metricas
covid
Buscar en
Cirugía Española (English Edition)
Toda la web
Inicio Cirugía Española (English Edition) Quality Criteria in Bariatric Surgery: Consensus Review and Recommendations of t...
Journal Information
Vol. 95. Issue 1.
Pages 4-16 (January 2017)
Visits
9666
Vol. 95. Issue 1.
Pages 4-16 (January 2017)
Review article
Full text access
Quality Criteria in Bariatric Surgery: Consensus Review and Recommendations of the Spanish Association of Surgeons and the Spanish Society of Bariatric Surgery
Criterios de calidad en cirugía bariátrica: revisión de conjunto y recomendaciones de la Asociación Española de Cirujanos y de la Sociedad Española de Cirugía de la Obesidad
Visits
9666
Fátima Sabench Pereferrera,l,*, Eduardo Domínguez-Adame Lanuzab,l, Ainitze Ibarzabalc,l, María Socas Maciasd,l, Víctor Valentí Azcáratee,l, Amador García Ruiz de Gordejuelaf,l, Francisca García-Moreno Nisag,l, Jesús González Fernándezh,l, Ramón Vilallonga Puyi,l, Nuria Vilarrasa Garcíaj,l, Raquel Sánchez Santosk,l,
Corresponding author
raquelsanchezsantos@gmail.com

Corresponding author.
, Sociedad Española de Cirugía de la Obesidad (SECO)
a General and Digestive Surgery Department, University Hospital of Sant Joan, Pere Virgili Health's Institute, Faculty of Medicine, Reus (Tarragona), Spain
b Metabolic and Gastroesophageal Surgery Unit, Virgen de la Macarena University Hospital, Sevilla, Spain
c Clinical Institute of Digestive and Metabolic Diseases, Hospital Clínic de Barcelona, Barcelona, Spain
d General and Digestive Surgery Department, Bariatric and Gastroesophageal Surgery Innovation Unit, University Hospital Virgen del Rocío, Sevilla, Spain
e Department of Surgery, Bariatric and Metabolic Surgery, Clínica Universidad de Navarra, CIBER Pathophysiology of Obesity and Nutrition (CIBERobn), Carlos III Health's Institut, Health Research Institute of Navarra, Pamplona, Spain
f Bariatric Surgery Unit, Surgery Department, Bellvitge University Hospital, L’Hospitalet de Llobregat (Barcelona), Spain
g Surgery Department, Ramón y Cajal University Hospital, Madrid, Spain
h Metabolic, Bariatric and General Surgery Department, Asturias Medical Center, Oviedo, Spain
i Endocrine, Metabolic and Bariatric Surgery Unit, Center of Excellence for the EAC-BC, General Surgery Department, Vall d’Hebron University Hospital, Barcelona, Spain
j Endocrinology and Nutrition Department, Bellvitge University Hospital, L’Hospitalet de Llobregat (Barcelona), Spain
k General and Digestive Surgery Department, Complejo Hospitalario de Pontevedra, Pontevedra, Spain
l Section of Morbid Obesity, Spanish Association of Surgeons, Spain
Ver más
This item has received
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Figures (1)
Tables (4)
Table 1. Main Indicators With Objectives and Recommendations.
Table 2. Summary of the Recommendations by the Morbid Obesity Division of the AEC and SECO.
Table 3. Specific Morbidity for Gastric Banding and Vertical Sleeve Gastrectomy Procedures.
Table 4. Specific Morbidity for Roux-en-Y Gastric Bypass According to the Type of Suture Used.
Show moreShow less
Abstract

Bariatric surgery has proven to be highly effective in controlling obesity and metabolic syndrome; the results of this surgery are not only expressed in terms of weight loss, but also in terms of resolution of comorbidities, improved quality of life and complications. The different parameters used to measure these outcomes require uniformity and reference patterns. Therefore, it is essential to identify those indicators and quality criteria that are helpful in defining the “best practice” principles in bariatric surgery. In this regard, the Section of Obesity of the Spanish Association of Surgeons, in collaboration with the Spanish Society for Bariatric Surgery (SECO), present as an objective to identify the key points that define “quality” in this type of surgery. We describe the main indicators based on the published literature as well as the criteria for referral of the main comorbidities according to the evidence found and grades of recommendation.

