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PubMed2005

The SAGES Bariatric Surgery Outcome Initiative.

BACKGROUND: The recent initiative for identifying centers of excellence in bariatric surgery calls for documentation of surgical outcomes. The SAGES Outcomes Initiative is a national database introduced in 1999 as a method for surgeons to accumulate and compare their data with summary national data. A bariatric-specific dataset was established later in 2001. The aim of this study was to compare the outcomes of bariatric surgery from the Society of American Gastrointestinal Endoscopic Surgeons' (SAGES) bariatric database with data derived from a national administrative database of academic centers. METHODS: Between 2001 and 2004, 24 surgeons with 1,954 patients participated in the SAGES Bariatric Outcome Initiative, and 97 institutions with 42,847 patients participated in the University HealthSystem Consortium (UHC) database. Only 7 of the 24 surgeons participating in the SAGES Bariatric Outcome Initiative submitted more than 50 cases. The main outcome measures included demographics, comorbidities, type of bariatric procedure, operative time, length of hospital stay, short- and long-term complications, mortality, and weight loss. RESULTS: Both datasets were comparable for gender. Roux-en-Y gastric bypass had been performed for 88% of the patients in the SAGES database and 96% of the patients in the UHC database. Associated comorbidities were similar between the two groups except for a higher rate of hyperlipidemia for the patients in the SAGES database. The SAGES database contains more bariatric-specific information such as body mass index, operative time, blood loss, bariatric-specific complications, long-term complications, and weight loss data than the UHC database. According to the available data, no statistically significant differences exist between the two datasets in terms of perioperative complications and mortality. CONCLUSIONS: The SAGES Bariatric Outcome Initiative provides valuable bariatric-specific data not currently available in an administrative database that may be useful for benchmarking purposes. However, this database is currently underutilized.

Adult↗
PubMed2006

Result of a national audit of bariatric surgery performed at academic centers: a 2004 University HealthSystem Consortium Benchmarking Project.

HYPOTHESIS: Bariatric surgery performed at US academic centers is safe and associated with low mortality. DESIGN: Multi-institutional consecutive cohort study. SETTING: Academic medical centers. PATIENTS AND INTERVENTIONS: We audited the medical records from 40 consecutive bariatric surgery cases performed between October 1, 2003, and March 31, 2004, at each of the 29 institutions participating in the University HealthSystem Consortium Bariatric Surgery Benchmarking Project. All medical records that met inclusion criteria (patient age, >17 and <65 years; and body mass index [calculated as weight in kilograms divided by the square of height in meters], 35-70) and exclusion criteria (previous bariatric surgery) were reviewed and data were collected on a standardized form. MAIN OUTCOME MEASURES: Demographic data, operative time, blood loss, transfusion requirement, complications, readmission, reoperation, and in-hospital and 30-day mortality. RESULTS: Data from 1144 bariatric surgery cases were reviewed from 29 University HealthSystem Consortium institutions. The specific bariatric procedures included gastric bypass (91.7%), gastroplasty or gastric banding (8.2%), and biliopancreatic diversion (0.1%). For gastric bypass procedures (n = 1049), the mean patient age was 43 years and mean body mass index was 49; 76% of procedures were performed laparoscopically, with a conversion rate of 2.2%; the overall complication rate was 16%, with an anastomotic leakage rate of 1.6%; the 30-day readmission rate was 6.6%; and the 30-day mortality rate was 0.4%. For restrictive procedures (n = 94), the mean patient age was 45 years and mean body mass index was 45; 92% of procedures were performed laparoscopically with no conversion; the overall complication rate was 3.2%; the 30-day readmission rate was 4.3%; and the 30-day mortality rate was 0%. CONCLUSIONS: Within the context of the 2004 University HealthSystem Consortium Bariatric Surgery Benchmarking Project, the risk for death within 30 days after bariatric surgery at academic centers is less than 1%. In addition, the practice of bariatric surgery at these centers has shifted from open surgery to predominately laparoscopic surgery. These quality-controlled outcome data can be used as a benchmark for the practice of bariatric surgery at most US hospitals.

