Defining Global Benchmarks in Bariatric Surgery

A Retrospective Multicenter Analysis of Minimally Invasive Roux-en-Y Gastric Bypass and Sleeve Gastrectomy

Daniel Gero, MD; Dimitri A. Raptis, MD, MSc, PhD; Wouter Vleeschouwers, MD; Sophie L. van Veldhuisen, MD; Andres San Martin, MD; Yao Xiao, MD; Manoela Galvao, MD; Marcoandrea Giorgi, MD; Marine Benois, MD; Felipe Espinoza, MD; Marianne Hollyman, MD, PhD; Aaron Lloyd, MPH; Hanna Hosa, MD; Henner Schmidt, MD; José Luis Garcia-Galocha, MD; Simon van de Vrande, MD; Sonja Chiappetta, MD; Emanuele Lo Menzo, MD; Cristina Mamédio Aboud, RN, MSc; Sandra Gagliardo Lüthy; Philippa Orchard, MD; Steffi Rothe, MBA; Gerhard Prager, MD; Dimitri J. Pournaras, MD, PhD; Ricardo Cohen, MD; Raul Rosenthal, MD; Rudolf Weiner, MD; Jacques Himpens, MD, PhD; Antonio Torres, MD, PhD; Kelvin Higa, MD; Richard Welbourn, MD; Marcos Berry, MD; Camilo Boza, MD; Antonio Iannelli, MD; Sivamainthan Vithiananthan, MD; Almino Ramos, MD; Torsten Olbers, MD, PhD; Matias Sepúlveda, MD; Eric J. Hazebroek, MD, PhD; Bruno Dillemans, MD; Roxane D. Staiger, MD; Milo A. Puhan, MD, PhD; Ralph Peterli, MD; Marco Bueter, MD, PhD

Disclosures

Annals of Surgery. 2019;270(5):859-867. 

In This Article

Results

Out of all 39,424 consecutive elective BS cases (RYGB, SG, bilio-pancreatic diversion, gastric banding, single anastomosis gastric bypass, single anastomosis duodenoileal bypass, gastric plication) performed over 5 years in the 19 included centers, 4120 RYGB and 1457 SG benchmark cases were identified (Supplementary Figure 1, http://links.lww.com/SLA/B717). The proportion of benchmark cases within the case mix of participating centers varied from 4% to 69% (Figure 1). Baseline characteristics of patients and procedures are presented in Supplementary Table 1, http://links.lww.com/SLA/B717. Majority of centers had a >90% uneventful postoperative course rate during the first 90-days for both procedures (Supplementary Figure 2, http://links.lww.com/SLA/B717). The cumulative hazard of CD grade >II events after BS was below 4% at 90 d (Figure 2); nevertheless, it increased constantly over time during the first 2 postoperative years (Supplementary Figure 3, http://links.lww.com/SLA/B717). The most common reasons for readmissions until last follow-up are shown in Figure 3 and Supplementary Table 2, http://links.lww.com/SLA/B717. There was a great between-center variability in the size of benchmark cohorts, in median length of follow-up, and in the cumulative hazard of reinterventions beyond 90 days (Supplementary Figure 4, http://links.lww.com/SLA/B717). Centers with higher caseload showed a trend toward achieving lower mean CCI over 90 days; however, these correlations were not statistically significant (Supplementary Figure 5, http://links.lww.com/SLA/B717).

Figure 2.

Cumulative hazard of Clavien–Dindo grade > II events in benchmark patients during the first 90-d after bariatric surgery (Roux-en-Y gastric bypass and sleeve gastrectomy).

Figure 3.

Cumulative incidence (%) of the most common reasons for readmission in benchmark patients after bariatric surgery. A, Roux-en-Y gastric bypass (n = 4120, median follow-up = 1.9 yr, [range: 0.25–6 yrs]). B, Sleeve gastrectomy (n = 1457, median follow-up = 1.6 yr, [range: 0.25–6 yrs]). GERD indicates gastro-esophageal reflux disease.

Benchmark Cutoffs of Quality Indicators

Outcome benchmarks of RYGB and SG are shown in Table 2 and Table 3, with additional data including range and median in Supplementary Table 3, http://links.lww.com/SLA/B717.

Roux-en-Y Gastric Bypass

At baseline, the cohort's mean age was 38.2 ± 11.1 years with a BMI of 41.3 ± 6.2 kg/m2. Before discharge, 3.4% of patients presented at least 1 complication. Readmissions due to grade >II events occurred in 2.5%, 4.1%, 5.5%, and 9.4% of cases at postoperative days 30, 90, 180, and 365. Ninety-day and 1-year mortality were 0% and 0.02% (1 patient died from a cardiovascular event on postoperative-day 211). At 1-year (follow-up: 82.5%), the cohort's mean BMI was 27.7 ± 4 kg/m2, EBMIL: 86.8 ± 25.5% and %weight loss: 32.7 ± 8.3%.

Sleeve Gastrectomy

At baseline, the cohort's mean age was 37.0 ± 10.8 years with a BMI of 38.9 ± 5.2 kg/m2. Before discharge, 3.6% of patients presented at least 1 complication. Readmissions due to grade >II events occurred in 2.5%, 3.1%, 3.7%, and 5.9% of cases at postoperative days 30, 90, 180, and 365. One-year mortality was zero. At 1-year (follow-up: 68.2%), the cohort's mean BMI was 28 ± 4.9 kg/m2, EBMIL: 84.3 ± 37.6% and %weight loss: 27.5 ± 10.2%.

Proof of Concept

The 90-day mortality rate in the nonbenchmark cases was 0.05% (11/21,830) after RYGB and 0.09% (8/8813) after SG. The 90-day postoperative outcomes of nonbenchmark RYGB patients operated at Center Number 2 (n = 468) are compared with the benchmark cutoffs for the same quality indicators in Supplementary Table 4, http://links.lww.com/SLA/B717. A literature search identified 10 publications covering 3993 RYGB cases operated at the participating centers (Supplementary Table 5, http://links.lww.com/SLA/B717), with a median 30-day major complication rate of 10.75%.

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