Causes of 30-day bariatric surgery mortality: with emphasis on bypass obstruction.

BACKGROUND: This is a study of the causes of 30-day postoperative death following surgical treatment for obesity and a search for ways to decrease an already low mortality rate. METHODS: Data were contributed from 1986-2004 to the International Bariatric Surgery Registry by 85 sites, representing 137 surgeons. A spread-sheet was prepared with rows for causes and columns for patients. The 251 causes contributing to 93 deaths were then marked in cells wherever a patient was noted to have one of the causes. Rows and columns were then moved into positions that provided patterns of best fit. RESULTS: 11 patterns were found. 10 had well known initiating causes of death. Overall operative 30-day mortality was 0.24% (93 / 38,501). The most common cause of death was pulmonary embolism (32%, 30/93). 14 deaths were caused by leaks (15%, 14/93), and were equally prevalent after simple (15%, 2/14) or complex (15%, 12/79) operations. Small bowel obstruction caused 8 deaths, exclusively after complex operations. 5 of these involved the bypassed biliopancreatic limb and were defined as "bypass obstruction". CONCLUSIONS: A spread-sheet study of cause of 30-day postoperative death revealed a rapidly lethal initiating complication of Roux-en-Y gastric bypass obstruction that requires the earliest possible recognition and treatment. Bypass obstruction needs a name and code to facilitate recognition, study, prevention and early treatment. Spread-sheet pattern analysis of all available data helped identify the initiating cause of death for individual patients when multiple data elements were present.

Bariatric surgery trends: an 18-year report from the International Bariatric Surgery Registry.

BACKGROUND: The epidemic of morbid obesity has increased bariatric procedures performed. Trend analyses provide important information that may impact individual practices. METHODS: Patient data from 137 surgeons were examined from 1987 to 2004 (41,860 patients) using Cochran-Armitage Trend test and Generalized Linear Model. RESULTS: Over an 18-year period, surgeon preference for combined restrictive-malabsorptive procedures increased from 33% to 94%, while simple gastric restriction decreased correspondingly (P < .0001). Surgeons per worksite doubled and cases per surgeon increased 71%. Laparoscopic procedures increased to 24%. The percentage of males, mean operative age, and initial body mass index (BMI) increased significantly (P < .0001). Postoperative hospital stay decreased from 5.0 to 3.9 days (P < .0001). The most common procedure in 2004 was Roux-en-Y gastric bypass (RYGB) (59%). CONCLUSION: Bariatric surgery patients are now older and heavier, length of stay is shorter, and the laparoscopic approach is more frequent. From 1987 to 2004, the general trend shows a clear preference for combined restrictive-malabsorptive operations.

Factors influencing survival following surgical treatment of obesity.

BACKGROUND: The prevalence of obesity in the United States and the surgical treatment of obesity have increased since 1999. An important measure of outcome following surgical treatment is survival. METHODS: This study began with data prospectively collected from Jan 1, 1986 to Dec 31, 1999 by 55 data collection sites, representing 77 surgeons who used standardized data collection software developed by the International Bariatric Surgery Registry (IBSR). A subset of 18,972 subjects was submitted to the National Death Index (NDI) for search of death occurring from Jan 1, 1986 to Dec 31, 2001. The univariate survival analysis included Kaplan-Meier plots and log-rank tests. Cox proportional-hazards (PH) frailty model was used to identify risk factors and estimate hazard ratios in a multi-factor survival analysis. Covariates included gender, operative age, body mass index, operation category (simple and complex), operation year, diabetes, smoking and hypertension as recorded prior to operation. RESULTS: Deaths were found for 3.45% of the patients (654/18,972). Average follow-up was 8.3 years. Age, gender, BMI, history of smoking, diabetes, and hypertension were significant predictors of survival. Operation category (P=0.13) and operation year (P=0.89) were not significant predictors of survival. CONCLUSION: Simple and complex operations were equally effective in keeping patients alive in this cohort of patients operated on for severe obesity from 1986 to 1999. Young, female, non-smoking patients with low BMI at operation and no history of diabetes or hypertension had the longest survival. Longer follow-up for death is needed before any recommendations can be made for operation category based on survival.

Psychiatric diagnosis and weight loss following gastric surgery for obesity.

