Skip to main content
SpringerLink
Log in

Volume and outcome relationship in bariatric surgery in the laparoscopic era

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

The relationship between volume and outcomes in bariatric surgery is well established in the literature. However, the analyses were performed primarily in the open surgery era and in the absence of national accreditation. The recent Metabolic Bariatric Surgery Accreditation and Quality Improvement Program proposed an annual threshold volume of 50 stapling cases. This study aimed to examine the effect of volume and accreditation on surgical outcomes for bariatric surgery in this laparoscopic era.

Methods

The Nationwide Inpatient Sample was used for analysis of the outcomes experienced by morbidly obese patients who underwent an elective laparoscopic stapling bariatric surgical procedure between 2006 and 2010. In this analysis, low-volume centers (LVC < 50 stapling cases/year) were compared with high-volume centers (HVC ≥ 50 stapling cases/year). Multivariate analysis was performed to examine risk-adjusted serious morbidity and in-hospital mortality between the LVCs and HVCs. Additionally, within the HVC group, risk-adjusted outcomes of accredited versus nonaccredited centers were examined.

Results

Between 2006 and 2010, 277,760 laparoscopic stapling bariatric procedures were performed, with 85 % of the cases managed at HVCs. The mean number of laparoscopic stapling cases managed per year was 17 ± 14 at LVCs and 144 ± 117 at HVCs. The in-hospital mortality was higher at LVCs (0.17 %) than at HVCs (0.07 %). Multivariate analysis showed that laparoscopic stapling procedures performed at LVCs had higher rates of mortality than those performed at HVCs [odds ratio (OR) 2.5; 95 % confidence interval (CI) 1.3–4.8; p < 0.01] as well as higher rates of serious morbidity (OR 1.2; 95 % CI 1.1–1.4; p < 0.01). The in-hospital mortality rate at nonaccredited HVCs was 0.22 % compared with 0.06 % at accredited HVCs. Multivariate analysis showed that nonaccredited centers had higher rates of mortality than accredited centers (OR 3.6; 95 % CI 1.5–8.3; p < 0.01) but lower rates of serious morbidity (OR 0.8; 95 % CI 0.7–0.9; p < 0.01).

Conclusion

In this era of laparoscopy, hospitals managing more than 50 laparoscopic stapling cases per year have improved outcomes. However, nonaccredited HVCs have outcomes similar to those of LVCs. Therefore, the impact of accreditation on outcomes may be greater than that of volume.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Flum DR, Salem L, Elrod JA, Dellinger EP, Cheadle A, Chan L (2005) Early mortality among medicare beneficiaries undergoing bariatric surgical procedures. JAMA 294:1903–1908

    Article  PubMed  CAS  Google Scholar 

  2. Pratt GM, McLees B, Pories WJ (2006) The ASBS Bariatric Surgery Centers of Excellence program: a blueprint for quality improvement. Surg Obes Relat Dis 2:497–503 discussion 503

    Article  PubMed  Google Scholar 

  3. Buchwald H, Oien DM (2013) Metabolic/bariatric surgery worldwide 2011. Obes Surg 23:427–436

    Article  PubMed  Google Scholar 

  4. American College of Surgeons. ACS BSCN accreditation program manual. Bariatric Surgery Centers Network, Chicago, IL. www.mbsaqip.org

  5. Dimick JB, Osborne NH, Nicholas L, Birkmeyer JD (2009) Identifying high-quality bariatric surgery centers: hospital volume or risk-adjusted outcomes? J Am Coll Surg 209:702–706

    Article  PubMed  Google Scholar 

  6. Nguyen NT, Paya M, Stevens CM, Mavandadi S, Zainabadi K, Wilson SE (2004) The relationship between hospital volume and outcome in bariatric surgery at academic medical centers. Ann Surg 240:586–593 discussion 593–584

    PubMed  Google Scholar 

  7. Markar SR, Penna M, Karthikesalingam A, Hashemi M (2012) The impact of hospital and surgeon volume on clinical outcome following bariatric surgery. Obes Surg 22:1126–1134

    Article  PubMed  Google Scholar 

  8. Gould JC, Kent KC, Wan Y, Rajamanickam V, Leverson G, Campos GM (2011) Perioperative safety and volume: outcomes relationships in bariatric surgery: a study of 32,000 patients. J Am Coll Surg 213:771–777

    Article  PubMed  Google Scholar 

  9. Zevin B, Aggarwal R, Grantcharov TP (2012) Volume–outcome association in bariatric surgery: a systematic review. Ann Surg 256:60–71

