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In bariatric surgery, leak test may backfire
SCOTTSDALE, ARIZ. – A test used to detect anastomotic leaks during bariatric surgery may in fact be a potential cause of leaks, since performance of the test was associated with double the frequency of 30-day postoperative leaks, a study showed.
Based on this finding from an analysis of the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, the researchers suggested that the use of an endoscope could lead to fewer complications.
The test itself is valuable, since surgeons hope to find and repair a leak immediately, but Dr. Nguyen said the wrong method is being used. “The technique of doing the test should be endoscopy rather than the use of an orogastric tube,” he said. The database did not indicate which technique was being used, but Dr. Nguyen said that use of endoscopy is rare. Surgeons “don’t want to break scrub to go around and perform the endoscopy. It’s easier to ask the anesthesiologist to put a tube down,” said Dr. Nguyen, who is chair of surgery at University of California Irvine Medical Center.
The study, which was presented at the annual meeting of the Western Surgical Association, is the first to look at intraoperative and postoperative procedures and risk of leaks during bariatric surgery, and was possible only because of the recent availability of the MBSAQIP database. The study cannot prove causation between performance of the provocative test and heightened leak risk, and one audience member suggested the possibility that the tests were ordered when a surgeon believed the patient was at higher risk. If so, the association wouldn’t be causative.
However, the provocation test was performed 82% of the time, suggesting that the test was being carried out routinely, said Dr. Nguyen.
By contrast, when the surgeon inserted a surgical drain, the risk of leak was nearly four times higher. “It is most likely that the surgeon only decided to place the drain because they were worried about that particular operation, since it was only done a small percentage of the time. Our results suggest that they were right [to be concerned]. We believe it’s a reflection of the knowledge of the surgeon for that particular case,” said Dr. Nguyen.
If indeed there is a risk associated with the provocation test, the use of endoscopy could reduce that risk. Dr. Nguyen also pointed out that endoscopy provides anatomical detail that can help guide revision surgery, and it’s a useful training exercise for residents. “This is an important skill that you need when you graduate from general surgery,” said Dr. Nguyen.
The researchers analyzed data from 133,478 patients who underwent laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB), excluding emergent and revisional cases; 69.3% of patients underwent LSG, while 30.7% underwent LRYGB. The researchers looked at the association between leak frequency and the presence of the provocative test, surgical drain, and swallow study.
The 30-day leak rate was 0.7% overall, and 0.5% in LSG and 1.2% in LRYGB (adjusted odds ratio for LSG, 0.52; 95% confidence interval, 0.44-0.61; P less than .001). The rate was higher in the 81.9% of patients who received the provocative test than in those who did not (0.8% vs. 0.4%; aOR, 1.41; 95% CI, 1.14-1.76; P = .02). The leak risk was also higher in the 24.5% of patients who had a drain placed (1.6% vs. 0.4%; aOR, 3.46; 95% CI, 3.01-3.98; P less than .001).
A total of 41.1% of patients received a swallow study, but their leak rate (0.7%) was identical to that of those who did not have a swallow study.
The study received no outside funding. Dr. Nguyen reported having no relevant financial disclosures.
SCOTTSDALE, ARIZ. – A test used to detect anastomotic leaks during bariatric surgery may in fact be a potential cause of leaks, since performance of the test was associated with double the frequency of 30-day postoperative leaks, a study showed.
Based on this finding from an analysis of the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, the researchers suggested that the use of an endoscope could lead to fewer complications.
The test itself is valuable, since surgeons hope to find and repair a leak immediately, but Dr. Nguyen said the wrong method is being used. “The technique of doing the test should be endoscopy rather than the use of an orogastric tube,” he said. The database did not indicate which technique was being used, but Dr. Nguyen said that use of endoscopy is rare. Surgeons “don’t want to break scrub to go around and perform the endoscopy. It’s easier to ask the anesthesiologist to put a tube down,” said Dr. Nguyen, who is chair of surgery at University of California Irvine Medical Center.
The study, which was presented at the annual meeting of the Western Surgical Association, is the first to look at intraoperative and postoperative procedures and risk of leaks during bariatric surgery, and was possible only because of the recent availability of the MBSAQIP database. The study cannot prove causation between performance of the provocative test and heightened leak risk, and one audience member suggested the possibility that the tests were ordered when a surgeon believed the patient was at higher risk. If so, the association wouldn’t be causative.
However, the provocation test was performed 82% of the time, suggesting that the test was being carried out routinely, said Dr. Nguyen.
By contrast, when the surgeon inserted a surgical drain, the risk of leak was nearly four times higher. “It is most likely that the surgeon only decided to place the drain because they were worried about that particular operation, since it was only done a small percentage of the time. Our results suggest that they were right [to be concerned]. We believe it’s a reflection of the knowledge of the surgeon for that particular case,” said Dr. Nguyen.
If indeed there is a risk associated with the provocation test, the use of endoscopy could reduce that risk. Dr. Nguyen also pointed out that endoscopy provides anatomical detail that can help guide revision surgery, and it’s a useful training exercise for residents. “This is an important skill that you need when you graduate from general surgery,” said Dr. Nguyen.
The researchers analyzed data from 133,478 patients who underwent laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB), excluding emergent and revisional cases; 69.3% of patients underwent LSG, while 30.7% underwent LRYGB. The researchers looked at the association between leak frequency and the presence of the provocative test, surgical drain, and swallow study.
The 30-day leak rate was 0.7% overall, and 0.5% in LSG and 1.2% in LRYGB (adjusted odds ratio for LSG, 0.52; 95% confidence interval, 0.44-0.61; P less than .001). The rate was higher in the 81.9% of patients who received the provocative test than in those who did not (0.8% vs. 0.4%; aOR, 1.41; 95% CI, 1.14-1.76; P = .02). The leak risk was also higher in the 24.5% of patients who had a drain placed (1.6% vs. 0.4%; aOR, 3.46; 95% CI, 3.01-3.98; P less than .001).
A total of 41.1% of patients received a swallow study, but their leak rate (0.7%) was identical to that of those who did not have a swallow study.
The study received no outside funding. Dr. Nguyen reported having no relevant financial disclosures.
SCOTTSDALE, ARIZ. – A test used to detect anastomotic leaks during bariatric surgery may in fact be a potential cause of leaks, since performance of the test was associated with double the frequency of 30-day postoperative leaks, a study showed.
Based on this finding from an analysis of the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, the researchers suggested that the use of an endoscope could lead to fewer complications.
The test itself is valuable, since surgeons hope to find and repair a leak immediately, but Dr. Nguyen said the wrong method is being used. “The technique of doing the test should be endoscopy rather than the use of an orogastric tube,” he said. The database did not indicate which technique was being used, but Dr. Nguyen said that use of endoscopy is rare. Surgeons “don’t want to break scrub to go around and perform the endoscopy. It’s easier to ask the anesthesiologist to put a tube down,” said Dr. Nguyen, who is chair of surgery at University of California Irvine Medical Center.
The study, which was presented at the annual meeting of the Western Surgical Association, is the first to look at intraoperative and postoperative procedures and risk of leaks during bariatric surgery, and was possible only because of the recent availability of the MBSAQIP database. The study cannot prove causation between performance of the provocative test and heightened leak risk, and one audience member suggested the possibility that the tests were ordered when a surgeon believed the patient was at higher risk. If so, the association wouldn’t be causative.
However, the provocation test was performed 82% of the time, suggesting that the test was being carried out routinely, said Dr. Nguyen.
By contrast, when the surgeon inserted a surgical drain, the risk of leak was nearly four times higher. “It is most likely that the surgeon only decided to place the drain because they were worried about that particular operation, since it was only done a small percentage of the time. Our results suggest that they were right [to be concerned]. We believe it’s a reflection of the knowledge of the surgeon for that particular case,” said Dr. Nguyen.
If indeed there is a risk associated with the provocation test, the use of endoscopy could reduce that risk. Dr. Nguyen also pointed out that endoscopy provides anatomical detail that can help guide revision surgery, and it’s a useful training exercise for residents. “This is an important skill that you need when you graduate from general surgery,” said Dr. Nguyen.
The researchers analyzed data from 133,478 patients who underwent laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB), excluding emergent and revisional cases; 69.3% of patients underwent LSG, while 30.7% underwent LRYGB. The researchers looked at the association between leak frequency and the presence of the provocative test, surgical drain, and swallow study.
The 30-day leak rate was 0.7% overall, and 0.5% in LSG and 1.2% in LRYGB (adjusted odds ratio for LSG, 0.52; 95% confidence interval, 0.44-0.61; P less than .001). The rate was higher in the 81.9% of patients who received the provocative test than in those who did not (0.8% vs. 0.4%; aOR, 1.41; 95% CI, 1.14-1.76; P = .02). The leak risk was also higher in the 24.5% of patients who had a drain placed (1.6% vs. 0.4%; aOR, 3.46; 95% CI, 3.01-3.98; P less than .001).
A total of 41.1% of patients received a swallow study, but their leak rate (0.7%) was identical to that of those who did not have a swallow study.
The study received no outside funding. Dr. Nguyen reported having no relevant financial disclosures.
AT WSA 2017
Key clinical point: Use of endoscopy to perform the provocative test may reduce the incidence of anastomotic leaks.
Major finding: The rate of leaks was 0.8% in patients who had the provocative test, compared with 0.4% in patients who didn’t have the test.
Data source: A retrospective analysis of 133,478 procedures.
Disclosures: The study received no outside funding. Dr. Nguyen reported having no relevant financial disclosures.
VIDEO: Bariatric experts discuss recent experience with gastric balloon devices
Two experts on bariatric surgery spoke at the Minimally Invasive Surgery Symposium, held in Las Vegas. Jaime Ponce, MD, FACS, and John Morton, MD, FACS, discussed several different types of gastric balloon devices and the factors guiding their use for patients. Dr. Morton suggested that the balloon devices could serve as an intermediate treatment between medications and surgery.
