complications: revisions miss 2010 bruce m. wolfe professor of surgery oregon health & science...
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Complications: RevisionsMISS 2010
Bruce M. WolfeProfessor of Surgery
Oregon Health & Science University
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Complications: Revisions
• Provider error– Large gastric pouch– Incomplete gastric division– Incorrect limbs
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Complications: Revisions
• Patient and/or provider factors– Marginal ulcer– Stricture– Intestinal obstruction
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Complications: Revisions
• Poor weight loss or regain– Anatomic factor
• Gastric pouch size• Dilated gastrojejunostomy• Gastrogastric fistula
– Patient factor• Operative anatomy as expected
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Marginal Ulcer
• Evaluation– Endoscopy– UGI
• Intraoperative endoscopy– Define pouch– Confirm resection– Test anastomosis
• ± Vagotomy
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Background
• Increase in prevalence of obesity1
– BMI>30 kg/m2
• Men: 33.3%• Women: 35.3%
• Increase in number of primary bariatric procedures2-3
– 1998: 12,775– 2008: 220,000
1. Ogden CL, et al. Gastroenterology 2007;132(6):2087-1022. Nguyen NT, Root J, Zainabadi K, et al. Arch Surg 2005;140(12):1198-2023. American Society for Metabolic and Bariatric Surgery
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Background
• Revisional bariatric surgery– Indications:
• Side effects or complications of prior bariatric surgery• Inadequate weight loss
– Higher morbidity than with first time procedures
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GSPH
Clinical Center
Data Coordinating Center
NIDDK / ORWH
OHSU/Legacy
UWashington/VMason
NRI/UND
UPMC
Columbia/Cornell
ECU
NIDDK/ORWH
Sacramento Bariatric
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Aim
– To determine independent risk factors for adverse outcome in patients undergoing revisional bariatric surgery
– To compare the outcome between first-time and revisional bariatric cases
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LABS-1Total 5069 patients/operations
5033 Primary, revisional or reversal operations
30 Second stage procedures6 Other secondary obesity procedures
3803 stapled bariatric procedures
1230 Adjustable gastric banding
3802 patients/operations
1 patient underwent 2 separate procedures: a revision followed by a reversal; The reversal was excluded from the analysis
3577 primary procedures 225 revision/reversal procedures
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Data definitions
• Composite endpoint (CE)– Death– Deep venous thrombosis (DVT) or
venothromboembolism (VTE)– Re-intervention with percutaneous, endoscopic or
operative techniques– Failure to discharge within 30-days of surgery
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Statistical Analysis• Characteristics across subgroups:
– Categorical variables:• Pearson’s chi-square test
– Continuous:• Kruskal-Wallis test
• 30-day adverse outcomes:– Fisher’s exact test
• Association between baseline patient characteristics and the odds of 30-day adverse outcome :– Multivariable generalized linear logistic regression models
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Patient characteristics for revisional patients
Characteristic
Median Age 49 years
Age categories (years) n (%)
<30 10 (4)
30-39 38 (17)
40-49 65 (29)
50-59 92 (41)
60-64 13 (6)
65+ 7 (3)
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Patient characteristics for revisional patients
Characteristic n (%)
Male 29 (13)
BMI (kg/m2)
<35 64 (29)
35-<40 38 (17)
40-<50 75 (34)
50-<60 36 (16)
60+ 11 (5)
Median BMI 41 kg/m2
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ComorbiditiesMean, median comorbidities 1.4, 1
# co-morbidities n (%)
None 71(32)
1 or more 151 (68)
2 or more 87 (39)
3 or more 40 (18)
4 or more 20 (9)
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Major comorbidities and medication use
Characteristic n (%)
Hypertension 103 (46)
Diabetes 46 (20)
History of DVT or PE
18 (8)
Sleep apnea 61 (27)
Ischemic heart disease
15 (7)
Narcotic use 63 (28)
Antidepressant 108 (48)
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Prior Obesity or Foregut Surgery
Procedure n (%)
Gastric bypass 84 (38.0)
BPD 1 (0.5)
DS 11 (5.0)
Gastric banding 42 (19.0)
VBG 47 (21.3)
Sleeve 4 (7.7)
Prior foregut 17 (22.2)
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Surgery PerformedProcedure n (%)
RYGB 146 (64.9)
BPD 2 (0.9)
DS 8 (3.6)
Banded RYGB 2 (0.9)
Sleeve 19 (8.4)
Other 48 (21.1)
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Adverse outcomeEvent n (%)
Death 1 (0.4)
DVT/PE 4 (1.8)
Tracheal reintubation 5 (2.2)
Placement of percutaneous drain 3 (1.3)
Endoscopy 10 (4.4)
Abd reoperation 18 (8)
Composite event 34 (15.1)
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Predictors of CE among revisional surgeries
Event OR (95% CI)
p Adjusted OR (95% CI)
p
Patient age (per year)
1.04 (0.999, 1.09)
0.054 1.04(0.995, 1.08)
0.08
History of DVTYes vs. No
4.09 (1.40, 11.92)
0.01 3.72(1.25, 11.1)
0.018
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Revisional vs. Primary
Unadjusted Odds of CE is more than twice high for revisional surgeries
compared to primary surgeries (OR = 2.4, 95% CI 1.6-3.6)
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Revisional vs. Primary
Adjusted for important comorbidities and other patient characteristics, odds of CE
was more than twice as high for revisional surgeries compared to primary surgeries
(OR = 2.3, 95% CI 1.5-3.8)
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Conclusions
• Revisional bariatric surgery can be performed without substantial mortality but with a greater incidence of adverse outcome compared to primary surgery
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AcknowledgmentsThis clinical study was a cooperative agreement funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Grant numbers: DCC -U01 DK066557; Columbia-Presbyterian - U01-DK66667; University of Washington - U01-DK66568 (in collaboration with GCRC, Grant M01RR-00037); Neuropsychiatric Research Institute - U01-DK66471; East Carolina University – U01-DK66526; University of Pittsburgh Medical Center – U01-DK66585; Oregon Health & Science University – U01-DK66555.
The authors thank the LABS study participants for their contributions.