Large Database Defines Bariatric Surgery Trends

28 GASTROENTEROLOGY SEPTEMBER 1, 2009 • INTERNAL MEDICINE NEWS Large Database Defines Bariatric Surgery Trends

BY BRUCE JANCIN comes achieved in ASMBS-designated Ǡ Mean preoperative body mass index Ǡ Most patients received two forms of centers of excellence, said Dr. DeMaria, was 46.5 kg/m2. A total of 53% of pa- venous thromboembolism prophylaxis G RAPEVINE, TEX. — First data from professor of surgery at Duke University, tients had a BMI of 40-49, and 17% had in-hospital, but 7% had none. the landmark Bariatric Outcomes Lon- Durham, N.C. a BMI of 35-39. Ǡ Duration of surgery averaged 91 min- gitudinal Database show that two types BOLD, the world’s largest prospective Ǡ Roux-en-Y gastric bypass was per- utes, with 129 minutes of anesthesia, 41 of surgery—Roux-en-Y gastric bypass clinical database for bariatric surgery, is mL of blood loss, and a 2.5-day length of and gastric banding—account for 93% of enrolling about 2,700 patients per month. hospital stay. all primary bariatric procedures per- The baseline BOLD data presented by Ǡ Adverse events occurred prior to dis- formed at U.S. centers of excellence. Dr. DeMaria provide a close-up of con- All-cause charge in 3.6% of cases. Among 57,918 bariatric surgery pa- temporary bariatric surgery as conduct- mortality at 90 Ǡ With a maximum follow-up of 16 tients enrolled during the first 16 months ed at 371 ASMBS-approved centers with days in this huge months, the percentage of patients ex- of BOLD, 53.5% had a gastric bypass and 639 ASMBS-approved surgeons. Anoth- series was just periencing one or more adverse events 39.2% had a gastric banding procedure. er 105 centers are provisionally approved. 0.112%. varied by procedure: gastric banding, Rounding out the top four most fre- Although it’s far too early to draw 4%; sleeve gastrectomy, 10%; gastric by- quently performed primary operations conclusions about the relative effective- DR. DEMARIA pass, 14%; and biliopancreatic diver- were sleeve gastrectomy (2.3%) and bil- ness of the various procedures in main- sion/duodenal switch, 25%. iopancreatic diversion/duodenal switch taining weight loss, Dr. DeMaria pre- formed laparoscopically in 89% of cases, The ambitious quality improvement (1%), Dr. Eric J. DeMaria said at the an- sented data on key demographics and as were 3% of sleeve gastrectomies and project is “believed to be a model for oth- nual meeting of the American Society short-term outcomes. Some of the find- two-thirds of biliopancreatic diversion/ er specialties,” Dr. DeMaria said. for Metabolic and Bariatric Surgery. ings are as follows: duodenal switches. He disclosed that he serves as unpaid All-cause mortality at 90 days in this Ǡ The patients’ average age was 46.6, and Ǡ Vertical gastric banding accounted for chair of the research advisory committee huge series was just 0.112%, a result that 79% were women. A total of 78% were less than 1% of all gastric banding pro- of the Surgical Review Corp., a nonprof- underscores the high quality of out- white, 10% black, and 6% Hispanic. cedures in BOLD. it company formed to run BOLD. ■ Complication Rate for Abnormal Glucose Tolerance Tests Bariatric Surgery 4.1% May Be Seen After Gastric Bypass