Two experts on bariatric surgery spoke at the Minimally Invasive Surgery Symposium, held in Las Vegas. Jaime Ponce, MD, FACS, and John Morton, MD, FACS, discussed several different types of gastric balloon devices and the factors guiding their use for patients. Dr. Morton suggested that the balloon devices could serve as an intermediate treatment between medications and surgery.
Two experts on bariatric surgery spoke at the Minimally Invasive Surgery Symposium, held in Las Vegas. Jaime Ponce, MD, FACS, and John Morton, MD, FACS, discussed several different types of gastric balloon devices and the factors guiding their use for patients. Dr. Morton suggested that the balloon devices could serve as an intermediate treatment between medications and surgery.
Large database analysis suggests safety of bariatric surgery in seniors
NATIONAL HARBOR, MD. – despite a slight increase in unadjusted mortality rates, according to an analysis of data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).
Based on data that was collected in 2015 and submitted to MBSAQIP, “bariatric surgery is safe in the elderly, even in those 70 years old and older,” reported Tallal Zeni, MD, director of the Michigan Bariatric Institute in Livonia.
There were 16,568 patients older than age 60 years entered into the MBSAQIP database in 2015. When those were compared with the 117,443 younger patients, the unadjusted rates of morbidity (6.5% vs. 6.0%) and mortality (0.3% vs. 0.1%) were higher for the older patients, but “they are close,” according to Dr. Zeni. Both rates reached significance by the conventional definition (P < .05), but he suggested that they are lower in this study than those in prior studies of MBSAQIP datasets and that they are acceptable relative to the anticipated health benefits.
Above the age of 60 years, no correlation could be made between increasing age and increasing risk of morbidity, mortality, or rate of reoperations, according to Dr. Zeni.
Why should bariatric surgery be considered in older patients? He cited data from a study that showed the life expectancy in a 70-year-old without functional limitations is 13 years. As a result, he added, “it behooves us to provide them with the best quality of life we can.”
Relative to prior MBSAQIP evaluations of bariatric surgery in the elderly, the proportion of patients undergoing sleeve gastrectomy relative to gastric bypass has been increasing, Dr. Zeni reported. In the analysis, approximately two-thirds of the bariatric procedures were performed with sleeve gastrectomy, which is higher relative to what previous MBSAQIP analyses have shown.
Based on rates of morbidity for those two surgical approaches in the analysis, that trend makes sense. While the higher 30-day mortality for gastric bypass, compared with sleeve gastrectomy, was not significant (0.38% vs. 0.26%; P = .221), all-cause morbidity was almost two times greater for those undergoing gastric bypass than it was for those undergoing sleeve gastrectomy (10.61% vs. 5.81%; P < .001), Dr. Zeni reported.
However, some of that difference may be explained by baseline disparities between the two groups. In the gastric bypass group, there were higher rates of preoperative diabetes (54% vs. 40%; P < .001), sleep apnea (57% vs. 50%; P < .001) and hyperlipidemia (59% vs. 54%; P < .001). Also, gastric bypass patients were more likely to have a history of a previous bariatric procedure (11% vs. 8.5%; P < .001) and to be in the American Society of Anesthesiologists Physical Status score of 3 (84% vs. 80%; P < .001), according to Dr. Zeni.
The specific complications more common in the gastric bypass group than the sleeve gastrectomy group included anastomotic leak (0.56% vs. 0.3%; P = .017), surgical site infection (1.74% vs. 0.61%; P < .001), pneumonia (0.87% vs. 0.32%; P < .001), and bleeding (1.14% vs. 0.5%; P = .024). Although the average operating time was 40 minutes longer in the bypass group, there were no significant differences in thromboembolic complications.
Overall, despite a modest increase in the risk of complications for bariatric surgery in elderly patients, that risk can be considered acceptable in relation to the potential health benefits, according to Dr. Zeni. He suggested that the data might encourage further growth in the rates of bariatric procedures among patients older than 60 years.
Dr. Zeni reports no relevant financial relationships.
NATIONAL HARBOR, MD. – despite a slight increase in unadjusted mortality rates, according to an analysis of data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).
Based on data that was collected in 2015 and submitted to MBSAQIP, “bariatric surgery is safe in the elderly, even in those 70 years old and older,” reported Tallal Zeni, MD, director of the Michigan Bariatric Institute in Livonia.
There were 16,568 patients older than age 60 years entered into the MBSAQIP database in 2015. When those were compared with the 117,443 younger patients, the unadjusted rates of morbidity (6.5% vs. 6.0%) and mortality (0.3% vs. 0.1%) were higher for the older patients, but “they are close,” according to Dr. Zeni. Both rates reached significance by the conventional definition (P < .05), but he suggested that they are lower in this study than those in prior studies of MBSAQIP datasets and that they are acceptable relative to the anticipated health benefits.
Above the age of 60 years, no correlation could be made between increasing age and increasing risk of morbidity, mortality, or rate of reoperations, according to Dr. Zeni.
Why should bariatric surgery be considered in older patients? He cited data from a study that showed the life expectancy in a 70-year-old without functional limitations is 13 years. As a result, he added, “it behooves us to provide them with the best quality of life we can.”
Relative to prior MBSAQIP evaluations of bariatric surgery in the elderly, the proportion of patients undergoing sleeve gastrectomy relative to gastric bypass has been increasing, Dr. Zeni reported. In the analysis, approximately two-thirds of the bariatric procedures were performed with sleeve gastrectomy, which is higher relative to what previous MBSAQIP analyses have shown.
Based on rates of morbidity for those two surgical approaches in the analysis, that trend makes sense. While the higher 30-day mortality for gastric bypass, compared with sleeve gastrectomy, was not significant (0.38% vs. 0.26%; P = .221), all-cause morbidity was almost two times greater for those undergoing gastric bypass than it was for those undergoing sleeve gastrectomy (10.61% vs. 5.81%; P < .001), Dr. Zeni reported.
However, some of that difference may be explained by baseline disparities between the two groups. In the gastric bypass group, there were higher rates of preoperative diabetes (54% vs. 40%; P < .001), sleep apnea (57% vs. 50%; P < .001) and hyperlipidemia (59% vs. 54%; P < .001). Also, gastric bypass patients were more likely to have a history of a previous bariatric procedure (11% vs. 8.5%; P < .001) and to be in the American Society of Anesthesiologists Physical Status score of 3 (84% vs. 80%; P < .001), according to Dr. Zeni.
The specific complications more common in the gastric bypass group than the sleeve gastrectomy group included anastomotic leak (0.56% vs. 0.3%; P = .017), surgical site infection (1.74% vs. 0.61%; P < .001), pneumonia (0.87% vs. 0.32%; P < .001), and bleeding (1.14% vs. 0.5%; P = .024). Although the average operating time was 40 minutes longer in the bypass group, there were no significant differences in thromboembolic complications.
Overall, despite a modest increase in the risk of complications for bariatric surgery in elderly patients, that risk can be considered acceptable in relation to the potential health benefits, according to Dr. Zeni. He suggested that the data might encourage further growth in the rates of bariatric procedures among patients older than 60 years.
Dr. Zeni reports no relevant financial relationships.
NATIONAL HARBOR, MD. – despite a slight increase in unadjusted mortality rates, according to an analysis of data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).
Based on data that was collected in 2015 and submitted to MBSAQIP, “bariatric surgery is safe in the elderly, even in those 70 years old and older,” reported Tallal Zeni, MD, director of the Michigan Bariatric Institute in Livonia.
There were 16,568 patients older than age 60 years entered into the MBSAQIP database in 2015. When those were compared with the 117,443 younger patients, the unadjusted rates of morbidity (6.5% vs. 6.0%) and mortality (0.3% vs. 0.1%) were higher for the older patients, but “they are close,” according to Dr. Zeni. Both rates reached significance by the conventional definition (P < .05), but he suggested that they are lower in this study than those in prior studies of MBSAQIP datasets and that they are acceptable relative to the anticipated health benefits.
Above the age of 60 years, no correlation could be made between increasing age and increasing risk of morbidity, mortality, or rate of reoperations, according to Dr. Zeni.
Why should bariatric surgery be considered in older patients? He cited data from a study that showed the life expectancy in a 70-year-old without functional limitations is 13 years. As a result, he added, “it behooves us to provide them with the best quality of life we can.”
Relative to prior MBSAQIP evaluations of bariatric surgery in the elderly, the proportion of patients undergoing sleeve gastrectomy relative to gastric bypass has been increasing, Dr. Zeni reported. In the analysis, approximately two-thirds of the bariatric procedures were performed with sleeve gastrectomy, which is higher relative to what previous MBSAQIP analyses have shown.
Based on rates of morbidity for those two surgical approaches in the analysis, that trend makes sense. While the higher 30-day mortality for gastric bypass, compared with sleeve gastrectomy, was not significant (0.38% vs. 0.26%; P = .221), all-cause morbidity was almost two times greater for those undergoing gastric bypass than it was for those undergoing sleeve gastrectomy (10.61% vs. 5.81%; P < .001), Dr. Zeni reported.
However, some of that difference may be explained by baseline disparities between the two groups. In the gastric bypass group, there were higher rates of preoperative diabetes (54% vs. 40%; P < .001), sleep apnea (57% vs. 50%; P < .001) and hyperlipidemia (59% vs. 54%; P < .001). Also, gastric bypass patients were more likely to have a history of a previous bariatric procedure (11% vs. 8.5%; P < .001) and to be in the American Society of Anesthesiologists Physical Status score of 3 (84% vs. 80%; P < .001), according to Dr. Zeni.
