Gastric bypass patients fare better as surgical programs' experience increases


CHICAGO Risk of serious complications and death following gastric bypass surgery for morbid obesity may be reduced substantially when the surgery is performed at high volume centers and the surgeons have reached the 100 case experience, according to an article in the April issue of Archives of Surgery, one of the JAMA/Archives journals.

The number of surgical procedures for morbid obesity has increased by 644 percent in the last decade, according to background information in the article. Although laparoscopic Roux-en-Y gastric bypass surgery has been the "gold standard" operative procedure for the treatment of intractable morbid obesity for more than 30 years, it remains a technically difficult operation that is performed on a high-risk patient population. "As most bariatric surgeons are well aware, morbidly obese patients do not tolerate complications," the authors write. "Complications, such as leaks [of the staple line], often result in catastrophic outcomes for these patients."

Scott A. Shikora, M.D., of Tufts-New England Medical Center, Boston, and colleagues analyzed the medical records of 750 consecutive morbidly obese patients who underwent laparoscopic Roux-en-Y gastric bypass surgery at Tufts-New England Medical Center from March 1998 to April 2004 to evaluate the role of experience and patient volume in reducing the rate of complications in patients undergoing this type of surgery. Eighty-five percent of the patients were female, with a mean age of 41 years. Their body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) ranged from 32 to 86 (a BMI greater than 29.9 is considered obese) with an average BMI of 47.

The overall complication rate was 15 percent with a death rate of 0.3 percent, according to the authors. But for the first 100 cases, the overall complication rate was 26 percent with a death rate of one percent. This complication rate decreased to approximately 13 percent and was stable for the next 650 patients. Major complications also decreased after the first 100 cases. The duration of the operation also decreased. Overall mean operating time was 138 minutes, with a range of from 65 to 310 minutes. It decreased from an average of 212 minutes for the first 100 cases to 132 for the next 650 and 105 minutes (with a range of 65-200 minutes) for the last 100 cases.

"Many bariatric surgeons believe that the degree of difficulty of the procedure and the unique high-risk nature of the patient population mandates limiting this field to centers that specialize in it and perform it on a regular basis," the authors write. Theoretically, high volume enables the surgeon and all involved clinicians to develop a significant experience with the procedure and these patients in a shorter period, according to the authors.

"Our data seem to support both premises that the learning curve is approximately 100 cases and a high-volume program may achieve better patient outcome than a low-volume program," the authors conclude. "Despite the limitations of a retrospective review, there is no dispute that the complications associated with the LRYGBP [laparoscopic Roux-en-Y gastric bypass surgery] were dramatically reduced after approximately 100 cases were preformed at a high-volume bariatric program." These findings are supported by other published studies, the authors note.

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