IFSO 2011 MGB Outperforms RnY Bypass


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IFSO 2011 MGB Outperforms RnY Bypass

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IFSO 2011 MGB Outperforms RnY Bypass

  1. 1. The Mini-Gastric Bypass Outperforms the RNY Gastric Bypass as Measured by Length of Stay (LOS) Dr Rutledge; Center for Laparoscopic Obesity Surgery Email: DrR@clos.net
  2. 2. Length of Stay (LOS) as a Measure of Quality <ul><li>A shorter Length of Stay (LOS) often is associated with a better outcome. </li></ul><ul><li>LOS is often an indicator of more efficient and effective care. </li></ul><ul><li>Shorter LOS means that the patient is able to return home earlier, providing the opportunity to recuperate in a familiar surrounding free from potential complications that result from the hospital environment. </li></ul>
  3. 3. Length of Stay (LOS) as a Measure of Quality <ul><li>Hospitals and Doctors are working feverishly to improve cost-effectiveness and quality in bariatric care. </li></ul><ul><li>Decreasing average Length of Stay (LOS) can help achieve optimal usage of hospital staff and resources. </li></ul><ul><li>Indicators such as LOS are useful for identifying areas for clinical practice changes and may contribute to the improvement in cost-effective patient care with a concomitant improvement in quality indicators. </li></ul>
  4. 4. Length of Stay (LOS) as a Measure of Quality <ul><li>Obviously LOS cannot be the only measure of quality but may be an important part of a multi-dimensional measure. </li></ul><ul><li>The goal is to add LOS to other outcomes such as weight loss, complication rate, patient satisfaction and resolution of co-morbidities to aide in selection of the ideal surgery </li></ul>
  5. 5. Purpose & Methods <ul><li>The purpose of this study was to compare the LOS in 6,125 patients with the LOS for RNY reported in 3 large scale national databases. </li></ul><ul><li>Patients undergoing Mini-Gastric bypass (MGB) have been followed for LOS, operative time, demographic data and follow up have been recorded and reported. </li></ul>
  6. 6. Results: LOS for RNY <ul><li>LOS for RNY was recently published. (Wolfe et al) </li></ul><ul><li>Bruce M. Wolfe, Robin Blackstone, John Morton, Jaime Ponce, Ninh Nguyen, Chris Eagon </li></ul><ul><li>In response to Milliman guideline changes Gastric Restrictive Procedure with Gastric Bypass by Laparoscopy, ORG code S-513. GLOS changed from 1 day to Ambulatory or 1 day </li></ul><ul><li>“ There are absolutely no data to support this very radical change” </li></ul>
  7. 7. “ Current Bariatric Surgery LOS Evidence” <ul><li>National Inpatient Sample Agency for Healthcare Research & Quality national dataset of 7 million/yr found 2.7 days, <1% 1 day stay </li></ul><ul><li>Surgical Review Corp; Bariatric Outcomes Longitudinal Database (BOLD) including 250,000. mean LOS 2.4 days with < 1% 1 day </li></ul><ul><li>Univ Health Consortium 8.3% LOS 1 day and readmission was 36% higher for these pts (2.1 vs 1.6%) </li></ul><ul><li>“ Given these data only a small minority of RNY patients could safely meet 1 day LOS goal.” </li></ul>
  8. 8. MGB Length of Stay <ul><li>In the MGB series the median LOS was 1 day with a mean of 1.2 days. </li></ul><ul><li>Recently an outpatient MGB program has begun for selected low risk patients with hospital stay of 8-10 hrs. </li></ul><ul><li>The patient population is similar to those reported in series of RNY's; 6,125 patients, 85% female, mean age 39, mean BMI 49, mortality rate =(3/6125)*100 # &quot;0.00%&quot; 0.05% and peri-operative compilation rate 6%. </li></ul>
  9. 9. Discussion <ul><li>MGB Clearly Outperforms RNY as measured by LOS </li></ul><ul><li>Re Wolfe et al attempts by RNY surgeons to meet these targets are radical and potentially deadly </li></ul><ul><li>LOS is not adequate alone but must bet part of a multidimensional tool to identify the best or Ideal weight loss surgery. </li></ul>
  10. 10. 30 Point Multidimensional Performance Assessment Tool Quality Dimension MGB Grade 1. Low Risk ***** 2. Major Weight Loss ***** 3. Easily performed ***** 4. Short operative time ***** 5. Outpatient or short hospital stay ***** 6. Minimal Blood Loss ***** 7. No Need for ICU Stay ***** 8. Minimal Pain ***** 9. Very High Patient Satisfaction ***** 10. A Good &quot;Exit Strategy&quot; ***** Safely & Easily Reversed or Revised Laparoscopically
  11. 11. Quality Dimension MGB Grade 11. Change in eating behavior and preferences; ***** Decreased Hunger & Increased Satiety 12. Minimal Retching and Vomiting ***** 13. Few adhesions or hernias ***** 14. Minimal impact on Heart and Lung Function ***** 15. Low Failure Rate ***** 16. Low Cost ***** 17. Short Recovery Time ***** 18. Rapid Return to Work ***** 19. Low Risk of Pulmonary Embolus ***** 20. Durable weight loss ***** 21. Low Risk of Ulcer *** 30 Point Multidimensional Performance Assessment Tool
  12. 12. Quality Dimension MGB Grade 22. Malabsorption of fat; ***** lower cholesterol and CV risk factors 23. No Plastic Foreign Body Material ***** 24. Easily Verifiable Results ***** over 10 years of Results 25. Low Risk of Bowel Obstruction ***** 26. Based upon sound surgical principles ***** and experience (i.e. Vagotomy and Antrectomy) 27. Independent confirmation of results ***** 28. Healthy life after surgery ***** 29. Supported by LEVEL I Evidence; ***** RCT (Controlled Prospective Randomized Trial Demonstrate Superiority) 30. Block “Sweet Eater” Failures ***** 30 Point Multidimensional Performance Assessment Tool
  13. 13. Uninformed Surgeons Fear Billroth II Educated Surgeons Use Billroth II <ul><li>1. Gastric Cancer (GC) rapidly declining, caused by environmental factors and preventable by diet, lifestyle and Rx of H. Pylori </li></ul><ul><li>2. Some studies show slight increased risk of gastric cancer with Billroth II, probably because the BII performed on ulcer pts </li></ul><ul><li>3. Other studies show No increased risk 1,000s pts followed for decades </li></ul><ul><li>4. General, Trauma and Oncologic surgeons routinely use BII </li></ul><ul><li>6. While some disagree, the BII & MGB excellent and effective RX </li></ul><ul><li>7. FEAR gastric cancer=> avoid ETOH, Tobacco, Processed & Preserved Meats, RX H. Pylori, Eat Fruits & Veggies, Yogurt & Drink Green Tea; +/-BII probably makes no difference </li></ul>
  14. 14. Conclusions <ul><li>There is general agreement that LOS is a useful if imperfect/incomplete measure of quality of care </li></ul><ul><li>The present study shows that the MGB LOS significantly outperforms RNY as compared to 3 large scale national databases with 1 day median LOS and high volume outpatient program </li></ul><ul><li>The MGB scores well on the 30 Point Multidimensional Performance Assessment Tool (30PMPAT) </li></ul>