Perioperative outcome of laparoscopic sleeve gastrectomy for high-risk patients

doi:10.1016/j.soard.2016.08.492

Surgery for Obesity and Related Diseases

Volume 13, Issue 2, February 2017, Pages 155-160

https://doi.org/10.1016/j.soard.2016.08.492 Get rights and content

Abstract

Background

Morbidly obese patients with excessive concomitant disease carry a significantly increased perioperative risk. Although they may benefit most from a bariatric intervention, they are often denied surgery. Laparoscopic sleeve gastrectomy (LSG), as it is less complication-prone than other bariatric procedures, suits the needs of those patients.

Objective

To review the short-term outcome of LSG for high-risk patients

Setting

University hospital, Switzerland.

Methods

A total of 110 patients with high perioperative risk undergoing LSG between January 2008 and December 2014 were prospectively recorded. Patients were defined as “high-risk” if they met 2 of the following criteria: American Society of Anesthesiologists physical status score (ASA)>III, Obesity Surgery Mortality Risk Score (OS-MRS)≥4, Revised Cardiac Risk Index (RCRI) class IV, Obstructive Sleep Apnea-Severity Index (OSA-SI)≥5, renal insufficiency chronic kidney disease ≥3, liver cirrhosis, or history of life-threatening perioperative events.

Results

Of the patients, 59 (54%) were male. Median age was 49 years (range: 18–69), and median BMI was 51.7 kg/m² (38.7–89.2). Median operating time was 65 minutes (27–260). Eighty-six patients (78%) were classified as ASA IV, 65 (59%) as RCRI class IV, 51 (46%) as OS-MRS≥4 and 63 (57%) as OSA-SI≥5. Eighty-nine (81%) had type 2 diabetes, 70 (64%) were under antiplatelet and or anticoagulant therapy. Four patients (4%) were converted to open. Length of stay was 5 days (1–70). Major complications occurred in 12 patients (11%), including 1 mortality (1%).

Conclusion

“High-risk”-patients identified using a combination of established obesity- and co-morbidity-related risk scores profit from LSG as part of a uniform treatment pathway. Given the severity of co-morbidities, LSG can be performed safely. (Surg Obes Relat Dis 2016;X:XXX–XXX.) © 2016 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Section snippets

Data collection

Data of “high-risk” patients undergoing primary LSG in a university hospital between January 2008 and December 2014 were recorded in a prospective computer database according to a standardized protocol. Patients were selected, treated, and followed up according to the guidelines of the Swiss Study Group for Morbid Obesity. This study was approved by the University of Bern Institutional Review Board.

Definitions

Patients were classified as “high-risk” if they met 2 of following criteria: definition as ASA

Results

A total of 110 patients met the “high-risk” criteria. Demographic data are shown in Table 2. Thirty-three patients had a BMI>60 kg/m² (30%). Of 89 patients with T2D (81%), 64 (72%) were insulin-dependent, and 56 (63%) were for>5 years. Patients with neurologic disease had ventriculoperitoneal shunts, epilepsy, or multiple sclerosis. Nine patients (7%) had a history of cancer (thyroid, prostate, colon, astrocytoma), and 4 (4%) had a history of cardiac or renal transplantation. Forty-one patients

Discussion

This study reports the short-term outcome of LSG for patients with the highest perioperative risk. Preoperative stratification of obesity-related, cardiopulmonary, and metabolic risk using well-known grading scores and subsequent uniform treatment leads to a safe and effective approach in this population burdened by significant co-morbidity.

With the increased use of bariatric surgery, patients refused for operation due to massive co-morbidities in earlier times are operated on more and more.

Conclusion

In conclusion, with LSG as part of a specialized treatment pathway for high-risk patients, complication rates stay well below the estimates of the underlying, population-defining risk scores. Still, postoperative morbidity is considerable, reflecting the severity of co-morbidities of “high-risk” patients.

Disclosures

The authors have no commercial associations that might be a conflict of interest in relation to this article.

Acknowledgments

The authors reported that they received no grant support for this study.