The specific complications more common in the gastric bypass group than the sleeve gastrectomy group included anastomotic leak (0.56% vs. 0.3%; P = .017), surgical site infection (1.74% vs. 0.61%; P < .001), pneumonia (0.87% vs. 0.32%; P < .001), and bleeding (1.14% vs. 0.5%; P = .024). Although the average operating time was 40 minutes longer in the bypass group, there were no significant differences in thromboembolic complications.
Overall, despite a modest increase in the risk of complications for bariatric surgery in elderly patients, that risk can be considered acceptable in relation to the potential health benefits, according to Dr. Zeni. He suggested that the data might encourage further growth in the rates of bariatric procedures among patients older than 60 years.
Dr. Zeni reports no relevant financial relationships.
AT OBESITY WEEK 2017
Key clinical point: Based on mortality and morbidity rates, bariatric surgery is acceptably safe in patients older than 60 years of age.
Major finding: Compared with patients younger than 60 years, older patients had only modestly increased rates of morbidity (6.5% vs. 6.0%) and mortality (0.3% vs. 0.1%).
Data source: A retrospective database analysis.
Disclosures: Dr. Zeni reports no relevant financial relationships.
VIDEO: MBSAQIP data looks at sleeve gastrectomy outcomes
Surgeon Matthew A. Hutter, MD, FACS, discusses the first report from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) focused on laparoscopic sleeve gastrectomy. The study (Ann Surg. 2016;264[3]:464-73) looked at outcomes, methods, and complications of this procedure based on a database of nearly 190,000 patients, more than 1,600 surgeons, and 720 centers. Dr. Hutter said that is high-quality data that offers surgeons good information on the procedure.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Surgeon Matthew A. Hutter, MD, FACS, discusses the first report from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) focused on laparoscopic sleeve gastrectomy. The study (Ann Surg. 2016;264[3]:464-73) looked at outcomes, methods, and complications of this procedure based on a database of nearly 190,000 patients, more than 1,600 surgeons, and 720 centers. Dr. Hutter said that is high-quality data that offers surgeons good information on the procedure.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Surgeon Matthew A. Hutter, MD, FACS, discusses the first report from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) focused on laparoscopic sleeve gastrectomy. The study (Ann Surg. 2016;264[3]:464-73) looked at outcomes, methods, and complications of this procedure based on a database of nearly 190,000 patients, more than 1,600 surgeons, and 720 centers. Dr. Hutter said that is high-quality data that offers surgeons good information on the procedure.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Gastrectomy mortality risk increased fivefold with same-day discharge
NATIONAL HARBOR, MD. – Laparoscopic sleeve gastrectomy has been associated with low mortality, but the mortality is even lower when it includes overnight observation, according to a national database evaluation.
Among patients discharged on the same day, 30-day mortality was 0.1%, but it fell to 0.02% among patients discharged the following day, according to Colette Inaba, MD, a surgery resident at the University of California, Irvine.*
“Surgeons who are considering same-day discharge in sleeve gastrectomy patients should have a low threshold to admit these patients for overnight observation given our findings,” Dr. Inaba reported at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.
Same-day discharge has been associated with an increased mortality risk in previously published descriptive institutional reviews, but this is the first study to evaluate this question through analysis of a national database, according to Dr. Inaba. It was based on 37,301 laparoscopic sleeve gastrectomy cases performed in 2015 and submitted to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. All participants in this database are accredited bariatric centers.
There were baseline differences between same-day and next-day discharges, but many of these differences conferred the next-day group with higher risk. In particular, the next-day group had significantly higher rates of hypertension, diabetes mellitus, hypercholesterolemia, chronic obstructive pulmonary disease, and sleep apnea. On average, the procedure time was 13 minutes longer in the next-day versus the same-day discharge groups.
In addition to mortality, 30-day morbidity and need for revisions were compared between the two groups, but there were no significant differences between groups in the rates of these outcomes.
Overall, the baseline demographics of the patients in same-day and next-day groups were comparable, according to Dr. Inaba. She described the population as predominantly female and white with an average body mass index of 45 kg/m2. In this analysis, only primary procedures (excluding redos and revisions) were included.
Relative to the next-day discharge cases, a significantly higher percentage of same-day discharge procedures were performed with a surgical tech or another provider rather than a designated first-assist surgeon, according to Dr. Inaba. For next-day cases, a higher percentage was performed with the participation of fellows or surgical residents. There were fewer swallow studies performed before discharge in the same-day discharge group.
Very similar results were generated by a study evaluating same-day discharge after laparoscopic Roux-en-Y gastric bypass, according to John M. Morton, MD, chief of bariatric and minimally invasive surgery, Stanford (Calif.) University. Dr. Morton, first author of the study and moderator of the session in which Dr. Inaba presented the LSG data, reported that same-day discharge in that study was also associated with a trend for an increased risk of serious complications (Ann Surg. 2014;259:286-92).
“Same-day discharge is often reimbursed at a lower rate, so there is less pay and patients are at greater risk of harm,” Dr. Morton said.
The reasons that same-day discharge is associated with higher mortality cannot be derived from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, but, Dr. Inaba said, “Our thought is it is a function of failure to rescue patients from respiratory complications.” She acknowledged that this is a speculative assessment not supported by data, but she suggested that history of sleep apnea might be a particular indication to consider next-day discharge.
Dr. Inaba reports no financial relationships relevant to this topic.
Correction, 12/4/17: An earlier version of this article misstated the 30-day mortality among patients discharged the next day.
NATIONAL HARBOR, MD. – Laparoscopic sleeve gastrectomy has been associated with low mortality, but the mortality is even lower when it includes overnight observation, according to a national database evaluation.
Among patients discharged on the same day, 30-day mortality was 0.1%, but it fell to 0.02% among patients discharged the following day, according to Colette Inaba, MD, a surgery resident at the University of California, Irvine.*
“Surgeons who are considering same-day discharge in sleeve gastrectomy patients should have a low threshold to admit these patients for overnight observation given our findings,” Dr. Inaba reported at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.
Same-day discharge has been associated with an increased mortality risk in previously published descriptive institutional reviews, but this is the first study to evaluate this question through analysis of a national database, according to Dr. Inaba. It was based on 37,301 laparoscopic sleeve gastrectomy cases performed in 2015 and submitted to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. All participants in this database are accredited bariatric centers.
There were baseline differences between same-day and next-day discharges, but many of these differences conferred the next-day group with higher risk. In particular, the next-day group had significantly higher rates of hypertension, diabetes mellitus, hypercholesterolemia, chronic obstructive pulmonary disease, and sleep apnea. On average, the procedure time was 13 minutes longer in the next-day versus the same-day discharge groups.
In addition to mortality, 30-day morbidity and need for revisions were compared between the two groups, but there were no significant differences between groups in the rates of these outcomes.
Overall, the baseline demographics of the patients in same-day and next-day groups were comparable, according to Dr. Inaba. She described the population as predominantly female and white with an average body mass index of 45 kg/m2. In this analysis, only primary procedures (excluding redos and revisions) were included.
Relative to the next-day discharge cases, a significantly higher percentage of same-day discharge procedures were performed with a surgical tech or another provider rather than a designated first-assist surgeon, according to Dr. Inaba. For next-day cases, a higher percentage was performed with the participation of fellows or surgical residents. There were fewer swallow studies performed before discharge in the same-day discharge group.
Very similar results were generated by a study evaluating same-day discharge after laparoscopic Roux-en-Y gastric bypass, according to John M. Morton, MD, chief of bariatric and minimally invasive surgery, Stanford (Calif.) University. Dr. Morton, first author of the study and moderator of the session in which Dr. Inaba presented the LSG data, reported that same-day discharge in that study was also associated with a trend for an increased risk of serious complications (Ann Surg. 2014;259:286-92).
“Same-day discharge is often reimbursed at a lower rate, so there is less pay and patients are at greater risk of harm,” Dr. Morton said.
The reasons that same-day discharge is associated with higher mortality cannot be derived from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, but, Dr. Inaba said, “Our thought is it is a function of failure to rescue patients from respiratory complications.” She acknowledged that this is a speculative assessment not supported by data, but she suggested that history of sleep apnea might be a particular indication to consider next-day discharge.
Dr. Inaba reports no financial relationships relevant to this topic.
Correction, 12/4/17: An earlier version of this article misstated the 30-day mortality among patients discharged the next day.
NATIONAL HARBOR, MD. – Laparoscopic sleeve gastrectomy has been associated with low mortality, but the mortality is even lower when it includes overnight observation, according to a national database evaluation.
Among patients discharged on the same day, 30-day mortality was 0.1%, but it fell to 0.02% among patients discharged the following day, according to Colette Inaba, MD, a surgery resident at the University of California, Irvine.*
“Surgeons who are considering same-day discharge in sleeve gastrectomy patients should have a low threshold to admit these patients for overnight observation given our findings,” Dr. Inaba reported at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.
Same-day discharge has been associated with an increased mortality risk in previously published descriptive institutional reviews, but this is the first study to evaluate this question through analysis of a national database, according to Dr. Inaba. It was based on 37,301 laparoscopic sleeve gastrectomy cases performed in 2015 and submitted to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. All participants in this database are accredited bariatric centers.
There were baseline differences between same-day and next-day discharges, but many of these differences conferred the next-day group with higher risk. In particular, the next-day group had significantly higher rates of hypertension, diabetes mellitus, hypercholesterolemia, chronic obstructive pulmonary disease, and sleep apnea. On average, the procedure time was 13 minutes longer in the next-day versus the same-day discharge groups.
In addition to mortality, 30-day morbidity and need for revisions were compared between the two groups, but there were no significant differences between groups in the rates of these outcomes.
Overall, the baseline demographics of the patients in same-day and next-day groups were comparable, according to Dr. Inaba. She described the population as predominantly female and white with an average body mass index of 45 kg/m2. In this analysis, only primary procedures (excluding redos and revisions) were included.