Adult↗
PubMed2006

Development of bariatric surgery-specific risk assessment tool.

BACKGROUND: Administrative databases have increasingly been used to assess bariatric surgery outcomes, resulting in policy recommendations about bariatric practice. However, surgical outcomes must be risk adjusted to compare patients of varying potential risk fairly with those to whom the policies will apply. To date, the risk adjustment tools used for database analysis of bariatric surgical outcomes have been those designed for other purposes, and their sensitivity for bariatric outcomes has not been established. METHODS: Bariatric surgical procedures contained in the National Hospital Discharge Summary for 1993-2003 were assembled into a database. The standard set of Elixhauser co-morbidity variables used by the Agency for Healthcare Research and Quality were entered into the database. Those variables that were significantly associated with adverse outcomes were entered into a stepwise-elimination logistic regression equation, yielding a set of variables related to adverse outcomes from bariatric surgery. These were then prospectively applied to another database (the National Inpatient Survey) to determine their sensitivity for predicting outcomes and were compared with the commonly used Charlson score. RESULTS: The variables significantly correlating with bariatric adverse events included chronic pulmonary disease, hypertension, diabetes with chronic complications, fluid and electrolyte disorders, deficiency anemias, and depression. Age and male gender were also signficantly related to adverse events. The c-index (a correlative index, with .5 showing no, and 1, a perfect, relationship) for bariatric surgery mortality with the Charlson index is .52. For the Elixhauser-based system we developed, it is .72. CONCLUSIONS: We have developed a new risk-adjustment tool for bariatric surgery outcomes studies that use administrative databases. Its performance was clearly better than that of the commonly used Charlson co-morbidity score. Bariatric studies that have used the Charlson index should not be considered adequately risk adjusted.

Adolescent↗
PubMed2004

Current status of bariatric surgery in the treatment of type 2 diabetes.

Bariatric surgery (from the Greek words baros meaning 'weight' and iatrikos 'the art of healing') is a rapidly evolving branch of surgical science. The aim is to induce major weight loss in those whose obesity places them at high risk of serious health problems. In an attempt to balance the risks of surgery against the benefits of weight loss, bariatric operations are currently performed only in the morbidly obese, or those with a body mass index (BMI) > 35 kgm(-2) who already have developed comorbidity such as type 2 diabetes. Although weight loss is beneficial for obese patients with diabetes, current medical treatment for obesity is difficult. In contrast, observational studies show a major impact of bariatric surgery on diabetes, raising the question whether this approach should be used more widely to treat diabetes in obese patients? If bariatric surgery were shown to be the best way to treat diabetes in obese subjects the implications for health services would be wide-ranging. Bariatric surgery leads to withdrawal of diabetic treatment in about 60% or more of patients, and reductions of therapy for many others. Although data on bariatric surgery in subjects with diabetes are provocative, most studies have been uncontrolled or flawed in other ways. Most importantly, bariatric surgery has not yet been compared against standard medical treatment for diabetes in randomized controlled trials with diabetes-specific endpoints in all relevant patient groups. Potential indications for bariatric surgery are discussed, and the unanswered questions that need to be addressed by clinical trials are summarized. Although small numbers of patients may be interested in bariatric surgery for type 2 diabetes, current data are insufficient to endorse its wide scale use for this indication. Until essential studies are undertaken the role and economics of bariatric surgery in the diabetic clinic will remain uncertain.

Biliopancreatic Diversion↗
PubMedDate not supplied

The ASBS Bariatric Surgery Centers of Excellence program: a blueprint for quality improvement.

