Prevalence of Adverse Intraoperative Events During Obesity Surgery and Their Sequelae
Alexander J. Greenstein*4, Abdus S. Wahed2, Abidemi Adeniji2, Anita P. Courcoulas3, Gregory Dakin8, David Flum5, Vincent L. Harrison1, James E. Mitchell7, Robert W. O'Rourke1, John R. Pender6, Ramesh Ramanathan3, Bruce M. Wolfe1
1Surgery, Oregon Health & Science University, Portland, OR; 2Data Coordinating Center, University of Pittsburgh, Pittsburgh, PA; 3Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; 4Surgery, Mount Sinai Medical Center, New York, NY; 5Surgery, University of Washington, Seattle, WA; 6Surgery, East Carolina University, Greenville, NC; 7Neuropsychiatric Research Institute, University of North Dakota, Fargo, ND; 8Surgery, Weill College of Medicine, New York, NY
Background:Adverse intraoperative events (AIEs) during surgery are a well known entity. A better understanding of AIEs and their relationship with outcomes is helpful for surgeon preparation and preoperative patient counseling. The goals of this study are to test the hypotheses that the laparoscopic approach to bariatric surgery results in fewer AIEs than the open approach and that patients who suffer an AIE are at greater risk of 30 day post-operative complications. Methods:The study included 5882 patients from the Longitudinal Assessment of Bariatric Surgery (LABS) study undergoing one of three types of primary bariatric surgeries between March 2005 and April 2009 - laparoscopic adjusted gastric banding (LAGB), laparoscopic Roux-en-Y gastric bypass (LRYGB), or open Roux-en-Y gastric bypass (ORYGB). AIEs included organ injuries, anesthesia related events, anastomotic revisions and equipment failure. Rates of AIE were compared between LRYGB and ORYGB groups using Fisher’s exact test. The relationship between AIEs and a composite end point of 30-day major adverse complications (death, venous thromboembolism, percutaneous, endoscopic, or operative reintervention and failure to be discharged from the hospital within 30 days from surgery) was evaluated using a multivariable relative risk model adjusting for DVT/PE, obstructive sleep apnea, body mass index, procedure type, and inability to walk 200ft, as well as for clustering due to surgeon and site.Results:There were 1608 LAGB (27%), 3770 LRYGB (64%), and 504 ORYGB (9%) surgeries. AIEs occurred in 5% of the overall sample and were most frequent during ORYGB (7.3%), followed by LRYGB (5.5%) and LAGB (3%), with no significant difference between the ORYGB and LRYGB groups (p=0.13). The most common AIEs were organ injuries (1.0%), followed by anesthesia events (0.9%) and equipment failure (0.8%). The rate of composite endpoint was 8.8% in the AIE group compared to 3.9% among those without a AIE (p < 0.001). While incidence of death (0.3%) and DVT/PE (0.4%) were similar (p>0.05) across those with or without an AIE, abdominal re-operation (4.8% vs. 2.4%; p=0.01), percutaneous drain placement (1.0% vs. 0.3%; p=0.02) and endoscopic intervention (2.4% vs. 1.1%; p=0.04) were more common among those with an AIE. Multivariable analysis revealed that patients with an AIE were at 90% greater risk of composite complication than those without an event (RR = 1.90, 95% CI: 1.26-2.88; p=0.002). Conclusion:There is no significant difference in the rate of AIEs in patients undergoing ORYGB versus LRYGB. While associations between specific AIEs and post-operative complications could not be assessed due to the rarity of both events, the occurrence of an AIE is not insignificant. Patients with AIEs are at nearly double the risk of future complication and thus merit close follow-up.
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