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Background: Previous investigations of the short-term operative outcomes associated with a concomitant cholecystectomy at time of Roux-en-Y gastric bypass (RYGB) for obesity are mixed and confined to the biases of single-center experiences. Using a robust multi-hospital surgical database, we sought to determine the influence of concomitant cholecystectomy (RYGB+C), hypothesizing that the addition of cholecystectomy will adversely impact operative outcomes following RYGB.

Methods: Patients who underwent a RYGB were identified in the 2005-2009 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Demographic and outcome variables were compared between patients that underwent RYGB alone versus RYGB+C using univariate analysis. Multivariate logistic regression with adjustment for confounding variables was utilized to identify risk factors for major adverse events, prolonged length of stay (PLOS), and mortality at 30 days. Prolonged LOS was defined as those who experienced a hospital stay beyond the 90th percentile.

Results: We identified 32,946 patients who underwent RYGB; of these, 1,731 (5.2%) underwent RYGB+C. Combined procedures were less common in 2009 compared to 2005 (OR; 95% CI, 0.7; 0.5, 0.8), and RYGB+C patients were more likely to receive an open operation (4.9; 4.4, 5.5), to have a severe ASA score (1.2; 1.0, 1.3), and be functionally dependent (2.1; 1.4, 3.0). Post-operatively, the percentage of RYGB+C patients experiencing a major complication was significantly greater compared to RYGB alone patients (6.6% vs 4.9%, P<0.001). While risk was increased for RYGB+C patients for developing septic shock (P=0.02), acute renal failure (P=0.01), prolonged intubation (P=0.001), and return to the operating room (P<0.001) on univariate analysis, only return to the operating room was significant in multivariate adjustment models (1.3; 1.0, 1.7). Overall, RYGB+C was a risk factor for predicting major adverse events following laparoscopic procedures but not open (Table). Prolonged LOS was more common among RYGB+C patients who underwent either laparoscopic (13.5% vs 9.5%, P<0.001) or open (14.1% vs 9.6%, P<0.001) RYGB following adjustment (Table). Overall mortality at 30-days (0.2%) was low and did not vary with concomitant cholecystectomy (0.35% RYGB+C vs 0.19% RYGB alone, P=0.16) following adjustment for confounding variables (Table).

Conclusion: The risk for major adverse events is significantly greater for RYGB+C patients following laparoscopic procedures, and the risk for PLOS is greater for RYGB+C patients following both open and laparoscopic procedures. While thirty-day mortality was greater, it was not significantly associated with concomitant cholecystectomy. The short-term risks identified in this study can assist in decision making when considering concomitant cholecystectomy at the time of RYGB.

Predictors of Major Complications, PLOS, and Mortality after RYGB

Predictors	Major Events+ N=32880		Prolonged Length Of Stay+ N=32880 OR (95% CI)	30-Day Mortality N=32946 OR (95% CI)
	Open OR (95% CI) N=4276	Laparoscopic OR (95% CI) N=28604
RYGB+C vs RYGB Alone	0.8 (0.6, 1.2)	1.3 (1.0, 1.7)	1.5 (1.3, 1.8)	1.2 (0.5, 2.9)
Age (Years) 35-49 50-64 ≥65	Ref. 1.3 (1.0, 1.7) 0.9 (0.5, 1.6)	Ref. 1.2 (1.0, 1.4) 1.2 (0.9, 1.7)	Ref. 1.3 (1.2, 1.5) 1.9 (1.5, 2.2)	Ref. 1.4 (0.8, 2.4) 2.3 (0.9, 5.9)
BMI (kg/m2) 45-49 50-54 55-59 ≥60	Ref. 1.4 (0.9, 1.9) 1.3 (0.9, 1.9) 1.8 (1.2, 2.5)	Ref. 1.0 (0.8, 1.2) 1.3 (1.0, 1.6) 1.3 (1.0, 1.6)	Ref. 1.1 (1.0, 1.2) 1.4 (1.2, 1.6) 1.6 (1.4, 1.8)	Ref. 1.9 (0.8, 4.5) 2.1 (0.8, 5.3) 3.8 (1.7, 8.6)
Open Surgery	--	--	0.9 (0.8, 1.0)	2.2 (1.3, 3.8)
Diabetes	1.3 (1.0, 1.7)	1.0 (0.9, 1.1)	1.1 (1.0, 1.2)	2.1 (1.2, 3.5)
Cardiac Co-morb.	1.6 (1.0, 2.5)	1.2 (0.9, 1.6)	1.4 (1.2, 1.7)	3.3 (1.7, 6.6)
Total Events N (%)	366 (8.5)	1224 (4.3)	3213 (9.8)	66 (0.2)
C-Index of model	0.61	0.58	0.62	0.77

Abbreviations: OR, odds ratio; CI, confidence interval; BMI, body mass index; Co-morb., co-morbidities. Significant values are bolded and italicized. Variables also adjusted for include, but are not limited to, race, sex, pulmonary comorbidities as well as preoperative liver enzymes, white blood cell count, hemoglobin, albumin, and sodium. Prolonged LOS was defined as those who experienced a hospital stay beyond the 90th percentile. Note: +Only patients discharged alive were included.