BACKGROUND: Variations in the techniques of bariatric surgery, coupled with the lack of a common database, has led to variable and, sometimes negative, outcomes from bariatric surgery. Thus, in November 2003, the American Society for Bariatric Surgery established Surgical Review Corporation (SRC) as an independent nonprofit entity for quality control of bariatric surgery and as a resource for data collection and analysis. METHODS: In November 2003, the leadership of the American Society for Bariatric Surgery founded SRC as an independent nonprofit entity for quality control of bariatric surgery and as resource for research. A national set of standards for the Bariatric Surgery Centers of Excellence program was developed using a meta-analysis of the relevant published English language data, a consensus conference at Georgetown University, and participation by stakeholders from industry, third-party payors, and malpractice carriers. A software program was developed to provide uniformity in data collection and ease of analysis. RESULTS: SRC developed standards that have been accepted by the bariatric surgical community and put in place. A system was developed for the designation of two levels for the centers, provisional and full. The growth of the Centers of Excellence program has been rapid. At present, 135 hospitals and 265 surgeons have achieved full approval. The centers for Medicare and Medicaid Services have recognized the program. On the basis of the reports of 55,567 patients from the first 176 applicants for full approval and confirmed by SRC during site inspections, the 90-day operative mortality rate was 0.35%. CONCLUSIONS: The first phase of development has gone well. Future steps include the development of a network of bariatric physicians and the development of a consortium for research.

Bariatric Surgery↗
PubMed2006

National trends in bariatric surgery, 1996-2002.

BACKGROUND: Surgical therapy for the long-term treatment of obesity ("bariatric surgery") in individuals whose body mass index (calculated as weight in kilograms divided by the square of height in meters) is 40 or higher or in those who have significant obesity-related comorbidities and a body mass index of 35 or higher is one of few interventions shown to be effective. Many aspects of recent national bariatric surgery trends are unclear, including the ages of individuals undergoing such procedures and the economic burden borne by public vs private payers. HYPOTHESIS: Population-adjusted rates of bariatric surgery are rapidly increasing and have economic implications that differ for private vs public payers. DESIGN AND SETTING: We examined hospitalization and charge data from the Nationwide Inpatient Sample from 1996 through 2002, representative of national patterns for children and adults. We derived nationally weighted estimates of population-adjusted hospitalization rates and inflation-adjusted charges for bariatric surgery. We also examined the relative economic burden for public vs private payers for bariatric surgery discharges. RESULTS: Population-adjusted rates of bariatric surgery in the overall sample increased more than 7-fold in the study period, from 3.5 per 100 000 US population in 1996 to 24.0 per 100 000 in 2002. During this period, among youth (<20 years old), rates increased from 0.23 per 100 000 to 0.73 per 100 000; and among elderly persons (>65 years old), rates increased from 0.30 per 100 000 to 1.69 per 100 000. The rate increased most dramatically among those aged 20 to 65 years, who composed 97% or more of bariatric surgery discharges annually. Increases in bariatric surgical volume corresponded with increasing economic consequences overall, exceeding USD $2 billion in annual charges by 2002 (mean, USD $29,107 per discharge). Since 2000, private payers have been charged for more than 80% of the national total; annual charges to Medicare and Medicaid have been comparatively modest, but each exceeded USD $100 million by 2002. CONCLUSIONS: National rates of bariatric surgery have increased markedly among children and adults, with attendant economic consequences, principally for private insurers. This trend may reflect the dearth of effective primary care and preventive interventions to address the obesity epidemic.

Adult↗
PubMed2005

National variations in morbid obesity and bariatric surgery use.

