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SAGES 2013

Age and sex are predictors of in-hospital mortality from surgery

Age, male gender and cardiac disease all associated with in-hospital mortality
Unknown whether high volume or COE status is responsible for improved morbidity and mortality rates

Two studies involving over 800,000 patients have provided important insights into mortality and morbidity rates following bariatric surgery.

The first study, from researchers at Staten Island University Hospital, reported that despite morbidly obese patients presenting with several comorbidities excellent outcomes have been achieved when patients are appropriately managed.

The researchers sought to assess the in-hospital outcomes from a large, prospectively collected database to determine predictors of in-hospital mortality to aid in pre-operative assessment of these challenging patients.

They examined data of primary bariatric operations (apart from revisional surgery and biliopancreatic diversion/duodenal switch procedures) performed from 2005-2009 from the National Inpatient Sample database, and recorded patient comorbid conditions, insurance status, ethnicity, age and gender, as well as In-hospital morbidity and mortality.

The estimated number of bariatric procedures performed was 548,106 with laparoscpic gastric bypass the most commonly performed procedure (60.7%).

followed by laparoscopic gastric banding (20.8%) and open gastric bypass (12.3%). Sleeve gastrectomy accounted for 3.9% of procedures.

The overall, in-hospital mortality was 0.1%: 0.1% for bypass, 0% for laparoscopic gastric band, 0.3% of open gastric bypass recipients and 0.1% for sleeve.

They researchers then performed a multivariate logistic regression to select factors which contributed to increased mortality, which revealed congestive heart failure, open procedures, age (>50years), male sex, obstructive sleep apnoea and chronic pulmonary disease (all p<0.01), were all statistically significant predictors of in-hospital mortality.

The authors concluded that bariatric operative mortality remains very low and is equivalent to more commonly accepted procedures such as laparoscopic cholecystectomy.

“These outcomes speak to the level of maturity and dedication to quality patient care in the field of bariatric surgery,” the authors concluded. “Even with the recent introduction of the sleeve gastrectomy, outcomes remain excellent.”

Volume/COE

Although the morbidity and mortality rates continue to improve at high volume centres, researchers from the University of California, Irvine, were unable to ascertain whether the improved outcomes are related to their higher volume or their status of accreditation as Centers of Excellence (CoE).

The rapid adoption of the laparoscopic approach for bariatric operations over the past decade has been accompanied by an exponential growth in the number of procedures performed annually.

Although numerous studies have looked at the effects of volume on surgical outcomes for bariatric surgery, most of these studies were perform when open procedure were dominant and there was no system of national accreditation. More recent studies have shown that volume is an independent predictor of serious complications.

The investigators examined the effect of volume on surgical outcomes in the current climate of bariatric surgery and used the Nationwide Inpatient Sample to collect some 381,674 elective admission cases of bariatric surgical cases from 2006-2010.

They examined patient demographics, comorbidities, serious postoperative morbidity and in-hospital mortality. Outcomes were analysed according to low volume (<50 cases), medium volume (50-100 cases) and high volume hospitals (>100 cases).

From the 381,674 cases sampled, 74% of cases were performed in high volume hospitals with gastric bypass and sleeve gastrectomy accounting for 72% of cases.

Patient age, gender distribution, race, hospital type and comorbidity score were similar for all groups. Hospital charges were highest in the low volume hospitals, while length of stay and anastomotic leak were similar among the three groups. In-hospital mortality was higher in the low volume hospitals (0.14%) compared to high volume hospitals (0.06%).

A multivariate analysis was performed to estimate and test the association of volume on mortality and serious morbidity while controlling for age, gender, hospital factors (teaching, size, and location), comorbidities, and procedure type (stapling and non-stapling).

Procedures performed in a low volume hospitals were associated with 2.9 fold increase in mortality rates (p<0.02) and a 1.3 fold increase in serious morbidity (p<0.01), compared to high volume hospitals. Stapling procedures performed in low volume hospitals were associated with a 2.9 fold increase in mortality rates (p<0.04) and a 1.3 fold increase in serious morbidity (p<0.01), compared to high volume hospitals.

Non-stapling procedures performed low volume hospitals were associated with a 1.6 fold increase in mortality rates (p<0.01), compared to high volume hospitals.

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