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


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

In This Article


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, 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, Majority of centers had a >90% uneventful postoperative course rate during the first 90-days for both procedures (Supplementary Figure 2, 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, The most common reasons for readmissions until last follow-up are shown in Figure 3 and Supplementary Table 2, 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, 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,

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,

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, A literature search identified 10 publications covering 3993 RYGB cases operated at the participating centers (Supplementary Table 5,, with a median 30-day major complication rate of 10.75%.