FROM THE JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
Bariatric surgery is generally safe and readmissions are rare, but prolonged operative time, operation complexity, and major postoperative complications are among several risk factors for readmission identified in a large retrospective cohort.
Of 18,186 patients from the 2012 American College of Surgeons National Surgical Quality Improvement program ( ACS NSQIP ) database who had bariatric surgery as a primary procedure, 5% were readmitted. Of 815 patients with any major complication, 31% were readmitted. Factors found on multivariate analysis to significantly predict readmission within 30 days were age, sex, body mass index, American Society of Anesthesiology ( ASA ) risk class, diabetes status, hypertension, and steroid use, Dr. Christa R. Abraham of Albany (N.Y.) Medical College and her colleagues reported online in the Journal of the American College of Surgeons.
Further, all major postoperative complications were significant predictors of readmission, including bleeding requiring transfusion, urinary tract infections, and superficial surgical site infection (SSI). Other significant predictors were deep SSI, organ space SSI, wound disruption, pneumonia, unplanned intubation, mechanical ventilation for more than 48 hours, pulmonary embolism, deep vein thrombosis, and sepsis, the investigators said (J. Am. Coll. Surg. 2015 [ doi:10.1016/j.jamcollsurg.2015.02.018 ]).
Of the patients included in the study, 1,819 had a laparoscopic gastric band, 9,613 had laparoscopic Roux-en-Y gastric bypass, 6,439 had gastroplasties, and 315 had open Roux-en-Y gastric bypass. All had a BMI of at least 30 kg/m2, and had a postsurgery length of stay of 14 days or fewer. Most were ASA risk class 3 or lower, and most were functionally independent.
Complications were more common with laparoscopic and open Roux-en-y gastric bypass (5.5% and 11.8%, respectively) rather than with gastroplasty and sleeve (3.4%) and laparoscopic banding (1.4%).
The findings are of value, because while bariatric surgery is a low-risk procedure, and it is extremely common; in 2013 there were 179,000 such surgeries performed in the United States.
“Bariatric surgery is one of the fastest-growing surgical interest areas, making analysis of patient outcomes and reasons for readmission important,” the investigators explained.
The ability to identify high-risk patients could allow for targeted interventions to prevent readmission, they said.
For example, steroid use, which was identified as a risk factor in the current study, is modifiable.
“In our practice, steroids are discontinued for 6 weeks prior to bariatric surgery and patients who are steroid dependent are unlikely to undergo bariatric surgery,” they said.
Additionally, they “try to minimize readmission for patients with infections by treating with antibiotics following operation and continuing antibiotics at discharge.”
The investigators noted that the ACS NSQIP MORBPROB (estimated probability of morbidity) tool is a good tool for predicting readmission among prospective bariatric patients, although it may not fully capture the effect of preexisting conditions.
“These data led us to change our own practice by risk-stratifying patients with higher ASA and BMI to consider surgical options, and to begin early surveillance soon after discharge,” they said.
The authors reported having no disclosures.