BACKGROUND: Exploring bariatric surgery use provides data on effective treatment allocation. This study analyzed national rates of bariatric surgery use and the burden of morbid obesity by gender, census region, and age. STUDY DESIGN: Patients 18 years of age or older undergoing bariatric surgery were identified from the US 2002 Nationwide Inpatient Sample, and the national morbidly obese population 18 years of age or older was determined using the Centers for Disease Control and Prevention 2002 Behavioral Risk Factor Surveillance System databases. General population data were obtained from 2000 census data. Annual rates of bariatric surgery procedures were determined by gender, age group, and census region (Northeast, Midwest, South, and West). Rate ratios were calculated and significance tested through 95% confidence intervals (95% CI), accounting for the Nationwide Inpatient Sample and Behavioral Risk Factor Surveillance System sampling design. RESULTS: In 2002, a national cohort of 69,490 bariatric surgery patients was identified. Of these patients 85% were women and 76% were ages 18 to 49 years. The prevalence of morbid obesity (body mass index > or = 40 kg/m(2)) in the US in 2002 was 1.8%; 60% of morbidly obese people were women, and 63% were ages 18 to 49 years. The rates of bariatric surgery procedures per 100,000 morbidly obese individuals ranged from a low of 139 in men aged 60 years and older in the Midwest to a high of 5,156 in women ages 40 to 49 years in the Northeast. For both men and women, bariatric surgery rates in the West and Northeast were 1.35 (95% CI 1.31 to 1.40, p < 0.05) to 4.51 (95% CI 4.15 to 4.89, p < 0.05) times higher than in the South, respectively; rates in the Midwest were similar to those in the South. CONCLUSIONS: National estimates suggest that bariatric surgery rates do not parallel the burden of morbid obesity by region or age. Additional evaluation of these differences is necessary for optimal bariatric surgery use.

Adolescent↗
PubMed2005

State laws on insurance coverage for bariatric surgery: help or a hindrance?

BACKGROUND: The purpose of this study was to determine which states have proposed or passed laws regarding insurance coverage for bariatric surgery and to obtain feedback from bariatric surgeons/programs regarding the effectiveness of these laws. METHODS: The Departments of Insurance in all 50 states and the District of Columbia in the United States and all members of the American Society for Bariatric Surgery were surveyed. RESULTS: Responses were obtained from all states and the District of Columbia, and 16 responses were received from the bariatric surgeons/programs. Michigan law requires all Health Maintenance Organizations to pay for all medically necessary treatments or procedures in general, such that if bariatric surgery can be shown to be medically necessary, it should be covered. Four states (Louisiana, Ohio, South Carolina, and Tennessee) have proposed state laws regarding bariatric surgery coverage, and four states (Georgia, Indiana, Maryland, and Virginia) have such laws in effect. However, none of the state laws that were passed "mandate" coverage, but rather "recommend" coverage or mandate that the insurer offer the coverage, for which the insurer can charge additional premiums. Although the numbers of responses from bariatric surgeons/programs were few, all of their responses were in agreement that the state laws have not increased insurance approvals for bariatric surgery and, in some cases, has made it more difficult to obtain approval. CONCLUSION: So far, the laws that have been passed have not adequately addressed the problems with decreasing coverage of bariatric surgery. Recommendations for future legislation are discussed.

Bariatric Surgery↗
PubMed2006

Outcome of portal injuries following bariatric operations.

BACKGROUND: Portal vein thrombosis is rare following Roux-en-Y gastric bypass (RYGBP). Its natural history is dependent on the etiology of the thrombosis. Iatrogenic injuries at bariatric operations resulting in portal vein thrombosis are lethal complications typically necessitating a liver transplant, whereas postoperative portal vein thrombosis without an injury to the portal vein has a benign course. There are currently no data on management or prognostic factors of portal vein thrombosis after bariatric operations. METHODS: 3 patients referred for liver transplantation secondary to portal vein injury following bariatric surgery between 2000 and 2003 are presented. RESULTS: 2 super-obese (BMI>or=50 kg/m2) and 1 morbidly obese (BMI 44 kg/m2) patients sustained portal vein injuries during bariatric surgery (RYGBP 2, VBG 1) by experienced bariatric surgeons. In each case, the portal injury was identified and repaired. Thrombosis followed reconstruction in all 3 patients. All 3 underwent emergency liver transplantation, but died of sepsis and multi-organ failure following transplantation. Review of the literature found no cases of traumatic portal vein injuries following bariatric operations and 2 cases of postoperative portal vein thrombosis: 1 following LRYGBP (BMI 46) and one after a Lap-Band (BMI 41). CONCLUSION: Injury to the portal vein resulting from difficulty in discerning the anatomy of the intra-abdominal structures in the morbidly obese, is a lethal complication of bariatric surgery. Super-obese patients submitting to bariatric surgery should lose weight, undergo a two-stage bariatric procedure, or undergo laparoscopic RYGBP to minimize the risk of portal injury. Postoperative portal vein thrombosis has a benign course and can be managed conservatively.

