Complications: Revisions MISS 2010

1. Complications: RevisionsMISS 2010 Bruce M. Wolfe Professor of Surgery Oregon Health & Science University

2. Complications: Revisions • Provider error • Large gastric pouch • Incomplete gastric division • Incorrect limbs

3. Complications: Revisions • Patient and/or provider factors • Marginal ulcer • Stricture • Intestinal obstruction

4. Complications: Revisions • Poor weight loss or regain • Anatomic factor • Gastric pouch size • Dilated gastrojejunostomy • Gastrogastric fistula • Patient factor • Operative anatomy as expected

5. Marginal Ulcer • Evaluation • Endoscopy • UGI • Intraoperative endoscopy • Define pouch • Confirm resection • Test anastomosis • ± Vagotomy

6. Background • Revisional bariatric surgery • Indications: • Side effects or complications of prior bariatric surgery • Inadequate weight loss • Higher morbidity than with first time procedures

7. UWashington/ VMason NRI/UND OHSU/ Legacy Sacramento Bariatric GSPH Columbia/ Cornell UPMC NIDDK/ ORWH ECU Clinical Center Data Coordinating Center NIDDK / ORWH

8. Aim • To determine independent risk factors for adverse outcome in patients undergoing revisional bariatric surgery • To compare the outcome between first-time and revisional bariatric cases

9. LABS-1 Total 5069 patients/operations 30 Second stage procedures 6 Other secondary obesity procedures 5033 Primary, revisional or reversal operations 1230 Adjustable gastric banding 3803 stapled bariatric procedures 1 patient underwent 2 separate procedures: a revision followed by a reversal; The reversal was excluded from the analysis 3802 patients/operations 3577 primary procedures 225 revision/reversal procedures

10. Data definitions • Composite endpoint (CE) • Death • Deep venous thrombosis (DVT) or venothromboembolism (VTE) • Re-intervention with percutaneous, endoscopic or operative techniques • Failure to discharge within 30-days of surgery

11. Statistical Analysis • Characteristics across subgroups: • Categorical variables: • Pearson’s chi-square test • Continuous: • Kruskal-Wallis test • 30-day adverse outcomes: • Fisher’s exact test • Association between baseline patient characteristics and the odds of 30-day adverse outcome : • Multivariable generalized linear logistic regression models

12. Patient characteristics for revisional patients

13. Patient characteristics for revisional patients

14. Comorbidities

15. Major comorbidities and medication use

16. Prior Obesity or Foregut Surgery

17. Surgery Performed

18. Adverse outcome

19. Predictors of CE among revisional surgeries

20. Revisional vs. Primary Unadjusted Odds of CE is more than twice high for revisional surgeries compared to primary surgeries (OR = 2.4, 95% CI 1.6-3.6)

21. Revisional vs. Primary Adjusted for important comorbidities and other patient characteristics, odds of CE was more than twice as high for revisional surgeries compared to primary surgeries (OR = 2.3, 95% CI 1.5-3.8)

22. Conclusions • Revisional bariatric surgery can be performed without substantial mortality but with a greater incidence of adverse outcome compared to primary surgery

23. Acknowledgments This clinical study was a cooperative agreement funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Grant numbers: DCC -U01 DK066557; Columbia-Presbyterian - U01-DK66667; University of Washington - U01-DK66568 (in collaboration with GCRC, Grant M01RR-00037); Neuropsychiatric Research Institute - U01-DK66471; East Carolina University – U01-DK66526; University of Pittsburgh Medical Center – U01-DK66585; Oregon Health & Science University – U01-DK66555. The authors thank the LABS study participants for their contributions.