Relative to the next-day discharge cases, a significantly higher percentage of same-day discharge procedures were performed with a surgical tech or another provider rather than a designated first-assist surgeon, according to Dr. Inaba. For next-day cases, a higher percentage was performed with the participation of fellows or surgical residents. There were fewer swallow studies performed before discharge in the same-day discharge group.
Very similar results were generated by a study evaluating same-day discharge after laparoscopic Roux-en-Y gastric bypass, according to John M. Morton, MD, chief of bariatric and minimally invasive surgery, Stanford (Calif.) University. Dr. Morton, first author of the study and moderator of the session in which Dr. Inaba presented the LSG data, reported that same-day discharge in that study was also associated with a trend for an increased risk of serious complications (Ann Surg. 2014;259:286-92).
“Same-day discharge is often reimbursed at a lower rate, so there is less pay and patients are at greater risk of harm,” Dr. Morton said.
The reasons that same-day discharge is associated with higher mortality cannot be derived from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, but, Dr. Inaba said, “Our thought is it is a function of failure to rescue patients from respiratory complications.” She acknowledged that this is a speculative assessment not supported by data, but she suggested that history of sleep apnea might be a particular indication to consider next-day discharge.
Dr. Inaba reports no financial relationships relevant to this topic.
Correction, 12/4/17: An earlier version of this article misstated the 30-day mortality among patients discharged the next day.
AT OBESITY WEEK 2017
Key clinical point: Thirty-day mortality after laparoscopic sleeve gastrectomy is several times higher with same-day discharge relative to an overnight stay.
Major finding: In an analysis of a national database with more than 35,000 cases, the mortality odds ratio for same-day discharge was 5.7 (P = .032) relative to next-day discharge.
Data source: Retrospective database analysis.
Disclosures: Dr. Inaba reports no financial relationships relevant to this topic.
ED visits after bariatric surgery may be difficult to reduce
NATIONAL HARBOR, MD. – In an evaluation of 633 emergency department visits following bariatric surgery in Michigan over a 1-year period, the vast majority were for complaints amenable to a phone call consultation or treatment in a lower-acuity setting, but few patients would have been satisfied with this type of management, according to an evaluation based on patient interviews presented at Obesity Week 2017.
“Unfortunately, 91% of the patients said that there was nothing the surgical team could have done that would have helped avoid the ED visit,” reported Haley Stevens, quality improvement coordinator at the Michigan Bariatric Surgery Collaborative, University of Michigan, Ann Arbor.
The 633 ED visits followed 7,617 bariatric surgeries for a rate of 8.3%. According to Ms. Stevens, this is consistent with the rates of 5%-11% reported previously. Based on clinically abstracted data and patient interviews conducted by trained nurses in a sample of patients involved in these ED visits, it was estimated that 62% were made without any attempt to first contact the surgical team, she reported at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.
In the interviews, a variety of reasons were offered for not first contacting the surgical team, according to Ms. Stevens. Most commonly, patients reported that a sense of urgency drove them to the ED. In 18% of cases, the complaint occurred after office hours, leading the patient to believe that the ED was the only option. Another 16% of patients reported that calling the surgeon simply did not occur to them.
“When interviewed, many patients considered the visit necessary and unavoidable even after learning subsequently that the symptoms were not serious,” Ms. Stevens reported.
The primary reasons for the ED visit were nausea, vomiting, or abdominal pain, which accounted for 50% of the visits. The next most common reasons were chest pain (8%) and concerns regarding the incision (7%). Only 30% of the ED visits ultimately resulted in a hospital admission, but 60% of the visits resulted in administration of intravenous fluids. Thirty-eight percent of ED visits resulted in oral or intravenous therapy for pain.
Based on the interviews, most patients reported that they visited the ED because they wanted an immediate evaluation of their symptoms, according to Ms. Stevens. She said that the goal in most cases was simply obtaining reassurance. While better patient education about symptoms and recovery might have circumvented patient concerns about nonurgent complaints, Ms. Stevens also suggested that visits to a lower-acuity center, such as an urgent care facility, might provide a lower-cost alternative for reassurance or simple treatments.
As this study represents the first in a series to guide a quality improvement initiative, Ms. Stevens acknowledged that the best solution to reducing unnecessary ED visits is unclear, but she did suggest that multiple strategies might be needed. Based on this and previously published studies evaluating this issue “there is no silver bullet” for reducing ED visits, Ms. Stevens said.
In an animated discussion that followed presentation of these results, others recounting efforts to reduce ED visits following bariatric surgery emphasized the importance of follow-up phone calls or home visits within 2 or 3 days of surgery. According to several of those who commented, these steps allow early identification of problems while providing the type of reassurance that can prevent unnecessary ED visits.
The average cost of an ED visit following bariatric surgery is approximately $1,300, according to Ms. Stevens. For this and other reasons, strategies to reduce ED visits are needed, but Ms. Stevens cautioned that the solutions might not be simple. Based on data from this study, the key may be providing patients with a clear route to the reassurance they need to avoid seeking care for nonurgent issues.
Ms. Stevens reports no financial relationships relevant to this topic.
NATIONAL HARBOR, MD. – In an evaluation of 633 emergency department visits following bariatric surgery in Michigan over a 1-year period, the vast majority were for complaints amenable to a phone call consultation or treatment in a lower-acuity setting, but few patients would have been satisfied with this type of management, according to an evaluation based on patient interviews presented at Obesity Week 2017.
“Unfortunately, 91% of the patients said that there was nothing the surgical team could have done that would have helped avoid the ED visit,” reported Haley Stevens, quality improvement coordinator at the Michigan Bariatric Surgery Collaborative, University of Michigan, Ann Arbor.
The 633 ED visits followed 7,617 bariatric surgeries for a rate of 8.3%. According to Ms. Stevens, this is consistent with the rates of 5%-11% reported previously. Based on clinically abstracted data and patient interviews conducted by trained nurses in a sample of patients involved in these ED visits, it was estimated that 62% were made without any attempt to first contact the surgical team, she reported at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.
In the interviews, a variety of reasons were offered for not first contacting the surgical team, according to Ms. Stevens. Most commonly, patients reported that a sense of urgency drove them to the ED. In 18% of cases, the complaint occurred after office hours, leading the patient to believe that the ED was the only option. Another 16% of patients reported that calling the surgeon simply did not occur to them.
“When interviewed, many patients considered the visit necessary and unavoidable even after learning subsequently that the symptoms were not serious,” Ms. Stevens reported.
The primary reasons for the ED visit were nausea, vomiting, or abdominal pain, which accounted for 50% of the visits. The next most common reasons were chest pain (8%) and concerns regarding the incision (7%). Only 30% of the ED visits ultimately resulted in a hospital admission, but 60% of the visits resulted in administration of intravenous fluids. Thirty-eight percent of ED visits resulted in oral or intravenous therapy for pain.
Based on the interviews, most patients reported that they visited the ED because they wanted an immediate evaluation of their symptoms, according to Ms. Stevens. She said that the goal in most cases was simply obtaining reassurance. While better patient education about symptoms and recovery might have circumvented patient concerns about nonurgent complaints, Ms. Stevens also suggested that visits to a lower-acuity center, such as an urgent care facility, might provide a lower-cost alternative for reassurance or simple treatments.
As this study represents the first in a series to guide a quality improvement initiative, Ms. Stevens acknowledged that the best solution to reducing unnecessary ED visits is unclear, but she did suggest that multiple strategies might be needed. Based on this and previously published studies evaluating this issue “there is no silver bullet” for reducing ED visits, Ms. Stevens said.
In an animated discussion that followed presentation of these results, others recounting efforts to reduce ED visits following bariatric surgery emphasized the importance of follow-up phone calls or home visits within 2 or 3 days of surgery. According to several of those who commented, these steps allow early identification of problems while providing the type of reassurance that can prevent unnecessary ED visits.
The average cost of an ED visit following bariatric surgery is approximately $1,300, according to Ms. Stevens. For this and other reasons, strategies to reduce ED visits are needed, but Ms. Stevens cautioned that the solutions might not be simple. Based on data from this study, the key may be providing patients with a clear route to the reassurance they need to avoid seeking care for nonurgent issues.
Ms. Stevens reports no financial relationships relevant to this topic.
NATIONAL HARBOR, MD. – In an evaluation of 633 emergency department visits following bariatric surgery in Michigan over a 1-year period, the vast majority were for complaints amenable to a phone call consultation or treatment in a lower-acuity setting, but few patients would have been satisfied with this type of management, according to an evaluation based on patient interviews presented at Obesity Week 2017.
“Unfortunately, 91% of the patients said that there was nothing the surgical team could have done that would have helped avoid the ED visit,” reported Haley Stevens, quality improvement coordinator at the Michigan Bariatric Surgery Collaborative, University of Michigan, Ann Arbor.
The 633 ED visits followed 7,617 bariatric surgeries for a rate of 8.3%. According to Ms. Stevens, this is consistent with the rates of 5%-11% reported previously. Based on clinically abstracted data and patient interviews conducted by trained nurses in a sample of patients involved in these ED visits, it was estimated that 62% were made without any attempt to first contact the surgical team, she reported at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.
In the interviews, a variety of reasons were offered for not first contacting the surgical team, according to Ms. Stevens. Most commonly, patients reported that a sense of urgency drove them to the ED. In 18% of cases, the complaint occurred after office hours, leading the patient to believe that the ED was the only option. Another 16% of patients reported that calling the surgeon simply did not occur to them.
“When interviewed, many patients considered the visit necessary and unavoidable even after learning subsequently that the symptoms were not serious,” Ms. Stevens reported.
The primary reasons for the ED visit were nausea, vomiting, or abdominal pain, which accounted for 50% of the visits. The next most common reasons were chest pain (8%) and concerns regarding the incision (7%). Only 30% of the ED visits ultimately resulted in a hospital admission, but 60% of the visits resulted in administration of intravenous fluids. Thirty-eight percent of ED visits resulted in oral or intravenous therapy for pain.
