Outcomes of sleeve gastrectomy tied more to patient factors than surgical technique

Last Updated: 2018-02-21

By Lorraine L. Janeczko

NEW YORK (Reuters Health) - Patient characteristics are better than surgical technique at predicting adverse outcomes after laparoscopic sleeve gastrectomy (LSG), according to a new study.

"Findings from the present study suggest that rates of leak and bleed after LSG have improved over time regardless of variations in technique. Committing resources to optimizing patients' medical comorbidities, such as diabetes and GERD (gastroesophageal reflux disease), may instead portend more favorable outcomes," researchers from the University of Cincinnati College of Medicine in Ohio write in the journal Surgery, online February 3.

Dr. Jonathan R. Thompson and his colleagues searched the database of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) and found more than 88,000 LSG surgeries in 2015.

In that year, over 460 variations of LSG were performed based on combinations of bougie size, distance from the pylorus, use of staple line reinforcement and oversewing of the staple line. These variations in technique variants did not predict outcomes, including perioperative morbidity, leak, or bleeding.

On multivariate analyses, preoperative patient factors, including history of hypertension, diabetes, deep-vein thrombosis, GERD, pulmonary embolism and chronic steroid use were significantly associated with unfavorable postoperative outcomes. Only history of gastroesophageal disease (odds ratio, 1.44; P<0.01) was linked with leak.

"This study reinforces the safety of sleeve gastrectomy, with a leak rate of 0.3% and a bleeding rate of 0.7% nationally. Sleeve gastrectomy is getting safer and safer over time, likely due to more surgeon experience," Dr. Thompson told Reuters Health by email.

"Bariatric surgery remains the most effective treatment modality for morbid obesity and it is underutilized," he said. "Hopefully, these findings will lead to more primary care referrals for bariatric surgery and reduce the threshold for patients seeking sleeve gastrectomy surgery."

Dr. Thompson was surprised by the high number of techniques the surgeons used.

"The findings highlight our lack of a standardized technique for sleeve gastrectomy - every surgeon does things a little bit differently," he noted. "I think the magnitude of the technique variation is a call for standardization, so we can further improve outcomes in sleeve gastrectomy, the most commonly performed bariatric procedure in the United States."

Dr. Farah A. Husain, an assistant professor of surgery in the Division of Bariatric Surgery of the Oregon Health & Science University in Portland, told Reuters Health by email, "Optimizing patients preoperatively is of the utmost importance. This will reinforce to our referral base, to our patients, and to their families, why bariatric surgery must require a strict pathway through our care teams that involves a significant investment of time and commitment."

"Since sleeve gastrectomy was accepted as a covered procedure by insurances around 2007-2008, there has not been a standardized technique. With so many variations, ranging from staple-line reinforcement to distance from the pylorus, the surgical community needs a study like this that tells us whether what we are doing is safe and whether specific techniques lead to better results," added Dr. Husain, who was not involved in the study.

"For all clinicians, this emphasizes the need to medically optimize patients and continue to balance aspects of care, like anticoagulation to prevent clots, with the risk for postoperative bleeding. In surgery, we already know the importance of good control of diabetes as related to surgical outcomes. It appears there may be additional medical conditions that should be evaluated and considered during and after surgery, when monitoring for complications," she advised.

Dr. Ali Aminian, a bariatric surgeon and associate professor of surgery at Cleveland Clinic in Ohio, urged caution when interpreting the new findings.

"A well-designed clinical trial would be an appropriate design to answer the effects of different techniques on surgical outcomes," he told Reuters Health by email. "It would be crucial to identify the potential risk factors of postoperative complications in order to address them to further improve outcomes."

"More data are needed to identify predictors of surgical complications and long-term outcomes," said Dr. Aminian, who also was not involved in the study.

SOURCE: http://bit.ly/2sLjiRi

Surgery 2018.