Keywords:
Quality criteria
Bariatric surgery
Recommendations
Resumen

La cirugía bariátrica ha demostrado ser muy eficaz en el control de la obesidad y el síndrome metabólico. Sus resultados no solo se expresan en términos de pérdida de peso, sino también en la resolución de comorbilidades, mejoría de la calidad de vida y de las complicaciones derivadas. Los diferentes parámetros utilizados para medir estos resultados requieren de una uniformidad y de unos patrones de referencia. Por ello, es fundamental establecer cuáles son los indicadores y los criterios de calidad que definen las «buenas prácticas» en cirugía bariátrica. En este sentido, la Sección de Obesidad de la Asociación Española de Cirujanos (AEC), en colaboración con la Sociedad Española de Cirugía de la Obesidad (SECO), se plantea como objetivo identificar los puntos clave que definen la calidad en este tipo de cirugía. Para ello se describen los principales indicadores basados en la literatura publicada, así como los criterios de remisión de las principales comorbilidades según las evidencias encontradas y sus grados de recomendación.

Palabras clave:
Criterios de calidad
Cirugía bariátrica
Recomendaciones
Full Text
Introduction

Bariatric surgery has been shown to be effective for controlling morbid obesity and metabolic syndrome, with a clear superiority over medical treatments.1,2 It is essential to establish quality criteria to define “good practice” in bariatric surgery in order to be able to compare results and know if we are offering effective surgical treatment. Taking into account that the loss of patient follow-up is the main limiting factor in the evaluation of results, there should be a minimum follow-up of 60% for at least 5 years according to the International Bariatric Surgery Registry and the Standards Committee.3 The Obesity Division of the Asociación Española de Cirujanos (Spanish Association of Surgeons, AEC) in collaboration with the Sociedad Española de Cirugía de la Obesidad (Spanish Society of Obesity Surgery, SECO) has proposed identifying the key points that define the quality of bariatric surgery.

Based on the published literature, the objective of this article is to describe current quality indicators and a minimum threshold required in clinical practice, as well as criteria for remission of the main comorbidities.

MethodsSearch

A bibliographic search was conducted by groups of 2 members of the AEC Morbid Obesity Division, using 3 bibliographic databases (Pubmed, Scopus and Web of Science) with the keywords “bariatric surgery and weight loss results/excess weight loss”, “bariatric surgery and comorbidities/diabetes mellitus/cholesterol/dyslipidaemia/obstructive apnea/hypertension”, “bariatric surgery and morbidity/complications”, “bariatric surgery and mortality”, “bariatric surgery and revisional surgery”, “bariatric surgery and standards” and “bariatric surgery and quality of life”. The members considered articles in both English and Spanish that had been published between 2005 and 2015. Articles were classified by subject areas and reviewed by division members, who initially decided to include or exclude them according to the information that answered the key questions raised. Subsequently, two supervisory members assessed the included articles and confirmed their inclusion/exclusion. Articles were excluded if they provided no specific numerical data or clinical cases, and type 2++ studies were accepted as a minimum level of evidence (cohort studies or well-conducted case–control studies with low risk of bias according to the Scottish Intercollegiate Guidelines Network4 [SIGN] scale). Quality standards were then defined based on the evidence found, as well as their levels of evidence and grades of recommendation.

Selection

Initially, 5423 references were identified, from which 312 articles were selected related to weight, 699 articles about comorbidities, 564 on quality of life, 30 on revision surgery, 30 on mortality and 34 about postoperative complications. The final selection of articles and their distribution are shown in Fig. 1. The figures provided in the standards or indicators are the same as those found during the review process.

Fig. 1.

Article selection algorithm.

(0.17MB).
Results

Table 1 summarizes the main quality indicators, objectives and grades of recommendation. In the case of comorbidities, the indicators are substituted by the remission criteria. Table 2 compiles the summary of the recommendations.

Table 1.

Main Indicators With Objectives and Recommendations.