Adult↗
PubMed2003

Who should be doing laparoscopic bariatric surgery?

BACKGROUND: The training and credentialing of surgeons for laparoscopic bariatric surgery is controversial. We sought to determine if there is an association between surgeons' practice and choice of open or laparoscopic bariatric surgery. METHODS: Members of the ASBS were surveyed via email. Associations were tested with Cochran-Mantel-Haenszel or Pearson's chi-square. RESULTS: 104/472 members responded; 65% were in private practice; 47% did 1-5 operations/week, 48% offered open procedures only, and 76% undertook gastric bypass. Respondents believe that laparoscopic procedures: should mimic open ones (77%), are safe (63%), should be evaluated by clinical trials (48%), and that expertise in bariatric surgery is more important than laparoscopic experience. 75% believe that courses and preceptorships are important. Regarding laparoscopic operations, surgeons doing only open procedures believe that: 1) the ASBS should be the main credentialing body; 2) surgeons should do > 25 open before laparoscopic ones; and 3) clinical trials are needed (P < 0.02, all). Surgeons with laparoscopic training or practices believe that laparoscopic surgery is safe and effective (P < 0.002). Both laparoscopic and open surgeons believe bariatric surgeons should be the only surgeons doing laparoscopic bariatric procedures (P < 0.008). CONCLUSIONS: There is consensus that laparoscopic bariatric surgery should be undertaken only by surgeons with strong interest in bariatric surgery. Laparoscopic bariatric surgeons should incorporate lessons learned from open surgery. Both laparoscopic and open bariatric surgeons should seek added expertise via courses and preceptorships. The skepticism of surgeons with 'open' practices could be addressed by clinical trials. The ASBS should maintain its leadership position and foster emerging technologies.

Clinical Competence↗
PubMed2004

Trends in bariatric surgery for morbid obesity in Wisconsin.

BACKGROUND: Obesity is a national epidemic with rates in Wisconsin and the United States doubling over the past decade. Research of available treatments for morbid obesity (body mass index > or = 40 kg/m2) suggests that bariatric surgery may be the only modality that provides any significant long term weight loss. METHODS: Using the data from Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System, we analyzed self-reported information on body weight and height among adults in Wisconsin. We used the WITHIN database for inpatient hospitalization and surgeries in Wisconsin to evaluate trends in gastric bypass surgery. Finally, we surveyed bariatric surgeons in Wisconsin to assess trends in bariatric surgery in the state. RESULTS: In Wisconsin, the percentage of the adults considered to be obese increased from 11% in 1990 to 22% in 2001. In 1999-2001, approximately 80,000 adults (2% of the population) were morbidly obese. The number of gastric bypass surgeries performed in Wisconsin more than doubled in 1 year, from 182 in 2001 to 426 in 2002. According to bariatric surgeons, gastric bypass accounts for approximately 90% of bariatric surgeries performed in Wisconsin. Thus, in 2002, there was roughly 1 bariatric surgery for every 200 morbidly obese Wisconsin adults. Most (84%) bariatric surgeons are planning to increase the number of procedures they perform, and 24% plan on adding an additional bariatric surgeon to their group. SUMMARY: Bariatric surgery rates are increasing in Wisconsin, yet the demand for surgery far exceeds current capacity of surgeons in the state.

Adolescent↗
PubMedDate not supplied

Centers of Excellence in Bariatric Surgery: design, implementation, and one-year outcomes.

