial revisions on their own patients rather than on patients who had primary procedures elsewhere. Patients presenting as candidates for a second revision should be cautiously evaluated, anticipating a high morbidity rate.

Adding malabsorption for weight loss failure after gastric bypass.

OBJECTIVE: To present a technique of revisional RY gastric bypass in patients with unsatisfactory weight loss after primary gastric bariatric operations. METHODS: The Roux limb was lengthened by creating a 75-100 cm common channel below the enteroenterostomy with concomitant revision of the gastrojejunostomy. RESULTS: Fifty-four patients had this distal modification of RYGB including 47 patients who had primary gastric bypass and 7 patients who failed pure restrictive operations. Mean excess weight loss was 47.9% in patients followed for > or = 1 year. CONCLUSIONS: This distal modification of RYGB resulted in satisfactory weight loss for nearly half of the 54 patients in this series.

Diagnosis and satisfaction scores in emergency department patients who return a mailed survey.

Previous studies of patient satisfaction scores (PSS) have been of insufficient size to examine the influence of diagnosis on PSS. Our objective was to utilize a large database to determine if PSS for patients who return a widely used mailed proprietary survey differ with different diagnoses. We retrospectively analyzed a cohort at 11 hospital emergency departments of non-admitted patients who returned a mailed satisfaction survey. We grouped patients according to International Classification of Diseases, 9(th) Revision (ICD9) diagnoses and calculated mean scores for each diagnostic group. We rank-ordered by mean scores all ICD diagnoses having at least 50 survey responses. Scores were compared using analysis of variance. We analyzed 14,098 surveys. Among all diagnoses, 65 had at least 50 responses. The analysis of variance for the scores showed significant differences (p < 0.0001). Scores differ with respect to diagnosis. This could be used to choose interventions to improve scores of patients who return a mailed survey.

Concepts in developing health-based indicators for ozone.

OBJECTIVES: The traditional manner to evaluate whether regulatory controls meet their public health goals of reducing adverse health effects associated with exposure to environmental pollutants is to compare measured concentrations of the target pollutant in the environment with a standard. A complementary approach is also to measure health-based indicators, e.g., changes in the prevalence of adverse health outcomes attributed to the pollutant. This manuscript presents the concepts of using asthma emergency room (ER) visits and hospital admission as potential health-based indicators for ozone. METHODS: The frequency of ER visits and hospital admissions for asthma in New Jersey in 1995 was compared with daily ozone concentrations, to establish the consistency of the relationship and the presence of potential confounders, and to establish whether routinely documented adverse outcomes in asthmatics could serve as health-based indicators. RESULTS: A mathematical model relating ER visits and hospital admissions of asthmatics to ozone concentration was developed for 1995, which was to be used as a baseline year within a health-based indicator program. A coherent relationship was found between same-day ambient air ozone concentrations and ER visits and 2-day time-lagged ambient ozone and hospital admissions during 1995; pollen was identified as a confounder and the association between ER visits and ozone concentration was similar to that determined for 1986 to 1990. CONCLUSIONS: Sufficient databases exist for ER visits by asthmatics in Northern and Central New Jersey, and throughout the state for hospital admissions, for these health outcomes to be used as health-based indicators, complementing air-monitoring data in assessing whether improvements in public health are occurring because of reduction in emissions of precursors of ozone.

Malabsorptive gastric bypass in patients with superobesity.

Weight loss in superobese patients has been problematic after conventional gastric restrictive operations including conventional Roux-en-Y gastric bypass (RYGB). The goal of the present study was to compare weight loss in patients with superobesity (body mass index > or =50 kg/m(2)) using a distal RYGB (D-RY) in which the Roux-en-Y anastomosis was performed 75 cm proximal to the ileocecal junction (N = 47) vs. patients who had Roux limbs of 150 cm (N = 152) and 50 to 75 cm (N = 99). All operations incorporated the same gastric restrictive parameters. Minimum follow-up was 3 years and ranged to 16 years. Weight loss and reduction in body mass index were significantly greater after D-RY vs. both RYGB-150 cm and short RYGB and in RYGB-150 cm vs. short RYGB through 5 years. Mean percentage of excess weight loss peaked at 64% after DRY, at 61% after RYGB-150 cm, and at 56% after short RYGB. Weight loss maintenance through 5 years was correlated with Roux limb length with D-RY greater than RYGB-150 cm greater than short RYGB. More than 95% of obesity-related comorbid conditions improved or resolved with weight loss. There was no difference in the early postoperative morbidity rates: 9% after D-RY; 8% after RYGB-150 cm; and 2% after short RYGB with one death (0.3%). All D-RY patients had at least one postoperative metabolic abnormality. Anemia was significantly more common after D-RY vs. the shorter RYGB with no difference in the incidence of metabolic sequelae between RYGB-150 cm and short RYGB. No operations were reversed or modified for nutritional complications. Two D-RY patients required total parenteral nutrition for protein malnutrition. These results show that Roux limb length is correlated with weight loss in superobese patients. However, the greater incidence of metabolic sequelae after D-RY vs. RYGB-150 cm calls into question its routine use in superobese patients undergoing bariatric surgery. We conclude that some degree of malabsorption should be incorporated into bariatric operations performed in superobese patients to achieve satisfactory long-term weight loss.