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Laparoscopic Vs Open Gastric Bypass Surgery Differences in Patient Demographics, Safety, and Outcomes

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Laparoscopic Vs Open Gastric Bypass Surgery Differences in Patient Demographics, Safety, and Outcomes ORIGINAL ARTICLE Laparoscopic vs Open Gastric Bypass Surgery Differences in Patient Demographics, Safety, and Outcomes Gaurav Banka, MD; Gavitt Woodard, MD; Tina Hernandez-Boussard, PhD, MPH; John M. Morton, MD, MPH Objective: To determine national outcome differences pitals (69% vs 61%; PϽ.001). A higher percentage of between laparoscopic Roux-en-Y gastric bypass (LRYGB) ORYGB compared with LRYGB patients were Medicare and open Roux-en-Y gastric bypass (ORYGB). (9.3% vs 7.1%) and Medicaid (10.4% vs 5.9%; PϽ.01) beneficiaries. More ORYGB patients compared with Design: Retrospective cohort study. LRYGB patients were discharged with nonroutine dis- positions (7.7% vs 2.4%; P=.005), died (0.2% vs 0.1%; Setting: The Nationwide Inpatient Sample. PϽ.001), and had 1 or more complications (18.7% vs 12.3%; PϽ.001). All Patient Safety Indicator rates were Patients: Patients undergoing ORYGB and LRYGB. higher for ORYGB. Patients who had ORYGB compared with LRYGB also had longer median lengths of stay (3.5 Main Outcome Measures: Outcome measures were vs 2.4 days; PϽ.001) and higher total charges ($35 018 number of procedures performed, patient and hospital vs $32 671; PϽ.001). Patients who had LRYGB had a characteristics, patient complications, mortality, length lower odds ratio than patients who had ORYGB for both of stay, resource use, and Agency for Healthcare Re- mortality (odds ratio, 0.54; PϽ.001) and having 1 or more search and Quality Patient Safety Indicators. Both demo- complications (odds ratio, 0.66; PϽ.001) even after ad- graphic and outcomes variables were compared by either justing for confounding variables. t test or ␹2 analysis, with regression analysis adjusting for confounding variables. Conclusion: In this population-based study, LRYGB pro- vided greater safety than ORYGB even after adjusting for Results: The ORYGB and LRYGB cohorts consisted of patient-level socioeconomic and comorbidity differ- 41 094 and 115 177 cases, respectively. From 2005 to ences. 2007, LRYGB was more commonly performed than ORYGB (72% vs 28%; PϽ.001) and at high-volume hos- Arch Surg. 2012;147(6):550-556 BESITY IS A MAJOR PUBLIC to the United States, as obesity has be- health concern as rates of come an international issue, even in less obesity have signifi- developed countries.7-9 cantly increased. In the United States, preva- CME available online at Olence of obesity in adults increased from 15% www.jamaarchivescme.com in 1980 to 32% in 2004 and 6% to 19% in and questions on page 495 children during the same period.1-3 Accord- ing to Centers for Disease Control and Pre- vention reports, 34% of US adults older than Obesity has been associated with nu- 20 years are obese. In addition, the Cen- merous adverse health conditions includ- ters for Disease Control and Prevention re- ing diabetes mellitus, cardiovascular dis- ports 66% of US adults are overweight or ease, nonalcoholic liver disease, increased obese and 5 million are extremely obese.4 risk of disability, hypertension, dyslipid- The 2008 FasinFatreport indicates that emia, some forms of cancers, gallstones, 25% of adults are obese in 28 states and that and musculoskeletal disorders.10-12 These no state has had a decrease in the numbers adverse health conditions lead to a sig- of obese individuals.5 nificant increase in early mortality and re- Author Affiliations: Stanford Studies have also shown troubling so- duction in life years in obese individu- Center for Outcomes Research ciodemographic disparities in the United als.13,14 In addition, obese individuals report and Evaluation, Section of States because higher proportions of Afri- lower quality of life and greater discrimi- Minimally Invasive and 15,16 Bariatric Surgery, Department of can American individuals, Hispanic indi- nation, bias, and stigma. Treating obe- Surgery, Stanford University viduals, Medicaid patients, and those of sity and its complications has been esti- School of Medicine, Stanford, low education and income status are mated to cost approximately $92 billion California. obese.6 Obesity concerns are not limited a year.17 ARCH SURG/ VOL 147 (NO. 6), JUNE 2012 WWW.ARCHSURG.COM 550 ©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 Bariatric surgery has proven to be the most effective urban vs rural location, and teaching vs nonteaching status. and enduring option in treating the morbidly obese. In Teaching status of the hospital was determined by hospital af- the 10-year Swedish Obesity Study, gastric bypass sur- filiation with either a medical school or an Accreditation gery patients showed greater long-term weight loss, health- Council for Graduate Medical Education residency program. related quality-of-life improvements, and reduction in vari- Hospital size (small, medium, and large) has differing defini- tions depending on urban or rural and teaching status. The ous risk