Based on the interviews, most patients reported that they visited the ED because they wanted an immediate evaluation of their symptoms, according to Ms. Stevens. She said that the goal in most cases was simply obtaining reassurance. While better patient education about symptoms and recovery might have circumvented patient concerns about nonurgent complaints, Ms. Stevens also suggested that visits to a lower-acuity center, such as an urgent care facility, might provide a lower-cost alternative for reassurance or simple treatments.
As this study represents the first in a series to guide a quality improvement initiative, Ms. Stevens acknowledged that the best solution to reducing unnecessary ED visits is unclear, but she did suggest that multiple strategies might be needed. Based on this and previously published studies evaluating this issue “there is no silver bullet” for reducing ED visits, Ms. Stevens said.
In an animated discussion that followed presentation of these results, others recounting efforts to reduce ED visits following bariatric surgery emphasized the importance of follow-up phone calls or home visits within 2 or 3 days of surgery. According to several of those who commented, these steps allow early identification of problems while providing the type of reassurance that can prevent unnecessary ED visits.
The average cost of an ED visit following bariatric surgery is approximately $1,300, according to Ms. Stevens. For this and other reasons, strategies to reduce ED visits are needed, but Ms. Stevens cautioned that the solutions might not be simple. Based on data from this study, the key may be providing patients with a clear route to the reassurance they need to avoid seeking care for nonurgent issues.
Ms. Stevens reports no financial relationships relevant to this topic.
AT OBESITY WEEK 2017
Key clinical point:
Major finding: In interviews after their ED visit, 91% of bariatric patients insisted the visit was needed, even when informed it was nonurgent.
Data source: Retrospective review and patient interview.
Disclosures: Ms. Stevens reports no financial relationships relevant to this topic.
Psych evaluation identifies bariatric surgery patients who do less well
NATIONAL HARBOR, MD. – Psychological screening prior to bariatric surgery is not effective for identifying who will do poorly after the procedure, but it can identify patients who are at risk for less weight loss and likely to benefit from additional support, according to one of the largest studies designed to evaluate the predictive accuracy of this screening. The results were presented at Obesity Week 2017.
“Psychological evaluations should not be used to exclude patients, because we do not appear to be very good at predicting who does well,” said Nina E. Boulard, PhD, a psychologist who currently performs preoperative psychological screening of bariatric surgery candidates at Eastern Maine Medical Center, Bangor. Rather, “our evaluations identify those who need to be followed more closely so we can intervene early when patients struggle,” she said at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.
The two primary outcomes of interest were the ability to predict postsurgical mental health issues and the ability to predict difficulty in complying with behavioral changes. Percent excess weight loss (EWL) was also monitored. For mental health screening, the protocol included clinical interviews augmented with standardized testing, such as the Minnesota Multiphasic Personality Inventory-2-Restuctured Form (MMPI-2-RF). Patients were placed into five risk categories: low, low-moderate, moderate, moderate-high, and high.
For compliance, the patient evaluation was based primarily on interviews capturing self-reports of adherence to presurgical dietary and other lifestyle recommendations. Patients were also asked about eating behaviors, such as binge eating, and history of sexual abuse and attention-deficit/hyperactivity disorder and other neurodevelopmental issues.
The psychological screening report is provided to the surgeon, who ultimately decides whether patients go on to surgery. In this analysis, relatively few high-risk patients were included because these patients, such as those with active psychosis, uncontrolled binge eating, or severe depression, were excluded from surgery and therefore did not generate postsurgical follow-up data.
As has been reported by others, Dr. Boulard reported that no single standardized test or clinical variable was an effective predictor of “who will and will not struggle” psychologically after surgery. However, after adjusting for age, gender, presurgery weight, diabetes history, and surgery type, several variables were associated with reduced proportion EWL. These included anxiety (P = .02), ADHD (P = .01), and prior hospitalization of a psychological indication (P less than .05). History of sexual abuse was predictive of reduced percentage EWL 1 year but not 2 years after surgery.
“So, what this tells us is the clinical interpretation of the big picture might be important,” Dr. Boulard commented.
The presurgical psychological screening was not predictive of compliance, a result that Dr. Boulard labeled as “surprising.” She speculated that because weight loss in the first 2 years after bariatric surgery is relatively uniform, longer follow-up, such as 5 years, might be needed to capture the impact of patients predicted to have poor compliance.
Importantly, percent EWL remained high even among patients with risk factors associated with mental health challenges after surgery, according to Dr. Boulard. She stressed that even those with less weight loss “did not do poorly.” Rather, the relative differences in postsurgical weight loss for those who were predicted to struggle versus those who were not was “a matter of degrees.”
While Dr. Boulard acknowledged a prospective study using a standardized psychological screening protocol would be appropriate to validate the findings of this study, the study results have already changed practice at her institution.
“We are following the at-risk patients more closely, so we can intervene quickly if there are issues after surgery,” Dr. Boulard explained. The question raised by this study is, “can we bring them [patients at higher risk] to a higher level of response so they are just as successful” as those without risk factors identified in psychological screening.
Dr. Boulard reports no financial relationships relevant to this topic.
NATIONAL HARBOR, MD. – Psychological screening prior to bariatric surgery is not effective for identifying who will do poorly after the procedure, but it can identify patients who are at risk for less weight loss and likely to benefit from additional support, according to one of the largest studies designed to evaluate the predictive accuracy of this screening. The results were presented at Obesity Week 2017.
“Psychological evaluations should not be used to exclude patients, because we do not appear to be very good at predicting who does well,” said Nina E. Boulard, PhD, a psychologist who currently performs preoperative psychological screening of bariatric surgery candidates at Eastern Maine Medical Center, Bangor. Rather, “our evaluations identify those who need to be followed more closely so we can intervene early when patients struggle,” she said at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.
The two primary outcomes of interest were the ability to predict postsurgical mental health issues and the ability to predict difficulty in complying with behavioral changes. Percent excess weight loss (EWL) was also monitored. For mental health screening, the protocol included clinical interviews augmented with standardized testing, such as the Minnesota Multiphasic Personality Inventory-2-Restuctured Form (MMPI-2-RF). Patients were placed into five risk categories: low, low-moderate, moderate, moderate-high, and high.
For compliance, the patient evaluation was based primarily on interviews capturing self-reports of adherence to presurgical dietary and other lifestyle recommendations. Patients were also asked about eating behaviors, such as binge eating, and history of sexual abuse and attention-deficit/hyperactivity disorder and other neurodevelopmental issues.
The psychological screening report is provided to the surgeon, who ultimately decides whether patients go on to surgery. In this analysis, relatively few high-risk patients were included because these patients, such as those with active psychosis, uncontrolled binge eating, or severe depression, were excluded from surgery and therefore did not generate postsurgical follow-up data.
As has been reported by others, Dr. Boulard reported that no single standardized test or clinical variable was an effective predictor of “who will and will not struggle” psychologically after surgery. However, after adjusting for age, gender, presurgery weight, diabetes history, and surgery type, several variables were associated with reduced proportion EWL. These included anxiety (P = .02), ADHD (P = .01), and prior hospitalization of a psychological indication (P less than .05). History of sexual abuse was predictive of reduced percentage EWL 1 year but not 2 years after surgery.
“So, what this tells us is the clinical interpretation of the big picture might be important,” Dr. Boulard commented.
The presurgical psychological screening was not predictive of compliance, a result that Dr. Boulard labeled as “surprising.” She speculated that because weight loss in the first 2 years after bariatric surgery is relatively uniform, longer follow-up, such as 5 years, might be needed to capture the impact of patients predicted to have poor compliance.
Importantly, percent EWL remained high even among patients with risk factors associated with mental health challenges after surgery, according to Dr. Boulard. She stressed that even those with less weight loss “did not do poorly.” Rather, the relative differences in postsurgical weight loss for those who were predicted to struggle versus those who were not was “a matter of degrees.”
While Dr. Boulard acknowledged a prospective study using a standardized psychological screening protocol would be appropriate to validate the findings of this study, the study results have already changed practice at her institution.
“We are following the at-risk patients more closely, so we can intervene quickly if there are issues after surgery,” Dr. Boulard explained. The question raised by this study is, “can we bring them [patients at higher risk] to a higher level of response so they are just as successful” as those without risk factors identified in psychological screening.
Dr. Boulard reports no financial relationships relevant to this topic.
NATIONAL HARBOR, MD. – Psychological screening prior to bariatric surgery is not effective for identifying who will do poorly after the procedure, but it can identify patients who are at risk for less weight loss and likely to benefit from additional support, according to one of the largest studies designed to evaluate the predictive accuracy of this screening. The results were presented at Obesity Week 2017.
“Psychological evaluations should not be used to exclude patients, because we do not appear to be very good at predicting who does well,” said Nina E. Boulard, PhD, a psychologist who currently performs preoperative psychological screening of bariatric surgery candidates at Eastern Maine Medical Center, Bangor. Rather, “our evaluations identify those who need to be followed more closely so we can intervene early when patients struggle,” she said at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.
The two primary outcomes of interest were the ability to predict postsurgical mental health issues and the ability to predict difficulty in complying with behavioral changes. Percent excess weight loss (EWL) was also monitored. For mental health screening, the protocol included clinical interviews augmented with standardized testing, such as the Minnesota Multiphasic Personality Inventory-2-Restuctured Form (MMPI-2-RF). Patients were placed into five risk categories: low, low-moderate, moderate, moderate-high, and high.
For compliance, the patient evaluation was based primarily on interviews capturing self-reports of adherence to presurgical dietary and other lifestyle recommendations. Patients were also asked about eating behaviors, such as binge eating, and history of sexual abuse and attention-deficit/hyperactivity disorder and other neurodevelopmental issues.