  Indicators  Objectives  Levels of evidence and grades of recommendation 
Weight  %EWL: percentage of excess weight loss (initial weight−final weight)/(initial weight−ideal weight)
%EBMIL: percentage of excess BMI lost (initial BMI−current BMI/initial BMI−25)×100
BMIexp=0.33BMIinitial+14
For everyday office visits and to provide patients with approximations
Expected percentage of excess BMI loss: [BMIinitial−BMIfinal/BMIinitial−(0.33 BMIinitial+14)]×100
At the individual clinical level and to compare series
Use of the percentage of total weight loss. %TWL: (initial weight−current weight/initial weight)×100
For the comparison and publication of results 
>50% within one year of surgery
>50% within one year of surgery
>100% within 2 years of surgery
≥40% within 2 years in GBP; use percentile tables 
1−/A/√1 
DM2a  Complete remission: HbA1c ≤6% and normalized fasting glucose (100mg/dL), without medication for at least one year
Partial remission: HbA1c 6%–6.5% and fasting glucose from 100 to 125mg/dL), without medication
Prolonged remission: at least 5 years of remission. Improved HbA1c <7%, with pharmacological treatment
(American Diabetes Association criteria) 
>60% with complete remission (1–5 years after surgery)  1−/A/√1 
HTNa  Complete remission: BP <120/80, without medication
Partial remission: systolic BP 120–140mmHg and diastolic BP 80–89mmHg, without medication 
Resolution of HTN, either with or without reduction of coadjuvant treatment, in all surgical procedures within 2 years of follow-up at a minimal percentage of 70%  2++/B/√1 
Dyslipidemiaa  cLDL <100mg/dL, TG <150mg/d, total cholesterol <200mg/dL, cHDL >60mg/dL  Resolution of hypercholesterolemia and hypertriglyceridemia, either with or without reduced coadjuvant treatment, in all surgical procedures within 2 years of follow-up at a minimum percentage of 70%  2++/B/√1 
Obstructive sleep apnea syndrome  Number of apneic-hypopnea episodes/hour, recorded by polysomnography  Normal polysomnography (<5events/h) at least in 25% of patients with OSAS at least one year after surgery  2++/B/√1 
Metabolic syndromeb  Visceral obesity with increased waist circumference ≥102cm in ♂ and ≥88cm in ♀
Elevated triglycerides (>150mg/dL)
HDL cholesterol <40mg/dL in ♂ and <50mg/dL in ♀
Elevated systolic blood pressure >130, or diastolic >85mmHg
Fasting glucose >100mg/dL 
Minimum goals for good metabolic control (with/without active coadjuvant treatment):
HbA1c <7%, cLDL <100mg/dL, triglycerides <150mg/dL, cHDL >40mg/dL ♂ or >50mg/dL ♀ and BP <140/80mmHg 
2012 SECO/SEEDO consensus
4/D/√1 
Mortality  • Number of deaths/number of surgical patients×100  <0.5%  2−/B/√1 
Morbidity  Postoperative complications: (patients with postoperative complications/surgical patients)×100  General <10%
Recommended limit for PE: <1.5%
Recommended limit for fistulas <4%
Recommended limit for internal hernias <3%
Specific by technique: see Tables 3 and 4 
1−/A/√1 
Quality of life  Complete BAROS test (Bariatric Analysis and Reporting Outcome System), Moorehead-Ardelt Quality of Life instrument (MAQOL)  Score >6 (1–5 years after surgery)  2−/B/√1 
Revision surgery  Percentage of deferred reoperations due to a lack of excess weight loss or quality of life  <2% annually  2−/B/√1 
a

Resolution criteria.

b

Diagnostic criteria.

Table 2.

Summary of the Recommendations by the Morbid Obesity Division of the AEC and SECO.

-It is recommended that bariatric surgeons complete the specific training programs promoted and supervised by the Spanish Association of Surgeons (Asociación Española de Cirujanos, AEC) and the Spanish Society of Obesity Surgery (Sociedad Española de Cirugía de la Obesidad, SECO) or other duly certified organisms. 
-A multidisciplinary approach to patient treatment is necessary: surgeon, anesthesiologist, endocrinologist, nutritionist, psychologist, etc. 
-The use of specific scales to predict risk of mortality is recommended before surgery. 
-It is necessary to incorporate the systematic use of the percentage of total weight loss (%TWL) to express the results of the weight loss, in addition to traditional indicators. These values should be included in the percentile tables for reference values. The use of expected BMI may be useful in everyday clinical practice. 
-The use of official resolution criteria (ADA, ASBMS and 2012 SECO-SEEDO Consensus) is recommended for expressing and publishing results in terms of comorbidities. 
-It is recommended to systematically record and analyze data on early- and late-onset complications, as well as mortality. 
-Specific quality-of-life tests are recommended, to be used before and after bariatric surgery. 
-Systematic, detailed follow-up is necessary for all comorbidities, as well as polysomnography follow-up studies after surgery in patients who are also affected by OSAS. 
-Bariatric revision surgery should be performed by experienced bariatric surgeons and at expert or certified institutions (with a recommended minimum of 50 cases per year, in accordance with criteria of the European Accreditation Council for Bariatric Surgery). 
DiscussionQuality Standards of Weight Loss: Weight Loss Should Be Measured Through Existing New Tools, Which Minimize the Bias Involved in Using the Initial Body Mass Index

