R. C. Dirks1, D. I. Athanasiadis1, S. Monfared1, W. A. Hilgendorf1, K. M. Ziegler2, C. L. Waldrop1, D. J. Selzer1 1Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA 2Oakland University William Beaumont School Of Medicine,Department Of Surgery,Royal Oak, MI, USA
Introduction: Standards for preoperative bariatric patient selection include a thorough psychological evaluation involving psychosocial history, substance use, cognitive functioning, and developmental and family history. While reported preoperative rates of psychopathology are high in bariatric patients, studies on related postoperative outcomes have mixed results. Identifying prognostic trends in these outcomes will further optimize bariatric patient selection.
Methods: A multidisciplinary team including surgeons, dieticians, nurses, and a psychologist held a case review conference (CRC) early in the preoperative process to discuss “red-flagged” patients identified as high-risk based on psychological evaluations. Some CRC patients were dismissed from the program, some received therapeutic goals to address high-risk characteristics, and others were cleared for surgery. A retrospective chart review was performed to compare CRC patients to control patients who underwent bariatric surgery in the same interval. Patients <18 years old and those with prior sleeve gastrectomy or Roux en Y bypass (RYGB) were excluded. High-risk characteristics causing CRC inclusion were collected in addition to preoperative demographics, percent follow-up and other postoperative outcomes. If univariate analysis revealed a significant difference between cohorts (p <0.05), multivariate analysis was performed.
Results: 255 patients were red-flagged and discussed by the CRC from 2012-2013, of which 79 were approved and underwent surgery. After excluding 21 revisions and 3 non-adult patients, 55 red-flagged patients were analyzed in addition to 279 control patients. Patient demographic and baseline data, including age, gender, initial BMI, ASA, and co-morbidities, were similar between groups. However, compared to control patients, CRC patients underwent RYGB more frequently than sleeve gastrectomy or lap band. Early complications (< 30 d), length of stay stratified by type of surgery, percent excess BMI loss, and percent follow-up (6 mos. – 5 yrs.) were similar between the cohorts. In multivariate analysis, high-risk RYGB patients were significantly more likely to have marginal ulcers and undergo dilation for stenosis compared to control RYGB patients. Rate of endoscopy was significant only in univariate analysis. Perforation, reoperation, revision, incisional hernia, and internal hernia were statistically similar in both groups.
Conclusion: Bariatric patients identified as high-risk for various psychosocial issues have similar BMI loss, follow-up, and early complications compared to control patients. However, they have more frequent marginal ulcers and stenosis after RYGB compared to controls. These results warrant greater investigation into the psychosocial evaluation of patients, to better predict which characteristics of red-flagged patients drive outcomes after bariatric surgery.