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Comment on: Predicting complications following bariatric surgery: the diagnostic accuracy of available tools
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Obesity surgery in patients with end-stage organ failure: Is it worth it?
2022, Surgery for Obesity and Related Diseases
Citation Excerpt :
Comparing the present results with other studies in obesity surgery that included patients with a high perioperative risk is somewhat difficult since the present study considers solely ESOF patients, while most other studies include a broader range of potentially high-risk patients. Borbléy et al. examined 110 patients at a single center and reported a major complication rate of 11% and a mortality rate of 1% in the first 30 days after surgery [2]. Patients were considered high risk if they met at least two out of seven criteria, including American Society of Anesthesiologists physical status ≥ 4, Revised Cardiac Risk Index class IV, Obesity Surgery Mortality Risk Score class C, OSA scoring system score ≥ 5, chronic kidney disease stage ≥ 3 (GFR <60 mL/min), liver cirrhosis, and a history of an adverse or life-threatening perioperative event.
Little is known about the long-term outcomes of patients with end-stage organ failure (ESOF) undergoing obesity surgery.
To investigate the perioperative and mid-term outcomes of patients with ESOF undergoing obesity surgery.
University hospital, Germany.
A total of 1 094 patients undergoing obesity surgery from 2006 to 2019 were screened. Inclusion criteria were ejection fraction <30%, continuous oxygen/noninvasive ventilation therapy, liver cirrhosis, or kidney failure stage 4/5. ESOF patients were compared with matched standard (MS) patients without advanced organ failure and matched for age, gender, body mass index (BMI), operation type, diabetes, arterial hypertension, and sleep apnea.
Twenty-seven ESOF patients (56% female, age 50.3 ± 8.6, BMI 53.8 ± 8.7 kg/m²) were identified. Eighty-five percent had a sleeve gastrectomy. Mid-term total weight loss was 26.6% ± 9.0% in the ESOF patients versus 17.8% ± 11.1% in MS patients (P = .181). Long-term improvement of type 2 diabetes was comparable (ESOF: HbA1C 8.79 ± 2.06% to 6.25±1.17%, P = .047; MS: HbA1C 7.94 ± 2.02% to 7.2 ± 1.28%; P = .343). Depression scores (Patient Health Questionnaire 9) among ESOF patients improved from 13.0 ± 6.3 to 6.1 ± 5.8 (P = .004) but without significant change in MS patients (9.4 ± 7.3 to 4.3 ± 5.7; P = .082). Lung function improved in all patients although only 15% were off oxygen therapy. Treatment goals were achieved in >50% of the other groups. Major complications occurred in 11% (ESOF) versus 4% (MS) of patients (P = .299) with one death in the ESOF group (4%).
Both groups had similar outcomes regarding weight loss and co-morbidity improvement. Depression only improved significantly in the ESOF group. Patients with ESOF should not be precluded from obesity surgery. Further investigation is needed to define optimized selection criteria.
Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures – 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists
2020, Surgery for Obesity and Related Diseases
Citation Excerpt :
Decisions regarding bariatric procedures should also be based on safety concerns regarding specific organ systems. In general, the greater the inherent risk of a specific bariatric procedure, independent of the risk of not treating obesity and severity of ORC, the less complicated the procedure selected [322]. In addition, preoperative estimation of the likelihood that a patient will experience a cardiac complication at the time of noncardiac surgery can guide procedure selection and prevent postoperative morbidity and mortality.
The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.
Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.
New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications–centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).
Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision–making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.
Clinical Practice Guidelines For The Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures – 2019 Update: Cosponsored By American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society For Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists
2019, Endocrine Practice
The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society, American Society of Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.
Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.
New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health-care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).
Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues. (Endocr Pract. 2019;25:1-75)
Application of the Revised Cardiac Risk Index to the Model for End-Stage Liver Disease Score Improves the Prediction of Cardiac Events in Patients Undergoing Liver Transplantation
2018, Transplantation Proceedings
Although the revised cardiac risk index (RCRI) is a useful tool for estimating the risk of postoperative cardiac events, whether it improves the prediction of cardiac events in patients undergoing liver transplantation (LT) has not been sufficiently demonstrated.
