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Relevance of the Obesity Surgery Mortality  Risk Score in Patients ...

Relevance of the Obesity Surgery Mortality Risk Score in Patients ...






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    Relevance of the Obesity Surgery Mortality  Risk Score in Patients ... Relevance of the Obesity Surgery Mortality Risk Score in Patients ... Presentation Transcript

    • Relevance of the Obesity Surgery Mortality Risk Score in Patients Undergoing Roux-en-Y Gastric Bypass. A Study in the United Kingdom
      S Mansour, V Kaur, G Vasilikostas, KM Reddy, A Wan
      St George’s Healthcare NHS Trust, London, UK
      • Obesity is a leading cause of death worldwide
      Mokdad AH et al, JAMA 2004
      • Bariatric surgery is currently, the only treatment available for sustained weight loss in the morbidly obese
      • Reduction in relative risk of death by up to 89%
      Colquitt JL et al Cochrane Database Systematic Review 2009
      Christou NV et al Annals of Surgery 2004
      • Good safety profile
      • Overall, 90-day MR* = 0.35% = lap chole 90-day MR*
      Pories WJ Journal of Clin Endo & Met 2008
      *MR – Mortality rate
    • Roux-en-Y gastric Bypass (RYGB)
      Overall, reported MR for patients undergoing primary RYGB
      0 – 1.5%
      DeMaria EJ et al Ann Surg2002, Schauer PR et al Ann Surg2000
      Wittgrove AC et al Am J Surg2000, Buchwald H et al JAMA 2004
      Published data on MR in ‘high-risk’ patients
      0 – 1.0%
      Usually addressed a single risk factor
      Age >60 yrs
      BMI >50 kg/m2
      Wittgroveet al ObesSurg2009, Adeles D et al J Am
      Figure 1: RYGB
    • Risk stratification
      • Important component of surgical decision – making
      • Risk stratification tools in surgery
      • APACHE
      • P – POSSUM
      • O – POSSUM
      • NSQIP
      • Surgical APGAR
      • Does not recognise factors specific to bariatric patients
      • Surgical scores - not designed as a pre-operative predictive tool
    • Identifying Risk Factors
      Recent publications have attempted to identify risk factors for morbidity and mortality in bariatric surgery
      Fernandez AZ et al Ann Surg 2004, Livingston EH et al Ann Surg 2002
      Sapala JA et al Obes Surg 2003, Jamal MK et al SOARD 2005
      Courcoulas A et al Surgery 2003, Nguyen NT et al Ann Surg 2004
    • Obesity Surgery Mortality Risk Score (OS-MRS)
      Developed from a single centre's experience with 2075 primary open and laparoscopic RYGB during a 10 year period
      Analysed multiple pre-op factors of potential significance
      Determined 5 pre-operative factors correlating with mortality
      Derived a pre-op scoring system for risk stratification
      • OS-MRS
      DeMaria EJ et al SOARD 2007

      Applied to a large (n=4431) multi-centre cohort
      accurately predicted mortality risk
      DeMaria EJ et al Annals Surg 2007
      OS-MRS is the first validated stratified scoring system for predicting post-op mortality in bariatric surgery
      Easy to use
    • AIM
      To assess the utility of OS-MRS in patients undergoing primary laparoscopic RYGB in a hospital in the United Kingdom
    • Methods
      All patients undergoing elective primary roux-en-Y gastric bypass surgery from June 2008 – Dec 2009
      Planned laparoscopic approach
      Exclusion criteria – revision surgery
      Prospectively maintained database
      demographic & pre-op clinical data
      90 day procedure-related mortality
      Eligibility for surgery – NICE guidelines
      BMI* >40 kg/m2 or BMI* >35 kg/m2 with obesity-related co-morbidities
      Assessed by a multidisciplinary team
      Patients have to display appropriate understanding of procedure
    • Methods
      • 5 OS-MRS variables (1 point each)
      SBP= systolic blood pressure, DBP = diastolic blood pressure, VTE = venous thromboembolism, IVC = inferior vena cava, HF = heart failure
    • methods
      OS-MRS points are grouped into 3 categories
    • Results
      18 month period
      Total =116 patients
      No mortalities
      All procedures were completed laparoscopically
      F= Female, M= Male, ASA = American Society of Anesthesiologists
    • results
      OS-MRS variables
    • Results
      OS-MRS points
    • Results
      OS-MRS classes (96.6%)
    • results
      OS-MRS mortalities
      No significant difference seen between the observed and expected mortality
      • OS-MRS was a valid tool for predicting mortality risk in our cohort
    • OS-MRS risk factors
      DeMaria EJ et al SOARD 2007
    • Utility of OS-MRS
      Provide objectivity
      Aid informed consent
      Risk prediction
      Understanding prognosis / severity
      Pre-op optimisation especially in high risk patients
      Risk reduction strategies – decreasing BMI, optimise BP
      Aid surgical decision making in high-risk patients
      use alternative lower risk or staged procedures
      Planned critical care admission post-operatively
      Allow standardisation of outcome comparisons between different units
      Instigate ‘new and improved’ risk-stratification scores in bariatric surgery
    • Conclusion
      Mortality risk in RYGB can be stratified based on independent variables that can be identified pre-operatively
      OS-MRS is a clinically relevant and valid scoring system for predicting mortality risk in our medium volume cohort
      OS-MRS may help contribute in surgical decision making in bariatric surgery
    • Thank you for ListeningQuestions & Answers
    • Relevance of the Obesity Surgery Mortality Risk Score in Patients Undergoing Roux-en-Y Gastric Bypass.
      Presenter’s name: Ms Vasha Kaur
      As previously disclosed I do not have a financial or other relationship with any company.