Extended postoperative venous thromboembolism prophylaxis after bariatric surgery: a comparison of existing risk-stratification tools and 5-year MBSAQIP analysis.

BACKGROUND: Venous thromboembolism (VTE) is a leading cause of 30-day mortality after metabolic and bariatric surgery (MBS). Multiple predictive tools exist for VTE risk assessment and extended VTE chemoprophylaxis determination. OBJECTIVE: To review existing risk-stratification tools and compare their predictive abilities. SETTING: MBSAQIP database. METHODS: Retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was performed (2015-2019) for primary minimally invasive MBS cases. VTE clinical factors and risk-assessment tools were evaluated: body mass index threshold of 50 kg/m2, Caprini risk-assessment model, and 3 bariatric-specific tools: the Cleveland Clinic VTE risk tool, the Michigan Bariatric Surgery Collaborative tool, and BariClot. MBS patients were deemed high risk based on criteria from each tool and further assessed for sensitivity, specificity, and positive predictive value. RESULTS: Overall, 709,304 patients were identified with a .37% VTE rate. Bariatric-specific tools included multiple predictors: procedure, age, race, gender, operative time, length of stay, heart failure, and dyspnea at rest; operative time was the only variable common to all. The body mass index cutoff and Caprini risk-assessment model had higher sensitivity but lower specificity when compared with the Michigan Bariatric Surgery Collaborative and BariClot tools. While the sensitivity of the tools varied widely and was overall low, the Cleveland Clinic tool had the highest sensitivity. The bariatric-specific tools would have recommended extended prophylaxis for 1.1%-15.6% of patients. CONCLUSIONS: Existing MBS VTE risk-assessment tools differ widely for inclusion variables, high-risk definition, and predictive performance. Further research and registry inclusion of all significant risk factors are needed to determine the optimal risk-stratified approach for predicting VTE events and determining the need for extended prophylaxis.

Does BMI Matter? A 10-Year Single Institutional Experience on 571 Bariatric Surgery Patients With BMI >50 kg/m 2.

INTRODUCTION: Patients undergoing bariatric surgery with body mass index (BMI) >50 kg/m 2 are at a higher risk of surgical morbidity when compared with less obese patients, however, there is limited data correlating surgical risk and efficacy with increasing BMI in patients with severe obesity. We hypothesize that regardless of the degree above 50 kg/m 2 their BMI, patients with severe obesity respond similarly to bariatric surgery. MATERIALS AND METHODS: We performed a retrospective analysis of patients with BMI >50 kg/m 2 who underwent biliopancreatic diversion with duodenal switch, Roux-en-Y gastric bypass, or sleeve gastrectomy at a single institution. Outcomes were compared in patients with a BMI between 50 and 60 kg/m 2 to patients with a BMI >60 kg/m 2 and included percent total weight loss as well as early and late complications. Statistical analyses were performed using logistic regression, univariate, and multivariate models. RESULTS: There were 571 patients with BMI >50 kg/m 2 who underwent bariatric surgery at our center, 170 (29.8%) had a BMI >60 kg/m 2 . Percent total weight loss was statistically significant between the BMI 50 and 60 kg/m 2 and BMI >60 kg/m 2 groups at 24 months ( P =0.047) but not at 60 months ( P =0.54). No significant difference was found in the incidence of early complications in a univariate ( P =0.46) or a multivariate ( P =0.06) analysis. The BMI >60 subgroup was associated with a higher rate of late complications in univariate analysis (heart rate=2.37; 1.03-5.47, P =0.04), but not in multivariate analysis ( P =0.78). CONCLUSIONS: Efficacy and complication rates of bariatric surgeries are similar in patients with BMI 50 to 60 kg/m 2 and >60 kg/m 2 , providing evidence supporting similar management of patients despite specific subgroups.

Postoperative Care Using a Secure Online Patient Portal: Changing the (Inter)Face of General Surgery.

BACKGROUND: Many patients seek greater accessibility to health care. Meanwhile, surgeons face increasing time constraints due to workforce shortages and elevated performance demands. Online postoperative care may improve patient access while increasing surgeon efficiency. We aimed to evaluate patient and surgeon acceptance of online postoperative care after elective general surgical operations. STUDY DESIGN: A prospective pilot study within an academic general surgery service compared online and in-person postoperative visits from May to December 2014. Included patients underwent elective laparoscopic cholecystectomy, laparoscopic ventral hernia repair, umbilical hernia repair, or inguinal hernia repair by 1 of 5 surgeons. Patients submitted symptom surveys and wound pictures, then corresponded with their surgeons using an online patient portal. The primary outcome was patient-reported acceptance of online visits in lieu of in-person visits. Secondary outcomes included detection of complications via online visits, surgeon-reported effectiveness, and visit times. RESULTS: Fifty patients completed both online and in-person visits. Online visits were acceptable to most patients as their only follow-up (76%). For 68% of patients, surgeons reported that both visit types were equally effective, while clinic visits were more effective in 24% and online visits in 8%. No complications were missed via online visits, which took significantly less time for patients (15 vs 103 minutes, p < 0.01) and surgeons (5 vs 10 minutes, p < 0.01). CONCLUSIONS: In this population, online postoperative visits were accepted by patients and surgeons, took less time, and effectively identified patients who required further care. Further evaluation is needed to establish the safety and potential benefit of online postoperative visits in specific populations.

Incisional Hernia Classification Predicts Wound Complications Two Years after Repair.

Classification of ventral hernias (VHs) into categories that impact surgical outcome is not well defined. The European Hernia Society (EHS) classification divides ventral incisional hernias by midline or lateral location. This study aimed to determine whether EHS classification is associated with wound complications after VH repair, indicated by surgical site occurrences (SSOs). A retrospective cohort study of patients who underwent VH repair at a tertiary referral center between July 1, 2005 and May 30, 2012, was performed. EHS classification, comorbidities, and operative details were determined. Primary outcome was SSO within two years, defined as an infection, wound dehiscence, seroma, or enterocutaneous fistula. There were 538 patients included, and 51.5 per cent were female, with a mean age of 54.2 ± 12.4 years and a mean body mass index of 32.4 ± 8.6 kg/m(2). Most patients had midline hernias (87.0%, n = 468). There were 47 patients (8.7%) who had a lateral hernia, and 23 patients (4.3%) whose repair included both midline and lateral components. Overall rate of SSO was 39 per cent (n = 211) within two years. The rate of SSO by VH location was: 39 per cent (n = 183) for midline, 23 per cent (n = 11) for lateral, and 74 per cent (n = 17) for VHs with midline and lateral components (P = <0.001). Patients whose midline hernia spanned more than one EHS category also had a higher rate of SSOs (P = 0.001). VHs are often described by transverse dimension alone, but a more descriptive classification system offers a richness that correlates with outcomes.