We retrospectively analyzed 1429 patients who underwent LT. Cardiac events were defined as myocardial infarction, death, or combined events within 30 days after surgery. The RCRI was defined as the number of independent predictors including high-risk surgery, ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin treatment, and creatinine level >2 mg/dL. Multivariate logistic regression analysis was performed to identify factors independently associated with cardiac events. The additive predictability of RCRI for the Model for End-Stage Liver Disease (MELD) score was assessed using receiver operating characteristic curve analysis.
Forty-four (3.1%) cardiac events occurred within 30 days after surgery. Both the MELD score (adjusted odds ratio [aOR], 1.05; P = .005) and RCRI (aOR, 4.35; P < .001 for RCRI score 2; aOR, 6.27; P = .009 for RCRI score 3 compared with RCRI score 1) independently predicted postoperative 30-day cardiac events. The model with MELD score plus RCRI was significantly more predictive for postoperative 30-day cardiac events than the model with MELD score alone (C-statistics 0.800 vs 0.757; P = .030).
For preoperative risk stratification, RCRI showed additive value to MELD score in predicting postoperative 30-day cardiac events after LT.
Electrical stimulation of the lower esophageal sphincter to address gastroesophageal reflux disease after sleeve gastrectomy
2018, Surgery for Obesity and Related Diseases
Citation Excerpt :
There is a linear relationship not only between body mass index and GERD, but also between central obesity and GERD [20]. Yet, central obesity complicates bariatric procedures and is one of the main reasons—together with the resulting co-morbidities—for the popularity of LSG [21]. Morbid obesity increases the intraabdominal pressure having an effect on intragastric pressure and the gastroesophageal pressure gradient, and leads further to a higher rate of hiatal hernias and postprandial transient LES relaxations [22].
Laparoscopic sleeve gastrectomy (LSG) can result in de novo and worsen preexisting gastroesophageal reflux disease (GERD). Post-LSG patients with GERD refractory to proton pump inhibitors (PPI) usually undergo more invasive, anatomy-altering Roux-en-Y gastric bypass surgery. Lower esophageal sphincter (LES) electrical stimulation (ES) preserves the anatomy and has been shown to improve outcomes in GERD patients.
To evaluate the safety and efficacy of LES-ES in post-LSG patients with GERD not controlled with maximal PPI therapy.
Prospective, international, multicenter registry.
Patients with LSG-associated GERD partially responsive to PPI underwent LES-ES. GERD outcomes pre- and poststimulation were evaluated based on quality of life, esophageal acid exposure (after 6–12 mo), and PPI use.
Seventeen patients (11 female, 65%), treated at 6 centers between May 2014 and October, 2016 with a median follow-up of 12 months (range 6–24), received LES-ES. Median age was 48.6 years (interquartile range, 40.5–56), median body mass index 31.7 kg/m² (27.9–39.3). All patients were on at least daily PPI preoperatively; at last follow-up, 7 (41%) were completely off PPI, 5 (29%) took PPI on an intermittent basis, and 5 (29%) were on single-dose PPI. Median GERD–health-related quality of life scores improved from 34 (on-PPI, 25–41) at baseline to 9 (6–13) at last follow-up (off-PPI, P<.001). Percentage of time with esophageal pH<4 improved from 13.2% (3.7–30.7) to 5.8% (1.1–54.4), P = .01.
LES-ES in post-LSG patients suffering from symptomatic, PPI-refractory GERD resulted in significant improvement of GERD-symptoms, esophageal acid exposure, and need for PPI. Preserving the post-LSG anatomy, it offers a valid option for patients unable or unwilling to undergo Roux-en-Y gastric bypass surgery.

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Original articlePerioperative outcome of laparoscopic sleeve gastrectomy for high-risk patients

Abstract

Background

Objective

Setting

Methods

Results

Conclusion

Section snippets

Data collection

Definitions

Results

Discussion

Conclusion

Disclosures

Acknowledgments

Surg Obes Relat Dis

Surg Obes Relat Dis

Surgery

Chest

Surg Obes Relat Dis

Obesity--a neglected culprit in renal disease

Nephrol Dial Transplant

Decreased survival of subjects with elevated liver function tests during a 28-year follow-up

Hepatology

Visceral obesity: the link among inflammation, hypertension, and cardiovascular disease

Hypertension

Early results of the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass

Ann Surg

Perioperative safety in the longitudinal assessment of bariatric surgery

N Engl J Med

Hospital complication rates with bariatric surgery in Michigan

JAMA

Validation of the obesity surgery mortality risk score in a multicenter study proves it stratifies mortality risk in patients undergoing gastric bypass for morbid obesity

Ann Surg

Can ASA grade or Goldman׳s cardiac risk index predict peri-operative mortality? A study of 16,227 patients

Anaesthesia

Original article
Perioperative outcome of laparoscopic sleeve gastrectomy for high-risk patients