Defining global benchmarks in elective secondary bariatric surgery comprising conversional, revisional and reversal procedures

Abstract

Objective Management of poor response and of long-term complications after bariatric surgery (BS) is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS. Benchmarking uses best performance in a given field as reference point for improvement. Our aim was to define ‘‘best possible’’ outcomes for elective secondary BS. Methods The establishment of benchmarks in secondary BS followed a standardized methodology, based on recommendations of a Delphi consensus panel of experts. This multicenter study analyzed patients undergoing elective secondary BS in 18 high-volume centers on 4 continents from 06/2013 to 05/2019. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of the centers. Benchmark cases had no: previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, history of thromboembolic events, BMI>50kg/m2 or age>65 years. Descriptive statistics, multivariate logistic regression and data visualization were performed using the R software. Results Out of 44’884 elective bariatric procedures performed in the participating centers, 5’328 secondary BS cases were identified. The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8±10 years, 8.4±5.3 years after primary BS, with a body mass index 35.2±7kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.57% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.36) and after conversional or revisional procedures with gastrointestinal suture/stapling (OR 1.7). Benchmark cutoffs at 90-days postoperatively were ≤5.8% re-intervention and ≤8.8% re-operation rate. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation. Conclusion Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.

Novel Benchmark Values for Redo Liver Transplantation

“…8 Consistently, benchmark cutoffs for CCI ® and biliary complications increase significantly after 6 months up to 1 year postoperatively (eg, CCI ® from 52 to 72 points and biliary complications from 24 to 30, respectively) underlining the need for a minimum follow-up of 1 year also for redo-LT. 8 Accordingly, with a very high 1-year benchmark morbidity of 100%, and a benchmark mortality of 15%, the best achievable results in redo-LT are expectedly inferior compared with primary LT 8,9 and also compared with other major liver 10,13 and abdominal surgeries. 11,12,[14][15][16] Only a benchmark study looking at surgery for perihilar cholangiocarcinoma, as FIGURE 2. Pearson correlation between transplant center volume and center-specific surgical outcome.…”

“…Benchmarks in redo-LT were established according to a standardized methodology as previously reported for other complex surgical procedures,8–17 and critically refined by a panel of experts through a Delphi consensus finding process 18…”

“…Benchmarks in redo-LT were established according to a standardized methodology as previously reported for other complex surgical procedures, [8][9][10][11][12][13][14][15][16][17] and critically refined by a panel of experts through a Delphi consensus finding process. 18 International high-volume LT reference centers were selected based on a caseload of ≥ 50 LT per year, having published in the field of LT, and holding a comprehensive prospective patient database covering a minimum follow-up of 2 years.…”

“…Accordingly, in this study, we aim to establish clinically relevant thresholds gathered in high-volume centers on 3 continents. For this purpose, an ideal cohort serving as benchmark redo-LT cohort was defined using a well-established methodology previously used to assess primary LT,8,9 and other major procedures 10–17. The benchmark values were subsequently used to assess outcome of redo-LT in recipients with severe liver disease stages, and in patients requiring an emergency high-risk redo-LT, such as those with primary nonfunction (PNF).…”

Classification of Adverse Events in Adult Surgery

“…18 The research group of Clavien et al introduced the notion of global outcome benchmarks, where procedure-specific outcome goals are set for a list of clinically relevant quality indicators (QIs), based on the 75th percentile of the outcomes obtained in international high-volume centers. 11,13,[19][20][21][22][23][24][25][26][27][28][29][30][31][32] Global outcome benchmarks have been so far established for minimally invasive esophagectomy, 25 liver surgery, 26 liver transplantation, 24,31 ALPPS (associating liver partition and portal vein ligation for staged hepatectomy), 22 pancreatic surgery, 20,23 colorectal resections, 32 as well as for bariatric surgery 19,21 (►Table 1). Meanwhile, Kolfschoten et al developed a composite outcome measure representing the percentage of patients with textbook outcomes, meaning that all desired health outcomes are reached simultaneously.…”