Complete weight normalization is not an essential condition for achieving a significant improvement in health.5 Some authors argue that the improvement of comorbidities and social repercussions are more important than the quantification of weight loss.6 In 1981, it was proposed to use the percentage of excess weight loss (%EWL) to quantify the outcome of bariatric surgery, putting the success limit at 50% EWL.7,8 In 1997, Baltasar et al.9 proposed considering body mass index (BMI) associated with the %EWL to classify the results. In 2004, the concept of percentage of excess BMI lost (%EBMIL)10 was introduced. In 2013, the meta-analysis by Courcoulas et al.11 analyzed the results of 161756 patients, in terms of %EWL, for up to 5 years of follow-up, with an initial mean BMI of 45.5kg/m2. One year after surgery, the estimated %EWL for gastric bypass (GBP) ranged from 63% to 72% and from 51% to 69% for vertical sleeve gastrectomy (VSG). After 2 years, the %EWL for GBP was 74%–80% vs 42%–50% for VSG. After the fourth and fifth years, the variability in the GBP increased (59%–93% and 44%–85%, respectively), with insufficient data for VSG. The Spanish VSG registry12 obtained, one year after surgery, a %EBMIL of 78% for a BMI <40kg/m2, 75% for a BMI between 40 and 49kg/m2, 55% for a BMI between 50 and 59kg/m2 and 67% for a BMI >60kg/m2. Three years after surgery, %EBMIL results were close to 100% in BMI <40kg/m2, while for BMI >40kg/m2 the range was between 60% and 78%.

Regarding biliopancreatic diversion (BPD) with duodenal switch (DS), the results of Nelson et al.13 reported a %EWL of 79% 2 years after surgery in patients with a BMI >50kg/m2, which is comparable to the results published by Buchwald et al.14 Also, VSG with duodenoileal bypass (SADIs) offered a %EWL of 94.7% one year after surgery.15

However, there are other ways to express weight loss. Along these lines, the Bariatric Outcomes Longitudinal Database (BOLD)16 in 2012 postulated that the most homogeneous value with the least variability is the percentage of total weight loss in kg (%TWL)=(initial weight−current weight/initial weight)×100.17 Several studies have already published their results in this manner, with values of −44% for BPD-DS and −34% for GBP at the 2-year follow-up,18 or −33.5% after 5 years.19 The %TWL allows for comparisons between series, while avoiding the bias of the initial BMI, and can be represented graphically in tables of percentiles created from the data of different series. It is difficult for a super-obese individual (BMI >50kg/m2) to reach a BMI of 25kg/m2 after surgery: it seems reasonable to set a more realistic limit to rationalize their expectations. In this context, Baltasar et al.20 propose the term of expected BMI (BMIexp=0.33BMIinitial+14), calculated by linear regression and eliminating the cut-off point of 25 as a constant. The formula applied for the EBMI is: [BMIinitial−BMIfinal/BMIinitial−(0.33BMIinitial+14)]×100. The result is classified as excellent if ≥100% and improvable if ≤100%. Subsequently, Baltasar has adjusted the constants for each surgical technique. Thus, there is a different formula for each, so series and surgical techniques can be compared more precisely.21

Quality Standards for the Resolution of Comorbidities: the Resolution of Comorbidities Should Be Collected, Analyzed and Reported According to the Official Resolution Criteria of the Scientific Societies Involved

Bariatric surgery significantly resolves obesity-related comorbidities and improves long-term morbidity and mortality.22,23 As early as 2004, Buchwald et al.24 described the resolution of comorbidities according to the different techniques in their meta-analysis that has been widely discussed in the scientific community.

Type 2 Diabetes Mellitus

According to a review published by the Cochrane Library,25 the remission rate of type 2 diabetes mellitus (DM2) depends on the type of surgery. For BPD, it is about 95% and 57% for gastric banding (GB), without sufficient long-term data for VSG. In 2009, Buchwald14 focused on the resolution of DM2 with an overall remission rate of 78%, which remained stable after 2 years at 62%. The highest resolution was obtained with BPD (95.1%), followed by GBP (80.3%), vertical banded gastroplasty (79.7%) and GB (56.7%). A recent meta-analysis published remission rates of 60.8% for VSG.26 With the SADIs technique, complete resolution is described in 75% of patients 3 years after surgery in patients treated with oral antidiabetics and 38.4% in patients receiving insulin.27 The most recently reported global remission rates are lower than previously reported in the literature: it is estimated that 60% of patients achieve remission within the first 5 years after surgery, as indicated by several clinical trials and meta-analyses.28–33 There are differences depending on the criteria used to consider diabetes resolved or not. Because of this variability, which has been recently demonstrated,34 it is recommended to use the criteria of the American Diabetes Association (ADA) exclusively (Table 1).35

Arterial Hypertension and Cardiovascular Risk

A good scale for measuring cardiovascular risk in the Western world is the Framingham risk score,36 although in Spain there are other scales adapted to our population, such as REGICOR, which is based on a lower cardiovascular risk than the Anglo-Saxon world.37 The estimated risk of coronary heart disease after GBP drops from 11% to 5% in men and 6% to 3% in women for both the diabetic and non-diabetic populations.38,39 After GBP, the resolution or improvement of arterial hypertension (HTN) ranges between 61% and 78.5% of patients at the 2-year follow-up, even in patients ≥55 years of age.40 In the SOS study,41 however, during the early years of follow-up there is a rebound of this disease, with 13.2% of patients relapsing into hypertension. Subsequently, the same study shows that restrictive techniques exert a transient effect on hypertension, whereas GBP is associated with more sustained reductions and even with increased daily diuresis.42 There are studies that indicate that vitamin D deficiency after surgery plays an important role in the development of hypertension: patients with vitamin supplementation resolve HTN more effectively than non-supplemented patients.43,44 Remission criteria are defined according to recently published standards by Brethauer et al.45 of the American Society for Bariatric and Metabolic Surgery (ASBMS) (Table 1).

