Optimizing Bariatric Surgery outcomes: the impact of preoperative elevated hemoglobin A1c levels on composite perioperative outcome measures

Abstract

Introduction The use of bariatric surgery in the management of obesity and its related morbidity has significantly increased in the US over the past decade. There is a lack of data on the impact of optimal preoperative glycemic control on the morbidity and mortality following bariatric surgery. The aim of this study was to analyze the impact of hemoglobin (Hb) A1c > 7 on outcomes among patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Methods Data were extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (2017) and limited to patients undergoing an elective laparoscopic RYGB or SG. Multivariable logistic regression was conducted to adjust for other preoperative variables. Results A total number of 31,060 (69.3%) patients underwent SG, while 13,754 (30.7%) received RYGB. Patients who were older, male, non-Hispanic, smokers, and those with a higher American Society of Anesthesiologist Classification (ASA) score were more likely to have elevated HbA1c levels. Compared to individuals with normal HbA1c levels, patients with elevated levels had no significant difference in mortality (p = 0.902) but did have a difference in composite morbidity and mortality (p < 0.001). On multivariable analysis, elevated HbA1c, older age, increasing body mass index (BMI), elevated creatinine, longer operations, African American race, receiving RYGB, and having a trainee as surgical assistant were found to increase the odds of having an adverse outcome. No significant difference was found within smoking status, sex, ASA Classification, robotic vs laparoscopic, or if a second attending surgeon was assisting. Conclusions HbA1c levels and presence of trainees in the OR are modifiable preoperative risk factors for adverse events following bariatric surgery. Improving preoperative glycemic control may be an effective and achievable quality improvement measure.

Duodenal–jejunal bypass liners are superior to optimal medical management in ameliorating metabolic dysfunction: A systematic review and meta‐analysis

“…Additionally, we characterize patient demographics for those who may benefit from DJBL, including those with obesity and T2D. Considering substantial data supporting improved bariatric surgery outcomes following pre‐operative weight loss and improved glycemic control, 51–53 especially for those with severe obesity and metabolic complications, 52,54 it appears that DJBL may provide a potential optimization strategy. Further studies evaluating outcomes following DJBL prior to definitive bariatric surgery are required to evaluate this as a therapeutic strategy.…”

Stratified Preoperative A1c is not Significantly Associated With Clavien-Dindo Major Complications Following Bariatric Surgery in the MBSAQIP Database

“…The authors conducted a multivariable logistic regression and reported that elevated HbA1c >7% was significantly associated with increased odds of having an adverse postoperative outcome following bariatric surgery. 12 Meister et al conducted a single-institution retrospective study to assess the clinical significance of peri-operative hyperglycemia on patients undergoing bariatric surgery and found perioperative hyperglycemia to be associated with higher composite infectious complications in patients with diabetes and non-diabetes. 14 On the other hand, Rawlins et al performed a single-institution retrospective analysis of 342 patients with T2DM undergoing bariatric surgery and found no difference in combined complication rates when comparing groups with HbA1c < 7% with HbA1c > 7%.…”

“…This, in our opinion, supports our findings on the stratification analysis, that the mild statistically significant increased risk demonstrated by the odds ratio is clinically insignificant. Hart et al 12 found that HbA1c >7% was associated with an increased risk of complications in the MBSAQIP database. 12 We hypothesize that the significant difference demonstrated by the authors in their study was due to the inclusion of patients without diabetes in their control group with HbA1c <7%.…”

“…Hart et al 12 found that HbA1c >7% was associated with an increased risk of complications in the MBSAQIP database. 12 We hypothesize that the significant difference demonstrated by the authors in their study was due to the inclusion of patients without diabetes in their control group with HbA1c <7%. Hence, this subset of patients was healthier than their counterpart group with HbA1c >7%, resulting in a statistically significant association of preoperative HbA1c with complications when comparing both groups.…”

“…Additionally, studies reporting the association of preoperative HbA1c with postoperative adverse events following bariatric surgery were conflicting. 11,12 This study aims to review the association between stratified preoperative HbA1c levels and 30 days postoperative Clavien-Dindo major complications, in an attempt to identify a cut-off that represents significantly worse outcomes following laparoscopic RYGB and Sleeve Gastrectomy (SG) in MBSIQIP database.…”