    Article  PubMed  Google Scholar 

  10. Campos GM, Ciovica R, Rogers SJ, Posselt AM, Vittinghoff E, Takata M, Cello JP (2007) Spectrum and risk factors of complications after gastric bypass. Arch Surg 142:969–975 discussion 976

    Article  PubMed  Google Scholar 

  11. Livingston EH, Elliott AC, Hynan LS, Engel E (2007) When policy meets statistics: the very real effect that questionable statistical analysis has on limiting health care access for bariatric surgery. Arch Surg 142:979–987

    Article  PubMed  Google Scholar 

  12. Livingston EH (2009) Bariatric surgery outcomes at designated centers of excellence vs nondesignated programs. Arch Surg 144:319–325 discussion 325

    Article  PubMed  Google Scholar 

  13. Livingston EH, Burchell I (2010) Reduced access to care resulting from centers of excellence initiatives in bariatric surgery. Arch Surg 145:993–997

    Article  PubMed  Google Scholar 

  14. Huber PJ (1967) The behavior of maximum likelihood estimates under nonstandard conditions. In Proceedings of the 5th Berkeley symposium on mathematical statistics and probability, Berkeley, CA

  15. Holm S (1979) Proceedings of the fifth Berkeley symposium on mathematical statistics and probability. Scand J Stat 6:65–70

    Google Scholar 

  16. van Walraven C, Austin PC, Jennings A, Quan H, Forster AJ (2009) A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data. Med Care 47:626–633

    Article  PubMed  Google Scholar 

  17. Parker M, Loewen M, Sullivan T, Yatco E, Cerabona T, Savino JA, Kaul A (2007) Predictors of outcome after obesity surgery in New York state from 1991 to 2003. Surg Endosc 21:1482–1486

    Article  PubMed  CAS  Google Scholar 

  18. Courcoulas A, Schuchert M, Gatti G, Luketich J (2003) The relationship of surgeon and hospital volume to outcome after gastric bypass surgery in Pennsylvania: a 3-year summary. Surgery 134:613–621 discussion 621–613

    Article  PubMed  Google Scholar 

  19. Liu JH, Zingmond D, Etzioni DA, O’Connell JB, Maggard MA, Livingston EH, Liu CD, Ko CY (2003) Characterizing the performance and outcomes of obesity surgery in California. Am Surg 69:823–828

    PubMed  Google Scholar 

  20. Flum DR, Kwon S, MacLeod K, Wang B, Alfonso-Cristancho R, Garrison LP, Sullivan SD, Bariatric Obesity Outcome Modeling Collaborative (2011) The use, safety, and cost of bariatric surgery before and after medicare’s national coverage decision. Ann Surg 254:860–865

    Article  PubMed  Google Scholar 

  21. Nguyen NT, Nguyen B, Nguyen VQ, Ziogas A, Hohmann S, Stamos MJ (2012) Outcomes of bariatric surgery performed at accredited vs nonaccredited centers. J Am Coll Surg 215:467–474

    Article  PubMed  Google Scholar 

  22. Ghaferi AA, Birkmeyer JD, Dimick JB (2009) Complications, failure to rescue, and mortality with major inpatient surgery in medicare patients. Ann Surg 250:1029–1034

    Article  PubMed  Google Scholar 

  23. Dimick JB, Nicholas LH, Ryan AM, Thumma JR, Birkmeyer JD (2013) Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence. JAMA 309:792–799

    Article  PubMed  CAS  Google Scholar 

Download references

Disclosures

Ninh T. Nguyen is the speaker bureau for Gore®. Mehraneh D. Jafari, Fariba Jafari, Monica T. Young, Brian R. Smith, and Michael J. Phalen have no conflicts of interest or financial ties to disclose.

Author information

Authors and Affiliations

  1. Department of Surgery, University of California, Irvine, 333 City Blvd. West Suite 850, Orange, CA, 92868, USA

    Mehraneh D. Jafari, Fariba Jafari, Monica T. Young, Brian R. Smith & Ninh T. Nguyen

  2. Department of Statistics, University of California, Irvine, Irvine, CA, USA

    Michael J. Phalen

Authors
  1. Mehraneh D. Jafari
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Fariba Jafari
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Monica T. Young
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Brian R. Smith
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Michael J. Phalen
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ninh T. Nguyen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ninh T. Nguyen.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Jafari, M.D., Jafari, F., Young, M.T. et al. Volume and outcome relationship in bariatric surgery in the laparoscopic era. Surg Endosc 27, 4539–4546 (2013). https://doi.org/10.1007/s00464-013-3112-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-013-3112-3

Keywords

Search

Navigation