BACKGROUND: Bariatric surgery procedures increased from <20,000 annually in the early 1990s to >100,000 in 2003. The complications related to surgery have increased disproportionately, causing some payers to discontinue coverage for bariatric procedures and reducing patient access to an effective treatment modality. This report describes an alternative approach-the creation of a network of Centers of Excellence (COE) in Bariatric Surgery. METHODS: Blue Cross and Blue Shield of North Carolina developed a COE program by working collaboratively with the bariatric surgery community. Through systematic review, the collaborative identified bariatric surgical programs that appropriately select patients, comprehensively evaluate and prepare patients for surgery, produce superior outcomes, and provide long-term follow-up for patients. RESULTS: Seven practices were selected as Blue Cross and Blue Shield of North Carolina Bariatric Surgery COE. The short-term results comparing the 12 months before COE implementation and the 12 months after implementation included a 14% decline in the number of bariatric procedures performed (693 versus 596), a 23% decrease in the number of surgeons billing for bariatric procedures (53 versus 41), a 30-day readmission rate of 4.7% for COE providers and 8.3% for non-COE providers, and an average inpatient length of stay of 2.5 days for COE providers and 3.0 days for non-COE providers. The proportion of procedures performed by the COE providers increased from 55% to 61%. CONCLUSION: The preliminary results are encouraging, with COE providers demonstrating reduced 30-day readmission rates and, surprisingly, overall reductions in the rate and number of procedures performed and the number of physicians performing them.

Bariatric Surgery↗
PubMed2005

Trends in bariatric surgical procedures.

CONTEXT: The increasing prevalence and associated sociodemographic disparities of morbid obesity are serious public health concerns. Bariatric surgical procedures provide greater and more durable weight reduction than behavioral and pharmacological interventions for morbid obesity. OBJECTIVE: To examine trends for elective bariatric surgical procedures, patient characteristics, and in-hospital complications from 1998 to 2003 in the United States. DESIGN, SETTING, AND PATIENTS: The Nationwide Inpatient Sample was used to identify bariatric surgery admissions from 1998-2002 (with preliminary data for 12 states from 2003) using International Classification of Diseases, Ninth Revision, codes for foregut surgery with a confirmatory diagnosis of obesity or by diagnosis related group code for obesity surgery. Annual estimates and trends were determined for procedures, patient characteristics, and adjusted complication rates. MAIN OUTCOME MEASURES: Trends in bariatric surgical procedures, patient characteristics, and complications. RESULTS: The estimated number of bariatric surgical procedures increased from 13,365 in 1998 to 72,177 in 2002 (P<.001). Based on preliminary state-level data (1998-2003), the number of bariatric surgical procedures is projected to be 102 794 in 2003. Gastric bypass procedures accounted for more than 80% of all bariatric surgical procedures. From 1998 to 2002, there were upward trends in the proportion of females (81% to 84%; P = .003), privately insured patients (75% to 83%; P = .001), patients from ZIP code areas with highest annual household income (32% to 60%, P<.001), and patients aged 50 to 64 years (15% to 24%; P<.001). Length of stay decreased from 4.5 days in 1998 to 3.3 days in 2002 (P<.001). The adjusted in-hospital mortality rate ranged from 0.1% to 0.2%. The rates of unexpected reoperations for surgical complications ranged from 6% to 9% and pulmonary complications ranged from 4% to 7%. Rates of other in-hospital complications were low. CONCLUSIONS: These findings suggest that use of bariatric surgical procedures increased substantially from 1998 to 2003, while rates of in-hospital complications were stable and length of stay decreased. However, disparities in the use of these procedures, with disproportionate and increasing use among women, those with private insurance, and those in wealthier ZIP code areas should be explored further.

Adult↗
PubMed2006

The impact of laparoscopic bariatric workshops on the practice patterns of surgeons.

