Advancing the Understanding of Bariatric Surgery Outcomes

Members of the Division of General and Gastrointestinal Surgery in the Department of Surgery at Brigham and Women’s Hospital were authors of three recently published retrospective studies focused on bariatric surgery.

The Brigham has been an accredited metabolic and bariatric surgery center for over 15 years. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), a rigorous peer evaluation performed by the American College of Surgeons, indicates that the institution has met or exceeded national surgical standards.

As an MBSAQIP center, the Brigham contributes to the program’s national outcomes registry, a resource that was utilized for the three studies detailed below.

Safety of Same-Day Discharge After Bariatric Surgery

Growing reliance on Enhanced Recovery After Surgery protocols and capacity issues accentuated by the pandemic have heightened the interest in same-day discharge (SDD) for bariatric surgery. To determine key trends in SDD for minimally invasive bariatric surgery, Brigham investigators analyzed data from the MBSAQIP registry from 2016-2021.

According to the authors, the resulting paper, published in the Journal of the American College of Surgeons, is the first “multicenter North American study evaluating the safety of SDD over six years…and identifying the factors associated with increased post-operative complications for SDD.”

The study found that SDD for minimally invasive bariatric surgery increased from 2.4% in 2016 to 7.4% in 2021. SDD rose for both sleeve gastrectomy (SG) (3.1% to 9.7%) and Roux-en-Y gastric bypass (RYGB) (0.8% to 2.4%) over that same period.

Black/African American race and a history of myocardial infarction, renal insufficiency, deep vein thrombosis, and smoking were among the primary preoperative factors associated with increased complications for SDD. The overall major complications were lower in the SDD cohort than in the admission (defined as discharge on postoperative day 1 through day 30) cohort. The risk of complications with SDD was found to be 1.72 times higher for RYGB than for SG.

With regard to safety, the analysis showed significantly higher rates of 30-day mortality, cardiac arrest, and dehydration requiring treatment in the SDD cohort versus the admission cohort. The authors called for further studies to guide the selection of appropriate patients for SDD for minimally invasive bariatric surgery.

“Although insurers and Medicare have pushed to make bariatric surgery an outpatient procedure, our work suggests that there are significant potential safety issues with this approach,” says corresponding author Eric G. Sheu, MD, PhD, section chief, Bariatric and Foregut Surgery, at the Brigham. “An alternative we are studying at the Brigham is the use of the home hospital for recovery after bariatric surgery, so patients can receive appropriate medical monitoring and care in their own home and at a lower cost.”

Gender‑associated Outcomes Following Bariatric Surgery

Eighty percent of patients who undergo bariatric surgery self-identify as female. Given the widely accepted safety of these procedures, why is there such a glaring gender-associated disparity in their use? Is male gender an independent risk factor for bariatric surgery?

In a study published in Obesity Surgery, Brigham investigators analyzed data from the MBSAQIP registry from 2017-2021 to assess the impact of gender on outcomes in bariatric surgery. Among the key results are the following:

  • Compared to males, females had a 32% higher risk of any complication, a 57% higher risk of post-op infections, a 7% lower risk of major complications, and a 46% lower risk of death.
  • Although men had a 0.15% (p < 0.01) higher risk of major complications compared to women, their overall risk of major complications (2.3%) and death (0.2%) was relatively low.
  • Men had a higher rate of major complications compared to women for SG, but there was no significant difference between the two cohorts for RYGB, biliopancreatic diversion, or placement of laparoscopic adjustable gastric band.

The study’s findings are a departure from previous studies of the MBSAQIP and of the German Bariatric Surgery Registry that showed significant gender-associated differences in outcomes.

“As a result of these findings, we hope that more eligible men receive bariatric surgical interventions for obesity,” says first/corresponding author and surgery resident Tina Bharani, MD.

Gastric Bypass, Sleeve Gastrectomy, and Conversion Surgery in Patients With GERD

Which form of bariatric surgery is the most effective for patients with gastroesophageal reflux disease (GERD)—RYGB or SG?

While previous studies have shown RYGB to be associated with a significant improvement in and/or resolution of GERD symptoms, the data around SG are less conclusive. As a result, the 2017 position statement by the American Society for Metabolic Bariatric Surgery called for further study to guide recommendations on utilizing SG in obese patients with GERD.

Members of the Brigham’s Department of Surgery comprised six of the seven authors of a paper published in Surgical Endoscopy examining this issue. Using MBSAQIP data, they aimed to:

  • Evaluate the trends in utilization and safety of primary RYGB and primary SG for patients with GERD requiring medications.
  • Compare the perioperative outcomes between primary RYGB and conversion surgery from SG to RYGB for GERD.

Among bariatric patients with GERD, the investigators found an increase in utilization of primary RYGB from 38% in 2015 to 45% in 2021, along with a decrease in primary SG from 62% in 2015 to 55% in 2021. This national shift toward RYGB may reflect data showing that RYGB is a more effective treatment than SG for GERD, although this study shows that RYGB has higher short-term risk.

Meanwhile, a comparison of perioperative outcomes between primary RYGB and SG-to-RYGB conversion revealed higher rates of readmissions, interventions, and ED visits for the latter cohort. However, there was no significant difference in rates of reoperation, reintervention, major complications, or death between the two cohorts.

“Our study shows that SG conversion to RYGB in patients with GERD is safer than previously thought,” Dr. Sheu says. “This raises the need for additional studies to understand the best first surgical options for the patient with GERD that balance overall short- and long-term benefits and risks.”

Summarizing the three studies, Dr. Sheu concludes that “this work illustrates the importance of participating in MBSAQIP, which gives us the opportunity to continue to improve the safety of bariatric surgery and quality of care for our patients.”

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