ASMBS 2009: Scoring System Helps Reduce Risk for Complications After Bariatric Procedures

Louise Gagnon

July 06, 2009

July 6, 2009 (Dallas, Texas) — Stratifying patients who are candidates for bariatric procedures according to their preoperative comorbidities results in fewer postoperative complications and decreases the use of healthcare resources, a study presented here at the 26th annual meeting of the American Society for Metabolic and Bariatric Surgery shows.

"We thought if we recognize and take into account the metabolic components of obesity — things like hypertension, diabetes, and sleep apnea — that we would be able to improve outcomes by recognizing and managing those things throughout the whole hospital course and postoperatively," said Robin Blackstone, MD, FACS, principal investigator of the study, bariatric surgeon at Scottsdale Bariatric Center in Arizona, and an associate clinical professor at the University of Arizona School of Medicine.

Researchers developed a Metabolic Acuity Score (MAS) to accompany the body mass index and permit a more personalized preoperative assessment of patients, according to Dr. Blackstone.

The MAS is a 4-point scoring system, with a score of 1 being the least severe and a score of 4 being the most severe. The system takes into account variables such as age, body mass index, weight, history of deep vein thrombosis/pulmonary embolism, sleep apnea, diabetes, hypertension, immobility, heart disease, and psychological classification.

"A young patient in his or her twenties and being 100 pounds over his or her ideal weight, who would not have insulin-resistant diabetes and does not yet have hypertension, would be assigned a score of 1," explained Dr. Blackstone, who performed all of the bariatric procedures between 2001 and 2008. "A patient who is morbidly obese and is about 55 [years of age and] has obstructive sleep apnea combined with asthma and insulin-dependent diabetes would be assigned a score of 4."

The investigators prospectively enrolled 1072 patients, with 597 patients receiving gastric bypass surgery and 475 patients receiving gastric banding, and assigned them a MAS score before the procedure.

The MAS groups were compared with each other and were compared with 1344 patients who had received bariatric procedures before August 2006, the time at which point the institution began dividing patients into MAS groups. This group served as controls.

There were 1821 patients who underwent Roux-en-Y gastric bypass surgery and 595 who received laparoscopic adjustable gastric band procedures before and after MAS was implemented.

Investigators found a dramatic drop in readmission rates within 30 days after the scoring system was put in place. The readmission rate was 8.5% before MAS and 1.7% after MAS (P < .001) for patients who received gastric bypass surgery. The readmission rate within 30 days was the same both before the use of MAS and after its use among laparoscopic adjustable gastric band patients.

Infection rates after surgery were lower after implementing the scoring system in gastric bypass patients at 3.5% before MAS and 0.7% after MAS (P < .001). There were also reductions in postoperative internal hernias, obstructions, intraabdominal abscesses, and pneumonia once MAS was implemented in gastric bypass patients.

There was no statistically significant difference in postprocedure infection rates among laparoscopic adjustable gastric band patients, with the rate being 0.8% before MAS and 1.1% after MAS.

Overall outcomes after laparoscopic adjustable gastric banding were improved with the implementation of the MAS system, with fewer band slips (6.7% before MAS and 0.6% after MAS; P < .001). In addition, gastric banding patients had a shortened hospital stay with the implementation of MAS, with a length of stay of 1.3 days before MAS and 0.8 days afterward (P = .01).

The reoperation rate for all patients decreased by 57% after MAS was implemented, from 2.1% before MAS to 0.9% after MAS, which was significant.

Although there does not appear to be a clear cause and effect from using a scoring system for bariatric surgery patients, the data suggest that patient outcomes with a scoring system in place seem to be superior compared to those without such a system.

"As surgeons develop better systems to evaluate their patients for risk, the outcomes improve," said Eric DeMaria, MD, FACS, FASMBS, member of the executive council of the American Society for Metabolic and Bariatric Surgery and vice-chairman of the Department of Surgery at Duke University in Durham, North Carolina. "There is a lot of work that is demonstrating that."

"It appears to make sense to identify and target patients who have numerous risk factors for much more attention and care," he added. "It makes sense to have more aggressive medical management of patients who have out-of-control blood pressure before surgery."

Dr. Blackstone has reported being a consultant for Ethicon Endo-Surgery Inc, an investigator for EnteroMedics Inc, and a member of the board of directors of the Surgical Review Corporation. Dr. DeMaria has disclosed no relevant financial relationships.

American Society for Metabolic and Bariatric Surgery 2009 Annual Meeting: Abstract PL-309. Presented June 26, 2009.

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