BACKGROUND: This study was designed to evaluate the impact of a 2-day laparoscopic bariatric workshop on the practice patterns of participating surgeons. METHODS: From October 1998 to June 2002, 18 laparoscopic bariatric workshops were attended by 300 surgeons. Questionnaires were mailed to all participants. RESULTS: Responses were received from 124 surgeons (41%), among whom were 56 bariatric surgeons (open) (45%), 30 advanced laparoscopic surgeons (24%), and 38 surgeons who performed neither bariatric nor advanced laparoscopic surgery (31%). The questionnaire responses showed that 46 surgeons (37%) currently are performing laparoscopic gastric bypass (LGB), 38 (31%) are performing open gastric bypass, and 39 (32%) are not performing bariatric surgery. Since completion of the course, 46 surgeons have performed 8,893 LGBs (mean, 193 cases/surgeon). Overall, 87 of the surgeons (70%) thought that a limited preceptorship was necessary before performance of LGB, yet only 25% underwent this additional training. According to a poll, the respondents thought that, on the average, 50 cases (range, 10-150 cases) are needed for a claim of proficiency. CONCLUSION: Laparoscopic bariatric workshops are effective educational tools for surgeons wishing to adopt bariatric surgery. Open bariatric surgeons have the highest rates of adopting laparoscopic techniques and tend to participate in more adjunctive training before performing LGB. There was consensus that the learning curve is steep, and that additional training often is necessary. The authors propose a mechanism for post-residency skill acquisition for advanced laparoscopic surgery.

Bariatric Surgery↗
PubMed2006

Long-term outcome of bariatric surgery: an interim analysis.

With the increasing number of bariatric surgical procedures being performed, outcome assessment is of even greater importance. Few randomized, controlled prospective trials have compared bariatric surgery to nonsurgical weight-loss treatments, and the quality of current outcome data is suboptimal. However, the available evidence suggests that bariatric surgery, and particularly gastric bypass, is the most effective weight-loss treatment for people with extreme (class III) obesity. In addition to reduced energy intake and to a lesser extent malabsorption, numerous other potential mechanisms related to bariatric surgery may play a role in promoting weight loss and improving comorbidities. After bariatric surgery, clinical improvement or resolution has been reported in 64% to 100% of patients with diabetes mellitus, 62% to 69% of patients with hypertension, 85% of patients with obstructive sleep apnea, 60% to 100% of patients with dyslipidemia, and up to 90% of patients with nonalcoholic fatty liver disease. A wide range of other weight-related conditions also appear to improve, and limited data suggest that overall mortality may decrease in patients undergoing bariatric surgery. Although not conclusive, evidence from available studies indicates that bariatric surgery is cost-effective. Further research with improved methodology is needed to define the mechanisms of action of bariatric surgery; to document its effect on long-term weight loss, comorbid conditions, and overall mortality; and to determine its cost-effectiveness.

Bariatric Surgery↗
PubMed2004

Panniculectomy as an adjuvant to bariatric surgery.

A large hanging panniculus can cause problems such as intertrigo, chronic infection, and immobility. Many patients undergoing weight reduction surgery can benefit from panniculectomy either done concomitantly with bariatric surgery or later after significant weight reduction. Over the last 5 years we performed 123 panniculectomies on patients (34 males, 89 females; mean age 44.5 +/- 10.3 years) undergoing bariatric surgery. The panniculectomy was either done at the same time as the bariatric surgery in 21 patients or after a time period of 17 +/- 11 months in 102 patients. The prebariatric surgery weight ranged from 107 to 341 kg (mean: 168.6 +/- 47.2 kg) with a mean body mass index (BMI) of 59 +/- 14 kg/m. After the bariatric surgery the patients had an average weight loss of 57.6 +/- 27 kg. The prepanniculectomy weight was 121.9 +/- 39.3 kg (BMI = 43.1 +/- 12.4 kg/m) for the patients who had the panniculectomy after the bariatric surgery. Ninety-two percent of the patients had multiple comorbidities. The weight of the panniculectomy specimen ranged from 4 to 54 kg. Any abdominal wall hernias (35.4% incisional and 8.9% umbilical) were fixed during the panniculectomy. Overall, patients who had panniculectomy simultaneously with the bariatric surgery had more complications than patients who had panniculectomy after their bariatric surgery. The wound infections were 48% versus 16% and respiratory distress was 24% versus 0%, respectively. The skin necrosis was 10% versus 6%, dehiscence was 33% versus 13%, and hematoma formation was 10% versus 2%, respectively. Overall, the patients had good outcomes, with 3 postoperative deaths in the group with panniculectomy at the same time of bariatric surgery. An interval of weight loss prior to the procedure makes this procedure safer and more effective.