The psychological screening report is provided to the surgeon, who ultimately decides whether patients go on to surgery. In this analysis, relatively few high-risk patients were included because these patients, such as those with active psychosis, uncontrolled binge eating, or severe depression, were excluded from surgery and therefore did not generate postsurgical follow-up data.
As has been reported by others, Dr. Boulard reported that no single standardized test or clinical variable was an effective predictor of “who will and will not struggle” psychologically after surgery. However, after adjusting for age, gender, presurgery weight, diabetes history, and surgery type, several variables were associated with reduced proportion EWL. These included anxiety (P = .02), ADHD (P = .01), and prior hospitalization of a psychological indication (P less than .05). History of sexual abuse was predictive of reduced percentage EWL 1 year but not 2 years after surgery.
“So, what this tells us is the clinical interpretation of the big picture might be important,” Dr. Boulard commented.
The presurgical psychological screening was not predictive of compliance, a result that Dr. Boulard labeled as “surprising.” She speculated that because weight loss in the first 2 years after bariatric surgery is relatively uniform, longer follow-up, such as 5 years, might be needed to capture the impact of patients predicted to have poor compliance.
Importantly, percent EWL remained high even among patients with risk factors associated with mental health challenges after surgery, according to Dr. Boulard. She stressed that even those with less weight loss “did not do poorly.” Rather, the relative differences in postsurgical weight loss for those who were predicted to struggle versus those who were not was “a matter of degrees.”
While Dr. Boulard acknowledged a prospective study using a standardized psychological screening protocol would be appropriate to validate the findings of this study, the study results have already changed practice at her institution.
“We are following the at-risk patients more closely, so we can intervene quickly if there are issues after surgery,” Dr. Boulard explained. The question raised by this study is, “can we bring them [patients at higher risk] to a higher level of response so they are just as successful” as those without risk factors identified in psychological screening.
Dr. Boulard reports no financial relationships relevant to this topic.
AT OBESITY WEEK 2017
Key clinical point: Psychological screening prior to bariatric surgery selects patients at risk for reduced postoperative weight loss.
Major finding: Prior psychological hospitalization (P less than .05) and number of previous psychological diagnoses (P = .04) are among markers of less postop weight loss.
Data source: Retrospective analysis.
Disclosures: Dr. Boulard reports no financial relationships relevant to this topic.
Chronicity of obesity provides rationale for physician-surgeon collaboration
NATIONAL HARBOR, MD. – When combined with bariatric surgery, adjunctive therapies for obesity should be individualized for specific drivers of weight gain, which can differ among obesity phenotypes, according to an expert view presented at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society .
“Surgery is the most effective therapy we have, but it is only one of multiple treatments that should be considered in a treatment paradigm,” suggested Robert F. Kushner, MD, a professor of endocrinology and specialist in obesity at the Northwestern University, Chicago.
“It is very useful to take a narrative approach to understand the patients in front of us and to understand who they are and how they got to where they are now,” Dr. Kushner explained. Dr. Kushner often asks patients to graph weight history over time. This can connect social, biological, and psychological events with significant weight gains, and these connections can generate insight into the underlying obesity phenotype.
“It is a like a fingerprint. Everyone has his or her own story to tell,” Dr. Kushner explained. A clinical picture of patients’ phenotypes can be developed from observing large jumps in weight connected to such factors as a stressful life event, a period of sustained inactivity, or a pregnancy. Over a weight history, several events may be identified that provide insight into each patient’s “unique weight journey.”
This understanding provides the basis for a systematic approach to combining strategies that may include lifestyle changes, surgery, and pharmacologic management, all tailored for the specific triggers and needs of the patient. Dr. Kushner advised that, even for those who are candidates for surgery, bariatric procedures are just one component of the treatment and must be integrated in a team approach with other modalities.
This approach may include pharmacologic therapy both before and after surgery; Dr. Kushner noted that the availability of drug options has expanded in recent years with approval of such therapies as lorcaserin and liraglutide. According to Dr. Kushner, drug therapy can be used for preoperative weight loss and may be useful for preventing postoperative weight gain in certain patients.
“There are no randomized trials demonstrating efficacy for prevention of postoperative weight gain, but there is supportive evidence from a retrospective study,” said Dr. Kushner, referring to a recently published two-center evaluation (Surg Obes Relat Dis. 2017;13:491-500).
In that study, 258 patients underwent Roux-en-Y gastric bypass, and 61 patients underwent sleeve gastrectomy. Those who received adjunctive drug support, particularly in the RYGB group, had greater sustained weight loss than those who did not, leading to the conclusion that postoperative pharmacotherapy “is a useful adjunct.” The advantage for drug therapy was observed even though patients did not receive the most recently approved and potentially more effective drugs, according to Dr. Kushner. However, he cautioned that information about the optimal timing of treatment after surgery remains “limited.”
The variability in weight loss and weight regain after bariatric procedures is one reason to consider bariatric surgery as only one component in a continuum of care, according to Dr. Kushner. He emphasized that obesity is a chronic condition that requires ongoing and perhaps indefinite treatment. While surgeons may already work with a team that manages preoperative and postoperative lifestyle changes to improve immediate surgical outcomes, Dr. Kushner believes that surgeons and physicians should work more collaboratively toward long-term management plans. By also appreciating obesity phenotypes and the specific mix of treatments that are most likely to help individual patients achieve durable weight loss, surgeons and physicians working together are likely to improve outcomes beyond those that could be expected from either working alone.
Dr. Kushner reports he has financial relationships with Novo Nordisk, Retrofit, Takeda Pharmaceuticals, and Vivus.
NATIONAL HARBOR, MD. – When combined with bariatric surgery, adjunctive therapies for obesity should be individualized for specific drivers of weight gain, which can differ among obesity phenotypes, according to an expert view presented at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society .
“Surgery is the most effective therapy we have, but it is only one of multiple treatments that should be considered in a treatment paradigm,” suggested Robert F. Kushner, MD, a professor of endocrinology and specialist in obesity at the Northwestern University, Chicago.
“It is very useful to take a narrative approach to understand the patients in front of us and to understand who they are and how they got to where they are now,” Dr. Kushner explained. Dr. Kushner often asks patients to graph weight history over time. This can connect social, biological, and psychological events with significant weight gains, and these connections can generate insight into the underlying obesity phenotype.
“It is a like a fingerprint. Everyone has his or her own story to tell,” Dr. Kushner explained. A clinical picture of patients’ phenotypes can be developed from observing large jumps in weight connected to such factors as a stressful life event, a period of sustained inactivity, or a pregnancy. Over a weight history, several events may be identified that provide insight into each patient’s “unique weight journey.”
This understanding provides the basis for a systematic approach to combining strategies that may include lifestyle changes, surgery, and pharmacologic management, all tailored for the specific triggers and needs of the patient. Dr. Kushner advised that, even for those who are candidates for surgery, bariatric procedures are just one component of the treatment and must be integrated in a team approach with other modalities.
This approach may include pharmacologic therapy both before and after surgery; Dr. Kushner noted that the availability of drug options has expanded in recent years with approval of such therapies as lorcaserin and liraglutide. According to Dr. Kushner, drug therapy can be used for preoperative weight loss and may be useful for preventing postoperative weight gain in certain patients.
“There are no randomized trials demonstrating efficacy for prevention of postoperative weight gain, but there is supportive evidence from a retrospective study,” said Dr. Kushner, referring to a recently published two-center evaluation (Surg Obes Relat Dis. 2017;13:491-500).
In that study, 258 patients underwent Roux-en-Y gastric bypass, and 61 patients underwent sleeve gastrectomy. Those who received adjunctive drug support, particularly in the RYGB group, had greater sustained weight loss than those who did not, leading to the conclusion that postoperative pharmacotherapy “is a useful adjunct.” The advantage for drug therapy was observed even though patients did not receive the most recently approved and potentially more effective drugs, according to Dr. Kushner. However, he cautioned that information about the optimal timing of treatment after surgery remains “limited.”
The variability in weight loss and weight regain after bariatric procedures is one reason to consider bariatric surgery as only one component in a continuum of care, according to Dr. Kushner. He emphasized that obesity is a chronic condition that requires ongoing and perhaps indefinite treatment. While surgeons may already work with a team that manages preoperative and postoperative lifestyle changes to improve immediate surgical outcomes, Dr. Kushner believes that surgeons and physicians should work more collaboratively toward long-term management plans. By also appreciating obesity phenotypes and the specific mix of treatments that are most likely to help individual patients achieve durable weight loss, surgeons and physicians working together are likely to improve outcomes beyond those that could be expected from either working alone.
Dr. Kushner reports he has financial relationships with Novo Nordisk, Retrofit, Takeda Pharmaceuticals, and Vivus.
NATIONAL HARBOR, MD. – When combined with bariatric surgery, adjunctive therapies for obesity should be individualized for specific drivers of weight gain, which can differ among obesity phenotypes, according to an expert view presented at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society .
“Surgery is the most effective therapy we have, but it is only one of multiple treatments that should be considered in a treatment paradigm,” suggested Robert F. Kushner, MD, a professor of endocrinology and specialist in obesity at the Northwestern University, Chicago.
“It is very useful to take a narrative approach to understand the patients in front of us and to understand who they are and how they got to where they are now,” Dr. Kushner explained. Dr. Kushner often asks patients to graph weight history over time. This can connect social, biological, and psychological events with significant weight gains, and these connections can generate insight into the underlying obesity phenotype.
“It is a like a fingerprint. Everyone has his or her own story to tell,” Dr. Kushner explained. A clinical picture of patients’ phenotypes can be developed from observing large jumps in weight connected to such factors as a stressful life event, a period of sustained inactivity, or a pregnancy. Over a weight history, several events may be identified that provide insight into each patient’s “unique weight journey.”