factors compared with controls receiving NIS includes sample weights, designated by the sampling de- conventional treatment. The Swedish Obesity Study trial sign, to make nationally representative estimates of inpatient found that the decrease in weight and risk factors was use. The NIS is based on a stratified probability sample of all greater in those treated by gastric bypass than those treated nonfederal US hospitals, which provides a national estimate by medical intervention, banding, or vertical banded gas- of inpatient health services. The data set contains information troplasty.18,19 on primary and secondary diagnoses, demographic character- However, mortality and other complications are se- istics, procedure use, length of stay, payer, total charges, and rious risks associated with bariatric surgery and are in- admission and discharge status. The NIS does not have versely correlated with the volume of cases performed unique patient identifiers, and as a result, patients cannot be by the surgeon.20 The Centers for Medicare & Medicaid followed up longitudinally. Additional information about the NIS is available from the Agency for Healthcare Research and Services determined that bariatric procedures should only Quality.30 be performed at high-volume facilities that are either cer- tified by the American College of Surgeons or the Ameri- STUDY SAMPLE can Society for Metabolic and Bariatric Surgery/Surgery Review Corporation as a Bariatric Surgery Center of Ex- 21,22 In this retrospective cohort study, patients were identified by cellence. The Centers for Medicare & Medicaid Ser- the ICD-9-CM procedure codes for LRYGB (44.38) and vices defines high-volume practices as performing 125 ORYGB (44.31 and 44.39).29 To ensure homogeneity, cases or more weight-loss operations annually.23 were restricted to adult nontransfer elective patients with a di- The efficacy of gastric bypass surgery has made it the agnosis-related group code 288, obesity. Patients were also most commonly performed bariatric surgery in the United excluded if they had malignant neoplasm of digestive organs States. In 2002, 88% of all bariatric surgeries were gas- or peritoneum (ICD-9-CM codes 150-159), inflammatory tric bypass procedures.24 Laparoscopic Roux-en-Y gas- bowel disease (ICD-9-CM codes 555.0-556.9), or noninfec- tric bypass (LRYGB) was first introduced by Wittgrove tious colitis (ICD-9-CM codes 557.0-558.9). The period stud- et al25 in 1994 and since then has become more com- ied was from January 1, 2005, through December 31, 2007. This period was chosen so that the results would be suffi- monly performed than open Roux-en-Y gastric bypass 26 ciently recent to include the new ICD-9 LRYGB code (44.38), (ORYGB). Weller and Rosati report that 75% of gastric which was first introduced in 2004 and not readily used in bypass procedures in 2005 were performed laparoscopi- practice until 2005. cally. The safety of LRYGB vs ORYGB has been addressed PATIENT CHARACTERISTICS in single-center trials, but to our knowledge, no na- tional data exist comparing the 2 approaches. Two ran- Patient age, sex, accompanying diagnoses, and comorbidities domized controlled trials have shown better outcomes were examined. The Deyo modification of the Charlson Co- for LRYGB compared with ORYGB.27,28 Prospective ran- morbidity Index31 (0-3, with 3 indicating greatest comorbid- domized controlled trials are used to establish the effi- ity) was calculated for each patient based on ICD-9-CM diag- cacy of interventions, but population-based studies are nosis codes. In addition, Elixhauser comorbidity measures were 32 critical to determine the effectiveness and adoption of in- calculated. To adjust for potential differences in delivery of terventions. However, few population-based studies have care that might bias outcomes, structure of care was assessed considered the effectiveness of LRYGB compared with by examining payer status, hospital size, hospital volume, and teaching status. ORYGB in terms of patient safety because International Classification of Diseases, Ninth Revision, Clinical Modi- fication (ICD-9-CM) laparoscopic codes for gastric by- OUTCOMES pass surgery were not available until 2004 and not fully 29 Our outcomes of interests were number of procedures per- adopted until 2005. formed, patient and hospital characteristics, patient complica- tions, mortality, length of stay, resource use, and Agency for METHODS Healthcare Research and Quality Patient Safety Indicators (PSIs). The ICD-9-CM codes for complications were gathered by ref- erencing Santry et al24 and performing our own review of ICD- DATA SOURCE 9-CM codes (see codes in the eTable, http://www.archsurg .com). The PSIs were adjusted for age, sex, diagnosis-related Data were derived from the 2005-2007 Nationwide Inpatient group, and Elixhauser comorbidity index.32 High-volume hos- Sample (NIS), a hospital discharge database created as part of pitals were defined as being hospitals that performed 125 or the Agency for Healthcare Research and Quality Healthcare more bariatric surgery cases per year. Cost and Utilization Project.
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