BACKGROUND: The authors examined associations between lifetime Axis I and Axis II disorders and weight loss following gastric surgery for morbid obesity. METHODS: 44 morbidly obese subjects who had undergone vertical banded gastroplasty (VBG) were systematically interviewed with the Diagnostic Interview Schedule (DIS) and were administered the Personality Diagnostic Questionnaire (PDQ). Subjects were followed-up 6 months post-VBG to determine weight loss. RESULTS: The subjects had a mean +/- SD age of 37.7 +/- 10.6 years. Their baseline weight was 135.3 +/- 28.0 kg and their baseline body mass index (BMI) was 50.0 +/- 7.4. 34 (77%) were female. Results of linear regressions show a significant association between baseline BMI and weight loss at 6-month follow-up. After adjustment for baseline BMI, there was a non-significant trend toward increased weight loss in association with alcohol abuse/dependence. Similarly, among our analysis of 41 subjects who had received the PDQ, we found a non-significant trend toward increased weight loss in association with "any" PDQ diagnosis and with antisocial personality disorder/trait after adjusting for baseline BMI. CONCLUSION: The data suggest that Axis I and Axis II diagnoses were not predictive of weight loss following VBG during a 6-month follow-up.

Severe metabolic bone disease as a long-term complication of obesity surgery.

BACKGROUND: Metabolic bone disease is a well-documented long-term complication of obesity surgery. It is often undiagnosed, or misdiagnosed, because of lack of physician and patient awareness. Abnormalities in calcium and vitamin D metabolism begin shortly after gastrointestinal bypass operations; however, clinical and biochemical evidence of metabolic bone disease may not be detected until many years later. CASE REPORT: A 57-year-old woman presented with severe hypocalcemia, vitamin D deficiency, and radiographic evidence of osteomalacia, 17 years after vertical banded gastroplasty and Roux-en-Y gastric bypass. Following these operations, she was diagnosed with a variety of medical disorders based on symptoms that, in retrospect, could have been attributed to metabolic bone disease. Additionally, she had serum metabolic abnormalities that were consistent with metabolic bone disease years before this presentation. Radiographic evidence of osteomalacia at the time of presentation suggests that her condition was advanced, and went undiagnosed for many years. These symptoms and laboratory and radiographic abnormalities most likely were a result of the long-term malabsorptive effects of gastric bypass, food intake restriction, or a combination of the two. CONCLUSION: This case illustrates not only the importance of informed consent in patients undergoing obesity operations, but also the importance of adequate follow-up for patients who have undergone these procedures. A thorough history and physical examination, a high index of clinical suspicion, and careful long-term follow-up, with specific laboratory testing, are needed to detect early metabolic bone disease in these patients.

Gallbladder management in obesity surgery.

BACKGROUND: In the 1980s, some surgeons recommended routine cholecystectomy for patients undergoing bariatric surgery. This was based on the high prevalence of gallstones in the obese and concern that rapid weight loss would increase the risk of gallbladder disease. Others recommended waiting for a lower weight and a definite need. With increasing prevalence and severity of obesity and increased use of gastric reduction surgery for weight control, it seemed appropriate to review the current standard of care for cholecystectomy. A survey was also made of ursodeoxycholic acid usage for prevention of gallstone formation. METHODS: Data collected from active contributors for the 28th Report of the International Bariatric Surgery Registry (IBSR) were examined. Two questionnaires were also sent to members of the American Society for Bariatric Surgery (ASBS). The first (Q1) asked about the indications for cholecystectomy. The second (Q2) asked about ursodeoxycholic acid usage for prevention of gallstone formation during rapid weight loss following surgical treatment of obesity. RESULTS: There has been an increase in concurrent cholecystectomy during the last 15 years. Some of this is due to a shift from simple gastric restrictive operations to gastric bypass with gastric restriction. When the most extensive bypass of intestine is used, as in distal Roux-en-Y gastric bypass (RYGBP-X) or biliopancreatic diversion with a duodenal switch (BPD-DS), all patients were reported to have undergone cholecystectomy. Only 30% of surgeons performing standard Roux-en-Y gastric bypass (RYGBP) remove normal-appearing gallbladders. Ursodeoxycholic acid is used to prevent gallstone formation in one-third of patients when a normal-appearing gallbladder is left in place. CONCLUSIONS: Prophylactic cholecystectomy is left to the discretion of the surgeon when RYGBP is used. There has been an increase in cholecystectomy and malabsorptive operations during the last 15 years. When most of the small bowel is bypassed, all remaining gallbladders are removed. For patients with simple restriction operations, normal-appearing gallbladders are usually left in place. Urso-deoxycholic acid during rapid weight loss for prevention of gallstone formation is used in one-third of patients with remaining gallbladders.