This understanding provides the basis for a systematic approach to combining strategies that may include lifestyle changes, surgery, and pharmacologic management, all tailored for the specific triggers and needs of the patient. Dr. Kushner advised that, even for those who are candidates for surgery, bariatric procedures are just one component of the treatment and must be integrated in a team approach with other modalities.
This approach may include pharmacologic therapy both before and after surgery; Dr. Kushner noted that the availability of drug options has expanded in recent years with approval of such therapies as lorcaserin and liraglutide. According to Dr. Kushner, drug therapy can be used for preoperative weight loss and may be useful for preventing postoperative weight gain in certain patients.
“There are no randomized trials demonstrating efficacy for prevention of postoperative weight gain, but there is supportive evidence from a retrospective study,” said Dr. Kushner, referring to a recently published two-center evaluation (Surg Obes Relat Dis. 2017;13:491-500).
In that study, 258 patients underwent Roux-en-Y gastric bypass, and 61 patients underwent sleeve gastrectomy. Those who received adjunctive drug support, particularly in the RYGB group, had greater sustained weight loss than those who did not, leading to the conclusion that postoperative pharmacotherapy “is a useful adjunct.” The advantage for drug therapy was observed even though patients did not receive the most recently approved and potentially more effective drugs, according to Dr. Kushner. However, he cautioned that information about the optimal timing of treatment after surgery remains “limited.”
The variability in weight loss and weight regain after bariatric procedures is one reason to consider bariatric surgery as only one component in a continuum of care, according to Dr. Kushner. He emphasized that obesity is a chronic condition that requires ongoing and perhaps indefinite treatment. While surgeons may already work with a team that manages preoperative and postoperative lifestyle changes to improve immediate surgical outcomes, Dr. Kushner believes that surgeons and physicians should work more collaboratively toward long-term management plans. By also appreciating obesity phenotypes and the specific mix of treatments that are most likely to help individual patients achieve durable weight loss, surgeons and physicians working together are likely to improve outcomes beyond those that could be expected from either working alone.
Dr. Kushner reports he has financial relationships with Novo Nordisk, Retrofit, Takeda Pharmaceuticals, and Vivus.
AT OBESITY WEEK 2017
Key clinical point: For treatment of obesity as a chronic disease, bariatric surgery must be incorporated into a continuum of therapies.
Major finding: Obesity phenotypes differ, requiring individualized adjunctive therapies to surgery in order to ensure durable benefit.
Data source: Expert interpretation of published studies.
Disclosures: Dr. Kushner reports he has financial relationships with Novo Nordisk, Retrofit, Takeda Pharmaceuticals, and Vivus.
Hiatal hernia repair more common at time of sleeve gastrectomy, compared with RYGB
SAN DIEGO – Concomitant hiatal hernia repair is significantly more common at the time of laparoscopic sleeve gastrectomy, compared with laparoscopic Roux-en-Y gastric bypass, according to a retrospective analysis.
“GERD [gastroesophageal reflux disease] is common in patients with a high body mass index,” lead study author Dino Spaniolas, MD, said at the annual clinical congress of the American College of Surgeons. “In fact, 35%-40% of patients who undergo bariatric surgery are diagnosed with a hiatal hernia, and the majority of them are diagnosed during surgery.”
In an effort to assess the differences in practice patterns in the performance of hiatal hernia repair during laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB), the researchers evaluated the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program public use files from 2015. They limited the analysis to LSG and LRYGB and also excluded revision procedures and patients with a history of foregut surgery.
In all, 130,686 patients were included in the study. Their mean age was 45 years, 79% were female, 75% were Caucasian, and their mean body mass index was 45.7 kg/m2. Most (70%) underwent LSG, while the remainder underwent LRYGB.
At baseline, a greater proportion of the LRYGB patients had a history of GERD than did LSG patients (37.2% vs. 28.6%, respectively; P less than .0001). They were also more likely to have hypertension (54.1% vs. 47.9%; P less than .0001), hyperlipidemia (29.9% vs. 23.2%; P less than .0001), and diabetes (35.5% vs. 23.3%; P less than .0001). Overall, about 15% of patients had a concomitant hiatal hernia repair in addition to their bariatric surgery.
Next, the investigators found what Dr. Spaniolas termed “the GERD paradox”: Although the LRYGB patients were more likely to have GERD before surgery, they were much less likely to undergo a hiatal hernia repair in addition to their bariatric procedure. Specifically, concomitant hiatal hernia repair was performed in 21% of LSG patients, compared with only 10.8% of LRYGB patients (P less than .0001). After investigators controlled for baseline BMI, preoperative GERD, and other patient characteristics, they found that LSG patients were 2.14 times more likely to undergo concomitant hiatal hernia repair, compared with LRYGB patients.
“This is a retrospective review, but nevertheless, I think we can conclude that these findings suggest that concomitant hiatal hernia repair is significantly more common after LSG, compared with LRYGB, despite having less GERD preoperatively,” Dr. Spaniolas said. “This suggests that there is a nationwide difference in the intraoperative management of hiatal hernia based on the type of planned bariatric procedure. This practice pattern needs to be considered while retrospectively assessing GERD-related outcomes of bariatric surgery in the future.”
Dr. Spaniolas disclosed that he has received research support from Merck and that he is a consultant for Mallinckrodt.
SAN DIEGO – Concomitant hiatal hernia repair is significantly more common at the time of laparoscopic sleeve gastrectomy, compared with laparoscopic Roux-en-Y gastric bypass, according to a retrospective analysis.
“GERD [gastroesophageal reflux disease] is common in patients with a high body mass index,” lead study author Dino Spaniolas, MD, said at the annual clinical congress of the American College of Surgeons. “In fact, 35%-40% of patients who undergo bariatric surgery are diagnosed with a hiatal hernia, and the majority of them are diagnosed during surgery.”
In an effort to assess the differences in practice patterns in the performance of hiatal hernia repair during laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB), the researchers evaluated the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program public use files from 2015. They limited the analysis to LSG and LRYGB and also excluded revision procedures and patients with a history of foregut surgery.
In all, 130,686 patients were included in the study. Their mean age was 45 years, 79% were female, 75% were Caucasian, and their mean body mass index was 45.7 kg/m2. Most (70%) underwent LSG, while the remainder underwent LRYGB.
At baseline, a greater proportion of the LRYGB patients had a history of GERD than did LSG patients (37.2% vs. 28.6%, respectively; P less than .0001). They were also more likely to have hypertension (54.1% vs. 47.9%; P less than .0001), hyperlipidemia (29.9% vs. 23.2%; P less than .0001), and diabetes (35.5% vs. 23.3%; P less than .0001). Overall, about 15% of patients had a concomitant hiatal hernia repair in addition to their bariatric surgery.
Next, the investigators found what Dr. Spaniolas termed “the GERD paradox”: Although the LRYGB patients were more likely to have GERD before surgery, they were much less likely to undergo a hiatal hernia repair in addition to their bariatric procedure. Specifically, concomitant hiatal hernia repair was performed in 21% of LSG patients, compared with only 10.8% of LRYGB patients (P less than .0001). After investigators controlled for baseline BMI, preoperative GERD, and other patient characteristics, they found that LSG patients were 2.14 times more likely to undergo concomitant hiatal hernia repair, compared with LRYGB patients.
“This is a retrospective review, but nevertheless, I think we can conclude that these findings suggest that concomitant hiatal hernia repair is significantly more common after LSG, compared with LRYGB, despite having less GERD preoperatively,” Dr. Spaniolas said. “This suggests that there is a nationwide difference in the intraoperative management of hiatal hernia based on the type of planned bariatric procedure. This practice pattern needs to be considered while retrospectively assessing GERD-related outcomes of bariatric surgery in the future.”
Dr. Spaniolas disclosed that he has received research support from Merck and that he is a consultant for Mallinckrodt.
SAN DIEGO – Concomitant hiatal hernia repair is significantly more common at the time of laparoscopic sleeve gastrectomy, compared with laparoscopic Roux-en-Y gastric bypass, according to a retrospective analysis.
“GERD [gastroesophageal reflux disease] is common in patients with a high body mass index,” lead study author Dino Spaniolas, MD, said at the annual clinical congress of the American College of Surgeons. “In fact, 35%-40% of patients who undergo bariatric surgery are diagnosed with a hiatal hernia, and the majority of them are diagnosed during surgery.”
In an effort to assess the differences in practice patterns in the performance of hiatal hernia repair during laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB), the researchers evaluated the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program public use files from 2015. They limited the analysis to LSG and LRYGB and also excluded revision procedures and patients with a history of foregut surgery.
In all, 130,686 patients were included in the study. Their mean age was 45 years, 79% were female, 75% were Caucasian, and their mean body mass index was 45.7 kg/m2. Most (70%) underwent LSG, while the remainder underwent LRYGB.
At baseline, a greater proportion of the LRYGB patients had a history of GERD than did LSG patients (37.2% vs. 28.6%, respectively; P less than .0001). They were also more likely to have hypertension (54.1% vs. 47.9%; P less than .0001), hyperlipidemia (29.9% vs. 23.2%; P less than .0001), and diabetes (35.5% vs. 23.3%; P less than .0001). Overall, about 15% of patients had a concomitant hiatal hernia repair in addition to their bariatric surgery.
Next, the investigators found what Dr. Spaniolas termed “the GERD paradox”: Although the LRYGB patients were more likely to have GERD before surgery, they were much less likely to undergo a hiatal hernia repair in addition to their bariatric procedure. Specifically, concomitant hiatal hernia repair was performed in 21% of LSG patients, compared with only 10.8% of LRYGB patients (P less than .0001). After investigators controlled for baseline BMI, preoperative GERD, and other patient characteristics, they found that LSG patients were 2.14 times more likely to undergo concomitant hiatal hernia repair, compared with LRYGB patients.