Dyslipidemia

Several studies analyze the improvement of dyslipidemia after surgery.46 One year after GBP, antidiabetic, antihypertensive and hypolipidemic medication was decreased by 76%, 51% and 59%, respectively.47 These results contrast with initial data from the SOS study,41 in which no differences were found in total cholesterol levels between the control patients and surgically treated patients after 10 years (except for the group treated with GBP). Afterwards, dyslipidemia was observed to normalize and continue to be stable after 10 years in 69.7% of the patients treated surgically, compared to 22% of the non-surgical patients.48 In the Buchwald meta-analysis,24 the lipid profile significantly improved in all the surgical procedures at the 2-year follow-up in a minimum percentage of 70%, with maximum improvements for BPD-DS (99.1%) and GBP (96.9%). The resolution criteria were those defined by Brethauer et al.45 (Table 1).

Metabolic Syndrome

Metabolic syndrome encompasses a set of risk factors that relate to cardiovascular disease and diabetes. For its definition, the criteria published by Alberti et al.49 are used (1: visceral obesity with increased waist circumference ≥102cm in ♂ and ≥88cm in ♀; 2: elevated triglycerides [>150mg/dL]; 3: HDL cholesterol <40mg/dL in ♂ and <50mg/dL in ♀; 4: elevated systolic arterial pressure >130 or diastolic >85mmHg; 5: fasting glucose >100mg/dL). The minimum follow-up goal after surgery is defined by the approved criteria in the SECO/SEEDO 2012 Consensus50 (Table 1).

Obstructive Sleep Apnea Syndrome

Several studies have demonstrated that weight loss due to bariatric surgery improves obstructive sleep apnea syndrome (OSAS), even in the long term.51 The diagnosis is made with ≥5 apneas or hypopneas/hour.52 The prevalence ranges in obese individuals vary from 55% to 100%, depending on whether all patients are evaluated or exclusively those with symptoms.24 Buchwald et al.24 show a significant improvement in the series analyzed of 85.7%. However, Greenburg et al.53 determine that residual disease continues to exist in the majority of older and more obese patients and only 23% meet resolution criteria. The lack of “daytime sleepiness” does not indicate OSAS resolution.54 Therefore, routine diagnostic tests including polysomnography should be carried out when a stable weight is reached (after the first year, at least).

Mortality Standards in Bariatric Surgery: Currently Mortality Should Be Less Than 0.5%

In 1991, the accepted mortality rate ranged from 0.5% to 1.5%.55 Currently, it is close to 0% thanks to laparoscopic procedures, training programs and multidisciplinary patient management.56 Recent publications of the Longitudinal Assessment of Bariatric Surgery Consortium data or the Bariatric Outcome Longitudinal Database (BOLD), among others, confirm that the mortality rate is below 0.5%.57–63 This is an acceptable rate, considering that long-term mortality in non-operated morbid obese patients is greater than 6%.64 In 2011, mortality from this cause was analyzed specifically, and the overall 30-day mortality rate was 0.3%.65 The most frequent cause of death was multiple organ failure due to sepsis (33%), followed by cardiac pathologies (28%) and pulmonary embolism (17%). Abdominal sepsis, especially when associated with anastomotic leakage, continues to be a challenge in this type of patients.66,67 Mortality is variable and depends on the experience of the surgical group, which reinforces the importance of the learning curve.68 Mortality during the learning curve of training programs is 0.57% for surgeons with no specific training and 0% for those who are trained, with a reduction in complications from 18% to 7.7% in surgeons who are well trained.69 A mortality rate of 5% has been recorded in groups that perform less than 10 procedures/year and 0.2% in groups with large patient volumes.70,71 Mortality is also influenced by the approach used and patient sex (0.30% in open surgery vs 0.07% in laparoscopic surgery; 4.74% ♂ vs 0.13% ♀).72 The surgical technique itself is an independent risk factor: mortality rates are reported at less than 0.3% for GB73 0.4% for GBP.74–76 Similarly, the Spanish VSG registry12 situates the rate at 0.36%, which is in line with other groups with extensive experience.

