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


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

  1. 1. Relevance of the Obesity Surgery Mortality Risk Score in Patients Undergoing Roux-en-Y Gastric Bypass. A Study in the United Kingdom<br />S Mansour, V Kaur, G Vasilikostas, KM Reddy, A Wan<br />St George’s Healthcare NHS Trust, London, UK<br />
  2. 2. BARIATRIC SURGERY<br /><ul><li>Obesity is a leading cause of death worldwide</li></ul>Mokdad AH et al, JAMA 2004<br /><ul><li>Bariatric surgery is currently, the only treatment available for sustained weight loss in the morbidly obese
  3. 3. Reduction in relative risk of death by up to 89%</li></ul>Colquitt JL et al Cochrane Database Systematic Review 2009<br />Christou NV et al Annals of Surgery 2004<br /><ul><li> Good safety profile
  4. 4. Overall, 90-day MR* = 0.35% = lap chole 90-day MR* </li></ul>Pories WJ Journal of Clin Endo & Met 2008<br />*MR – Mortality rate<br />
  5. 5. Roux-en-Y gastric Bypass (RYGB)<br />Overall, reported MR for patients undergoing primary RYGB<br />0 – 1.5% <br />DeMaria EJ et al Ann Surg2002, Schauer PR et al Ann Surg2000<br />Wittgrove AC et al Am J Surg2000, Buchwald H et al JAMA 2004<br />Published data on MR in ‘high-risk’ patients<br />0 – 1.0% <br />Usually addressed a single risk factor<br />Age >60 yrs<br />BMI >50 kg/m2<br />Wittgroveet al ObesSurg2009, Adeles D et al J Am<br />Figure 1: RYGB<br />
  6. 6. Risk stratification<br /><ul><li>Important component of surgical decision – making
  7. 7. Risk stratification tools in surgery
  8. 8. APACHE
  9. 9. P – POSSUM
  10. 10. O – POSSUM
  11. 11. NSQIP
  12. 12. Surgical APGAR
  13. 13. Does not recognise factors specific to bariatric patients
  14. 14. Surgical scores - not designed as a pre-operative predictive tool</li></li></ul><li>Identifying Risk Factors<br />Recent publications have attempted to identify risk factors for morbidity and mortality in bariatric surgery<br />Fernandez AZ et al Ann Surg 2004, Livingston EH et al Ann Surg 2002<br />Sapala JA et al Obes Surg 2003, Jamal MK et al SOARD 2005<br />Courcoulas A et al Surgery 2003, Nguyen NT et al Ann Surg 2004<br />
  15. 15. Obesity Surgery Mortality Risk Score (OS-MRS)<br />Developed from a single centre's experience with 2075 primary open and laparoscopic RYGB during a 10 year period <br />Analysed multiple pre-op factors of potential significance<br />Determined 5 pre-operative factors correlating with mortality<br />Derived a pre-op scoring system for risk stratification<br /><ul><li>OS-MRS </li></ul>DeMaria EJ et al SOARD 2007<br />…<br />Applied to a large (n=4431) multi-centre cohort <br />accurately predicted mortality risk <br />DeMaria EJ et al Annals Surg 2007<br />OS-MRS is the first validated stratified scoring system for predicting post-op mortality in bariatric surgery<br />Easy to use<br />Pre-operative<br />
  16. 16. AIM<br />To assess the utility of OS-MRS in patients undergoing primary laparoscopic RYGB in a hospital in the United Kingdom<br />
  17. 17. Methods<br />All patients undergoing elective primary roux-en-Y gastric bypass surgery from June 2008 – Dec 2009<br />Planned laparoscopic approach<br />Exclusion criteria – revision surgery<br />Prospectively maintained database<br />demographic & pre-op clinical data<br />90 day procedure-related mortality<br />Eligibility for surgery – NICE guidelines<br />BMI* >40 kg/m2 or BMI* >35 kg/m2 with obesity-related co-morbidities <br />Assessed by a multidisciplinary team<br />Patients have to display appropriate understanding of procedure<br />
  18. 18. Methods<br /><ul><li>5 OS-MRS variables (1 point each)</li></ul> SBP= systolic blood pressure, DBP = diastolic blood pressure, VTE = venous thromboembolism, IVC = inferior vena cava, HF = heart failure<br />
  19. 19. methods<br />OS-MRS points are grouped into 3 categories<br />
  20. 20. Results<br />18 month period<br />Total =116 patients<br />No mortalities<br />All procedures were completed laparoscopically<br /> F= Female, M= Male, ASA = American Society of Anesthesiologists<br />
  21. 21. results<br />OS-MRS variables<br />
  22. 22. Results<br />OS-MRS points<br />
  23. 23. Results<br />OS-MRS classes (96.6%)<br />
  24. 24. results<br />OS-MRS mortalities<br />No significant difference seen between the observed and expected mortality<br /><ul><li>OS-MRS was a valid tool for predicting mortality risk in our cohort</li></li></ul><li>OS-MRS risk factors<br />DeMaria EJ et al SOARD 2007<br />
  25. 25. Utility of OS-MRS<br />Provide objectivity<br />Aid informed consent<br />Risk prediction<br />Understanding prognosis / severity<br />Pre-op optimisation especially in high risk patients<br />Risk reduction strategies – decreasing BMI, optimise BP<br />Aid surgical decision making in high-risk patients<br />use alternative lower risk or staged procedures<br />Planned critical care admission post-operatively<br />Allow standardisation of outcome comparisons between different units<br />Instigate ‘new and improved’ risk-stratification scores in bariatric surgery<br />
  26. 26. Conclusion<br />Mortality risk in RYGB can be stratified based on independent variables that can be identified pre-operatively<br />OS-MRS is a clinically relevant and valid scoring system for predicting mortality risk in our medium volume cohort <br />OS-MRS may help contribute in surgical decision making in bariatric surgery <br />
  27. 27. Thank you for ListeningQuestions & Answers<br />
  28. 28. Relevance of the Obesity Surgery Mortality Risk Score in Patients Undergoing Roux-en-Y Gastric Bypass.<br />Presenter’s name: Ms Vasha Kaur<br />As previously disclosed I do not have a financial or other relationship with any company.<br />