“This is a retrospective review, but nevertheless, I think we can conclude that these findings suggest that concomitant hiatal hernia repair is significantly more common after LSG, compared with LRYGB, despite having less GERD preoperatively,” Dr. Spaniolas said. “This suggests that there is a nationwide difference in the intraoperative management of hiatal hernia based on the type of planned bariatric procedure. This practice pattern needs to be considered while retrospectively assessing GERD-related outcomes of bariatric surgery in the future.”
Dr. Spaniolas disclosed that he has received research support from Merck and that he is a consultant for Mallinckrodt.
AT THE ACS CLINICAL CONGRESS
Key clinical point: LSG patients are more likely to undergo concomitant hiatal hernia repair, compared with LRYGB patients.
Major finding: According to multivariate analysis, LSG patients were more likely to undergo concomitant HH repair (odds ratio, 2.14).
Study details: A retrospective analysis of 130,686 patients who underwent bariatric surgery in 2015.
Disclosures: Dr. Spaniolas disclosed that he has received research support from Merck and that he is a consultant for Mallinckrodt.
New, persistent opioid use more common after bariatric surgery
SAN DIEGO – Bariatric patients are nearly 50% more likely than general surgery patients to start using opioids after their procedures and continue taking the painkillers for a year, a new study finds.
It’s not clear why bariatric patients are at higher risk of continued opioid use, nor whether they are more likely to become addicted. Still, bariatric patients are a target for “intervention, enhanced education, early referral to specialists, protocols minimizing inpatient and outpatient narcotics, opioid-free operations, system-based interventions and prescribing guidelines,” says study lead author Sanjay Mohanty, MD, a surgery resident with the Henry Ford Health System, who spoke in a presentation at the annual clinical congress of the American College of Surgeons.
There’s been little research into opioid use among bariatric patients, said Dr. Mohanty. In 2013, a retrospective study found that 8% of 11,719 bariatric patients were chronic opioid users, and more than three-quarters of those remained so after 1 year. However, that study was completed in 2010 before the height of the opioid epidemic (JAMA. 2013;310(13):1369-76).
More recently, a 2017 study found that opioid use among 1,892 bariatric patients who weren’t using at baseline grew from 5.8% at 6 months to 14.2% at 7 years. The study tracked patients until January 2015 (Surg Obes Relat Dis. 2017 Aug;13 (8):1337-46).
For the new study, researchers tracked 14,063 bariatric patients in the Michigan Bariatric Surgery Collaborative, a group of Michigan hospitals and health systems, from 2006-2017.
Of the patients, 73% were opioid-naive at baseline and 27% were users. At 1 year after procedure, overall use dropped slightly to 24%. However, 905 patients – 8.8% of the initial opioid-native group – were new and persistent opioid users.
According to Dr. Carlin, this is almost 50% higher than in patients after general surgical procedures.
These users were significantly more likely to be black (OR 1.67), less likely to have private insurance (0.76 OR), more likely to have income under $25,000 (OR 1.43), and more likely to have a mobility limitation (OR 1.78).
The researchers also found evidence linking a higher risk of new and persistent opioid use to lack of unemployment, depression, musculoskeletal disorders, tobacco use and gastric bypass procedures.
Why might bariatric patients in general be more susceptible to new and persistent opioid use? “We don’t know that answer,” Dr. Carlin said. “Maybe there’s some addiction transfer. Or maybe it’s something physiologic. We’re doing an operation on the gut, and that could have an impact on absorption.”
As for solutions, Dr. Carlin says “prescribe less, prescribe differently, be more patient-specific. We’re looking at different modalities to treat the pain such as nerve blocks during surgery, anti-inflammatories and muscle relaxants.”
And if patients aren’t using opioids in the hospital and not having that much pain, he said, physicians don’t send any pills home with them.
The next steps should include research into links between opioids and perioperative complications and surgical outcomes, the researchers suggested.
Dr. Carlin and Dr. Mohanty report no relevant disclosures.
SAN DIEGO – Bariatric patients are nearly 50% more likely than general surgery patients to start using opioids after their procedures and continue taking the painkillers for a year, a new study finds.
It’s not clear why bariatric patients are at higher risk of continued opioid use, nor whether they are more likely to become addicted. Still, bariatric patients are a target for “intervention, enhanced education, early referral to specialists, protocols minimizing inpatient and outpatient narcotics, opioid-free operations, system-based interventions and prescribing guidelines,” says study lead author Sanjay Mohanty, MD, a surgery resident with the Henry Ford Health System, who spoke in a presentation at the annual clinical congress of the American College of Surgeons.
There’s been little research into opioid use among bariatric patients, said Dr. Mohanty. In 2013, a retrospective study found that 8% of 11,719 bariatric patients were chronic opioid users, and more than three-quarters of those remained so after 1 year. However, that study was completed in 2010 before the height of the opioid epidemic (JAMA. 2013;310(13):1369-76).
More recently, a 2017 study found that opioid use among 1,892 bariatric patients who weren’t using at baseline grew from 5.8% at 6 months to 14.2% at 7 years. The study tracked patients until January 2015 (Surg Obes Relat Dis. 2017 Aug;13 (8):1337-46).
For the new study, researchers tracked 14,063 bariatric patients in the Michigan Bariatric Surgery Collaborative, a group of Michigan hospitals and health systems, from 2006-2017.
Of the patients, 73% were opioid-naive at baseline and 27% were users. At 1 year after procedure, overall use dropped slightly to 24%. However, 905 patients – 8.8% of the initial opioid-native group – were new and persistent opioid users.
According to Dr. Carlin, this is almost 50% higher than in patients after general surgical procedures.
These users were significantly more likely to be black (OR 1.67), less likely to have private insurance (0.76 OR), more likely to have income under $25,000 (OR 1.43), and more likely to have a mobility limitation (OR 1.78).
The researchers also found evidence linking a higher risk of new and persistent opioid use to lack of unemployment, depression, musculoskeletal disorders, tobacco use and gastric bypass procedures.
Why might bariatric patients in general be more susceptible to new and persistent opioid use? “We don’t know that answer,” Dr. Carlin said. “Maybe there’s some addiction transfer. Or maybe it’s something physiologic. We’re doing an operation on the gut, and that could have an impact on absorption.”
As for solutions, Dr. Carlin says “prescribe less, prescribe differently, be more patient-specific. We’re looking at different modalities to treat the pain such as nerve blocks during surgery, anti-inflammatories and muscle relaxants.”
And if patients aren’t using opioids in the hospital and not having that much pain, he said, physicians don’t send any pills home with them.
The next steps should include research into links between opioids and perioperative complications and surgical outcomes, the researchers suggested.
Dr. Carlin and Dr. Mohanty report no relevant disclosures.
SAN DIEGO – Bariatric patients are nearly 50% more likely than general surgery patients to start using opioids after their procedures and continue taking the painkillers for a year, a new study finds.
It’s not clear why bariatric patients are at higher risk of continued opioid use, nor whether they are more likely to become addicted. Still, bariatric patients are a target for “intervention, enhanced education, early referral to specialists, protocols minimizing inpatient and outpatient narcotics, opioid-free operations, system-based interventions and prescribing guidelines,” says study lead author Sanjay Mohanty, MD, a surgery resident with the Henry Ford Health System, who spoke in a presentation at the annual clinical congress of the American College of Surgeons.
There’s been little research into opioid use among bariatric patients, said Dr. Mohanty. In 2013, a retrospective study found that 8% of 11,719 bariatric patients were chronic opioid users, and more than three-quarters of those remained so after 1 year. However, that study was completed in 2010 before the height of the opioid epidemic (JAMA. 2013;310(13):1369-76).
More recently, a 2017 study found that opioid use among 1,892 bariatric patients who weren’t using at baseline grew from 5.8% at 6 months to 14.2% at 7 years. The study tracked patients until January 2015 (Surg Obes Relat Dis. 2017 Aug;13 (8):1337-46).
For the new study, researchers tracked 14,063 bariatric patients in the Michigan Bariatric Surgery Collaborative, a group of Michigan hospitals and health systems, from 2006-2017.
Of the patients, 73% were opioid-naive at baseline and 27% were users. At 1 year after procedure, overall use dropped slightly to 24%. However, 905 patients – 8.8% of the initial opioid-native group – were new and persistent opioid users.
According to Dr. Carlin, this is almost 50% higher than in patients after general surgical procedures.
These users were significantly more likely to be black (OR 1.67), less likely to have private insurance (0.76 OR), more likely to have income under $25,000 (OR 1.43), and more likely to have a mobility limitation (OR 1.78).
The researchers also found evidence linking a higher risk of new and persistent opioid use to lack of unemployment, depression, musculoskeletal disorders, tobacco use and gastric bypass procedures.
Why might bariatric patients in general be more susceptible to new and persistent opioid use? “We don’t know that answer,” Dr. Carlin said. “Maybe there’s some addiction transfer. Or maybe it’s something physiologic. We’re doing an operation on the gut, and that could have an impact on absorption.”
As for solutions, Dr. Carlin says “prescribe less, prescribe differently, be more patient-specific. We’re looking at different modalities to treat the pain such as nerve blocks during surgery, anti-inflammatories and muscle relaxants.”
And if patients aren’t using opioids in the hospital and not having that much pain, he said, physicians don’t send any pills home with them.
The next steps should include research into links between opioids and perioperative complications and surgical outcomes, the researchers suggested.
Dr. Carlin and Dr. Mohanty report no relevant disclosures.
AT THE ACS CLINICAL CONGRESS
Key clinical point: It’s common for opioid-naive bariatric patients to begin using opioids after surgery and continuing at 1 year.
Major finding: At 1 year after surgery, 8.8% of the 73% of bariatric patients who were opioid-naive were new and persistent opioid users.
Data source: 14,063 Michigan bariatric patients tracked from 2006-2017.
Disclosures: The study authors report no relevant disclosures.