There are several predictive scales for risk of mortality that stratify patients into subgroups. Such tools have shown increased rates of complications, reoperations and mortality when certain factors are present.77 These scales are the Obesity Surgery Mortality Risk Score (which contemplates BMI >50kg/m2, age >45 years, male sex, HTN and risk of pulmonary embolism [PE]),78 the Longitudinal Assessment of Bariatric Surgery (LABS) Consortium Study (which contemplates extreme obesity, history of thromboembolism, presence of OSAS and inability to walk 60m)79 and the Metabolic Acuity Score (which adds DM and psychological factors to the previous scores).80

Morbidity Standards in Bariatric Surgery: Recording and Analyzing Complications Is Mandatory at Hospitals Where This Type of Surgery is Performed

In the postoperative period, we refer to early morbidity (<30 days: PE, leaks and hemorrhages) or late morbidity (>30 days: marginal ulcers, stenosis and internal hernias). Currently, the overall early morbidity rate is below 7% in centers with more extensive experience.81,82 The complication rate was influenced by the surgical technique, with a higher rate of major complications in GBP (2.5%–3.6%) compared to the VSG (2.2%–2.4%) and, finally, compared to GB (0.9%–1%).82 Morbidity is also related to the volume of procedures performed, both by the hospital in general as well as by the specific surgeon. The performance of fewer procedures has been identified as a risk factor (morbidity at hospitals with <150 patients: 4.1%; 150–300 patients: 2.7%; >300 patients: 2.3%), although no differences were found depending on whether the hospital was a certified “center of excellence” in bariatric surgery.82,83

As a general complication, the incidence of thromboembolic disease varies widely, ranging from 0%84 to 3.5%.85 An incidence of 0.9% has been reported for PE, 1.3% for deep vein thrombosis and 2.2% for thrombosis associated with PE.86 As for surgical wounds, the open approach has an associated risk of seromas of approximately 40%, with a risk for incisional hernias of 32%.87,88 The percentage of incisional hernias through trocar wounds is 0.57%.89 With regard to the risk of developing internal hernias, there is consensus on its reduction if an antecolic gastric bypass is created, and it is recommended to close all defects with non-absorbable sutures.90–92 Its late diagnosis can lead to perforation of the herniated loop and, consequently, the death of the patient.93 The incidence of internal hernias published in cases of laparoscopic GBP had reached 10%,94 although currently the incidence has been reduced to 0.2%, which has probably been influenced by the non-division of the small bowel mesentery.95–97 The specific morbidity according to the surgical technique is summarized in Tables 3 and 4. The overall risk of bleeding after GBP ranges from 0.94% to 4.4%, which usually occurs in most cases in the immediate postoperative period as a consequence of hemorrhage at the anastomoses, staple lines, dissection of the mesentery or visceral lesions.98,99

Table 3.

Specific Morbidity for Gastric Banding and Vertical Sleeve Gastrectomy Procedures.

Gastric banding147,148  Sleeve gastrectomy 
Dilatations of the pouch: 6.4%
Problems with trocar wounds: 5.9%
Erosion: 0.8%
Band withdrawal: 2.2%
Re-operations (all-cause): 11% with initial BMI >40kg/m2
Re-operations (all-cause): 2.6% with initial BMI 35–39kg/m2 
• Stenosis: 0.1%–3.9% (angular incisure)149–151
• Leakage (++ angle of His): 0%–3.9%152,153
• Staple-line hemorrhage: 0%–9%154,155
• Gastroesophageal reflux: 4.7%–39%156 
Table 4.

Specific Morbidity for Roux-en-Y Gastric Bypass According to the Type of Suture Used.

Complications of the GBP and suture types, in %
  Manual157,158  Mechanical linear159  Circular 25mm/21mm160–162
Suture dehiscence  0.22–1  0–6.8  0–6.6
Hemorrhage of the anastomosis  0.4–0.6  1–9.7  1.6–6.6
Marginal ulcers  0.82–1.4  0–7.9  2.5–7.6   
Stenosis  0.17–4.9  0–10  2.6–8.7  9.4–26.8 

GBP: Roux-en-Y gastric bypass.