Abdomen↗
PubMed2005

The role of price, sociodemographic factors, and health in the demand for bariatric surgery.

OBJECTIVES: To estimate the effect of price, sociodemographic factors, and health on the demand for bariatric surgery among eligible individuals with private health insurance, in order to enable policy makers and insurers to make more informed decisions concerning access to care for bariatric surgery. STUDY DESIGN: We conducted an Internet-based contingent valuation survey of 1802 obese persons eligible for bariatric surgery but who had not undergone the procedure. METHODS: We used multivariate regression analysis to separately estimate the likelihood of having gastric bypass and gastric banding surgery at different out-of-pocket costs. We combined the results with estimates of the privately insured bariatric surgery-eligible population from the National Health and Nutrition Examination Survey, 1999-2002, to estimate aggregate demand. RESULTS: Out-of-pocket cost was negatively and highly significantly related to the self-reported likelihood of having surgery. Persons with higher incomes and younger persons also reported a significantly higher likelihood of surgery. No effect was found for body mass index or for most comorbidities. We estimate that about 150 000 bariatric operations per year would be demanded by those with private health insurance at an out-of-pocket cost of USD 25 000. At USD 5000, we estimate a demand of 250 000 bariatric operations per year. CONCLUSIONS: Price is significantly and negatively related to the demand for bariatric surgery. At an out-of-pocket cost of USD 5000, about 2.2% of the bariatric surgery-eligible population would strongly consider surgery.

Adolescent↗
PubMed2004

A case-match analysis of failed prior bariatric procedures converted to resectional gastric bypass.

BACKGROUND: Failure to lose weight or intractable symptoms after bariatric surgery presents a complex diagnostic and management challenge. The outcome of a standardized surgical approach to this problem has not been well described. Conversion of failed bariatric procedures to a resectional gastric bypass (RGB) can achieve symptomatic relief and acceptable weight loss. METHODS: We reviewed all patients in a prospectively maintained database who underwent reoperative bariatric surgery over a 4-year period. Reoperative patients (RO) were case-matched (by age, body mass index, and comorbidities) in a 1:2 ratio with control patients undergoing an initial bariatric procedure (IN). RESULTS: Twenty-seven reoperative patients and 54 case-matched control patients were identified. Mean body mass index was 42 in the RO group versus 45 in the IN group (P = not significant). Indications for conversion were weight gain (89%), dysphagia/emesis (30%), esophagitis (19%), and marginal ulcer (7%). All patients in both groups underwent RGB (subtotal gastrectomy with Roux-Y gastrojejunostomy). Compared with IN patients, the RO patients had significantly longer operative times (420 versus 268 minutes), greater blood loss (650 versus 315 cc), longer time to oral intake (3.1 versus 2.2 days), and longer hospital stays (6.5 versus 4.7 days), all P <0.01. There were no deaths or anastomotic leaks in either group. Excess body weight lost at 6 months was 46% for RO versus 54% for IN (P = 0.02). One-year excess weight lost was 71% for RO versus 77% for IN (P = not significant). All RO patients achieved symptomatic relief, and no patient required further bariatric revision. There was significant improvement in weight-related comorbidity in each group. CONCLUSIONS: Conversion of failed bariatric procedures to RGB, although technically demanding, resulted in relief of presenting symptoms, significant 6-month and 1-year weight loss, and improvement of major comorbidities. Conversion of failed bariatric procedures to resectional gastric bypass can achieve results comparable with those of patients undergoing an initial bariatric procedure.

Blood Loss, Surgical↗