BY MARY ANN MOON within 30 days. That occurred in BY BRUCE JANCIN normal glucose tolerance test. Six had hy- 1% of the patients undergoing la- perglycemia as defined by any postchallenge he most common bariatric paroscopic adjustable gastric band- G RAPEVINE, TEX. — Gastric bypass blood glucose value greater than 200 mg/dL, Tsurgeries carry low rates of ing, 4.8% with Roux-en-Y gastric surgery’s status as the gold-standard weight- with none below 80 mg/dL. Significantly, all adverse perioperative outcomes bypass, and 7.8% with open Roux- loss procedure has come under question by but one of these six patients had normal fast- when performed by experienced en-Y gastric bypass. new evidence that many recipients develop ing blood glucose. “That means we need to surgeons in established centers, ac- Patients who had a history of late, often-unrecognized glucose abnormali- be very careful what we call surgical cure or cording to a recent report. thrombotic disorders, had poor ties contributing to significant weight regain. control of diabetes,” he observed. In a prospective, multicenter, ob- functional status, or had sleep ap- “The gastric bypass has been the procedure Another 35 patients had reactive hypo- servational study, 30-day mortality nea were at increased risk of poor of choice, especially for sweet eaters. I think glycemia, defined as a blood glucose value be- was 0.3% and the rate of major outcomes. it’s time to reconsider. I actually believe that low 60 mg/dL or a decrease of at least 100 complications was 4.1%, which are “Regardless of the type of pro- vertical sleeve gastrectomy and duodenal mg/dL between hours 1 and 2, with no val- comparable to rates for other major cedure, the predicted probability of switches that are not severely malabsorptive ue greater than 200 mg/dL. Another eight pa- operations. Those rates are will be the best operations in the future,” Dr. tients had both reactive hypoglycemia and considered low for bariatric Mitchell S. Roslin said at the annual meeting hyperglycemia. Thus, more than two-thirds surgery, because most pa- Patients who had of the American Society for Metabolic and of the study group had evidence of hypo- tients are extremely obese a history of Bariatric Surgery. glycemia. These patients displayed a rapid and have multiple comorbid thrombotic After weight loss induced by gastric bypass, postchallenge upsurge in blood glucose cor- conditions, said Dr. David R. disorders were at patients have an enhanced insulin response. A relating with a rising insulin level, then a rapid Flum of the University of increased risk of substantial subgroup of these patients devel- decline in glucose in the second hour. Washington, Seattle, and his poor outcomes. op rapid emptying of their surgically created A normal maximum-to-minimum glucose associates in the Longitudinal pouch, with resultant reactive hypoglycemia ratio on the 100-g test is 1.5-2:1. However, 22 Assessment of Bariatric DR. FLUM that contributes to grazing and other mal- patients in this study had ratios greater than Surgery (LABS) study (N. adaptive eating behaviors, hypothesized Dr. 3:1, and 7 had ratios greater than 4:1. Engl. J. Med. 2009;361:445-54). the composite end point was lowest Roslin of Lenox Hill Hospital, New York. Dr. Harvey J. Sugerman, whose studies in The investigators evaluated among patients who did not have a This hypothesis arose from conversations the late 1990s are widely credited as en- 4,776 consecutive patients who un- history of deep vein thrombosis or with large numbers of post–gastric bypass pa- throning gastric bypass as the gold-standard derwent first-time bariatric surgery venous thromboembolism or of ob- tients contemplating revisional bariatric bariatric surgery procedure, rose from the au- in 2005-2007, which was per- structive sleep apnea, and who were surgery because of troubling weight regain. dience to tell Dr. Roslin, “I think your hy- formed by 33 surgeons certified by in the middle range of the spectrum “They were essentially saying that 1 or 2 pothesis may be very valid. I see a lot of rapid the LABS consortium. of body mass index for the cohort,” hours after eating they were ravenously hun- emptying.” A nonsurgical solution to these The most common procedure Dr. Flum and his colleagues said. gry. Many complained of being light-headed. problems, he added, is simply to have affect- was Roux-en-Y gastric bypass (71% The researchers added that the The symptoms sounded to me a lot like hy- ed patients drink half a glass of orange juice of patients), which was performed study focused on perioperative ad- poglycemia,” he recalled. 30 minutes after they eat. laparoscopically in 87% of cases verse events. Another study that To test his hypothesis, he gave a 100-g oral “It levels off their insulin and glucose lev- and as an open procedure in 13%. has just completed recruitment glucose tolerance test to 63 patients coming els. It takes away the unpleasant symptoms of Another 25% of the patients un- (LABS-2) will assess the long-term to the obesity surgery clinic for routine fol- dumping and also that ravenous hunger,” said derwent laparoscopic adjustable effects of bariatric surgery on health low-up a mean of 4 years after Roux-en-Y gas- Dr. Sugerman of Sanibel, Fla., who is editor- gastric banding, and the remaining conditions, quality of life, health tric bypass. Their mean age was 48.5 years, in-chief of Surgery for Obesity and Related 4% had other bariatric procedures. care costs, and psychosocial issues. 81% were women, and one-third of the pa- Diseases, the official journal of the American The primary outcome of the Dr. Flum said he has received tients had diabetes preoperatively. Their Society for Metabolic and Bariatric Surgery. study was a composite end point of grants from Sanofi-Aventis and Co- mean preoperative weight was 138 kg. They Dr. Roslin said that he has potential conflicts death, deep vein thrombosis, ve- vidien AG and served as an expert had a maximum 55% excess weight loss, but of interest resulting from relationships with nous thromboembolism, reinter- witness on cases involving adverse had regained an average of 12 kg. Covidien AG, C.R. Bard Inc., ValenTx Inc., vention, or failure to be discharged events after bariatric surgery. ■ Fully 49 of the 63 patients (78%) had an ab- Scientific Intake Ltd., and VentralFix Inc. ■