Quality of Life Indicators in Bariatric Surgery: Quality of Life Should Be Measured by Specific Tests Before and After Surgery

Bariatric surgery improves quality of life, with changes that are maintained in the long term.100,101 Several instruments are available to assess quality of life102; the most widely used are the Bariatric Analysis and Reporting Outcome System (BAROS),103 Moorehead-Ardelt Quality of Life instrument (MAQOL),104 Impact of Weight on Quality of Life (IWQOL),105 36-Short Form Health Survey (SF-36)106 and the Nottingham Health Profile (NHP).105 Several studies have confirmed a very significant improvement in quality of life after GBP, both one and 5 years after surgery and at different BMI categories.107–109 Patients with a lower BMI prior to surgery correlate with better scores in BAROS and MAQOL-II.110 With regard to long-term follow-up (>6 years), Himpens et al.111,112 demonstrate high satisfaction levels after GBP and VSG (despite the latter having an incidence of 23% of gastroesophageal reflux). Other studies show that, after VSG, a PSP >50% correlates with better scores in areas related to physical function and general health perception within the SF-36 test.113 There are comparative studies on the quality of life for VSG vs GBP and BPD vs GB, with similar results.114,115 Differences have been found between the VSG technique vs GB (in favor of VSG) in the Bariatric Quality of Life (BQL) telephone survey.116 Often the results do not correlate with what is medically desirable and patient expectations: in the case of weight, there are publications that situate the ideal weight desired by patients at a weight equivalent to an EWL of 90%, which makes one realize that their expectations are an important factor to take into account in the overall score of these tests.117

Quality Indicators in Bariatric Revision Surgery: Revision Surgery Should Be Performed at Hospitals With Extensive Experience in Bariatric Surgery

Revision surgery is performed when an initial bariatric procedure has failed or has caused intolerable sequelae. Over the years, several failure criteria have been defined based on final weight, but we can also affirm that there is a failure when the comorbidities related to early mortality cannot be controlled.10 The causes of failure are related to the surgical technique selected, multidisciplinary bariatric team, correct patient selection and follow-up, and the patient's inability to follow a proper diet.118–123 The standards published by Baltasar et al.9 contemplate an annual percentage below 2%; however, as the volume of primary surgeries increases, this percentage increases. There have been reports of series with reoperation rates from 5% to 56%.124–126 Revision surgery is technically complex and is generally associated with higher risk than primary procedures,127,128 and there appears to be no standardized surgical approach.129 Although traditionally performed by laparotomy, today there is a growing tendency to use a laparoscopic approach.130,131 Laparoscopic revision surgery can be conducted safely if performed by experienced bariatric surgeons at hospitals with a high volume of bariatric and laparoscopic surgeries.129,132–135 The restrictive procedures that most frequently require revision surgery due to insufficient weight loss are vertical banded gastroplasty (25%–54%) and GB (40%–50%), most of which are converted to GBP.136,137 Despite the success of primary GBP, between 10% and 20% of patients have a lack of adequate weight loss or regain weight.138–140 The latest published series describe 5- and 13-year reoperation rates between 8.1% and 9%, respectively.141,142 In VSG, published results are based on complications such as gastroesophageal reflux or stenosis, and rates between 2% and 10% are described.143 Conversion from VSG to BPD-DS is not considered revision surgery in the publications found.144 Furthermore, in cases of insufficient weight loss, many authors perform the second surgery with GBP and not the theoretical secondary procedure (DS), which presents more complications than GBP.145 Revision surgery can present complications of up to 14% and a mortality rate of 0.86%.146 Follow-up periods of more than 5 years are required to evaluate its efficacy.

Limitations

This study is the result of joint collaboration between different members of the scientific societies represented. The main aim was to identify objective indicators and minimum quality criteria in the overall context of bariatric surgery. Our intention was not to make a systematic comparison between the different surgical techniques, so that specific recommendations for each cannot be extrapolated with sufficient scientific analysis and rigor. Undoubtedly, this represents a future challenge for our work within the Spanish scientific societies.

Conclusions

Advances in technology, better training of multidisciplinary teams and simplification of laparoscopic surgical techniques have made bariatric surgery one of the safest and most effective procedures, but this efficacy and safety must be verified based on minimum required results. Existing clinical practice guidelines do not always include strict criteria, hence the establishment of quality standards and recommendations is very useful to serve as a basis for the continuous improvement of care provided by all professionals dedicated to the treatment of morbid obesity. Determining how the results fit within a defined framework also undoubtedly benefits patients, and the use of objective tools in daily clinical practice will also help us rationalize expectations in this type of surgery.

Authorship/collaborations

Design, data collection and composition of the article: Fátima Sabench Pereferrer, Eduardo Domínguez-Adame Lanuza, Ainitze Ibarzabal Olano, María Socas Macias and Víctor Valentí Azcárate

Review of the results: Amador García Ruiz de Gordejuela and Francisca García-Moreno Nisa, Jesús González Fernández, Ramón Vilallonga Puy and Nuria Vilarrasa García

Critical review of the manuscript: Raquel Sánchez Santos and Fátima Sabench Pereferrer

Institutional results and review: Asociación Española de Cirujanos (Spanish Association of Surgeons, AEC) and Sociedad Española de Cirugía de la Obesidad (Spanish Society of Obesity Surgery, SECO).

Conflict of Interests

The authors have no conflicts of interests to declare.

References
[1]
G. Mingrone, S. Panunzi, A. De Gaetano, C. Guidone, A. Iaconelli, G. Nanni, et al.
Bariatric-metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre, randomized controlled trial.
[2]
A.P. Courcoulas, S.H. Belle, R.H. Neiberg, S.K. Pierson, J.K. Eagleton, M.A. Kalarchian, et al.
Three-year outcomes of bariatric surgery vs lifestyle intervention for type 2 diabetes mellitus treatment: a randomized clinical trial.
JAMA Surg, 150 (2015), pp. 931-940
[3]
The Committee on Standards.
Standards for reporting results.
Obes Surg, 4 (1994), pp. 56-65
[4]
R. Harbour, J. Miller, for the Scottish Intercollegiate Guidelines Network Grading Review Group.
A new system for grading recommendations in evidence based guidelines.
BMJ, 323 (2001), pp. 334-336
[5]
M. Deitel.
How much weight loss is sufficient to overcome major co-morbidities?.
[6]
S. Biron, F.S. Hould, S. Lebel, S. Marceau, O. Lescelleur, S. Simard, et al.
Twenty years of biliopancreatic diversion: what is the goal of the surgery?.
Obes Surg, 14 (2004), pp. 160-164
[7]
J.D. Halverson, R.E. Koehler.
Gastric bypass: analysis of weight loss and factors determining success.
Surgery, 90 (1981), pp. 446-455
[8]
G.W. Lechner, D.W. Elliot.
Comparison of weight loss after gastric exclusion and partitioning.
Arch Surg, 118 (1983), pp. 685-692
[9]
A. Baltasar, R. Bou, J. del Río, M. Bengochea, C. Escrivá, J. Miró, et al.
Cirugía bariátrica: resultados a largo plazo de la gastroplastia vertical anillada. ¿Una esperanza frustrada?.
Cir Esp, 62 (1997), pp. 175-179
[10]
A. Larrad, C. Sanchez-Cabezudo.
Indicadores de calidad en cirugía bariátrica y criterios de éxito a largo plazo.
Cir Esp, 75 (2004), pp. 301-304
[11]
A.P. Courcoulas, N.J. Christian, S.H. Belle, P.D. Berk, D.R. Flum, L. Garcia, et al.
Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity.
[12]
R. Sánchez-Santos, C. Masdevall, A. Baltasar, C. Martínez-Blázquez, A. García Ruiz de Gordejuela, E. Ponsi, et al.
Short and mid-term outcomes of sleeve gastrectomy for morbid obesity: the experience of the Spanish National Registry.
Obes Surg, 19 (2009), pp. 1203-1210
[13]
D.W. Nelson, K.S. Blair, M.J. Martin.
Analysis of obesity-related outcomes and bariatric failure rates with the duodenal switch vs gastric bypass for morbid obesity.
Arch Surg, 147 (2012), pp. 847-854
[14]
H. Buchwald, R. Estok, K. Fahrbach, D. Banel, M.D. Jensen, W.J. Pories, et al.
Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis.
Am J Med, 122 (2009), pp. 248-256
[15]
A. Sánchez-Pernaute, Rubio MÁ, L. Cabrerizo, A. Ramos-Levi, E. Pérez-Aguirre, A. Torres.
Single-anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) for obese diabetic patients.
Surg Obes Relat Dis, 11 (2015), pp. 1092-1098
[16]
A. Van de Laar.
Bariatric Outcomes Longitudinal Database (BOLD) suggests excess weight loss and excess BMI loss to be inappropriate outcome measures, demonstrating better alternatives.
Obes Surg, 22 (2012), pp. 1843-1847
[17]
A. Van de Laar, L. de Caluwé, B. Dillemans.
Relative outcome measures for bariatric surgery. Evidence against excess weight loss and excess body mass index loss from a series of laparoscopic Roux-en-Y gastric bypass patients.
Obes Surg, 21 (2011), pp. 763-767
[18]
R.B. Dorman, N.F. Rasmus, B.J. Al-Haddad, F.J. Serrot, B.M. Slusarek, B.K. Sampson, et al.
Benefits and complications of the duodenal switch/biliopancreatic diversion compared to the Roux-en-Y gastric bypass.
Surgery, 152 (2012), pp. 758-765
[19]
L. Angrisani, A. Santonicola, A. Hasani, G. Nosso, B. Capaldo, P. Iovino.
Five-year results of laparoscopic sleeve gastrectomy: effects on gastroesophageal reflux disease symptoms and co-morbidities.
Surg Obes Relat Dis, 26 (2015), pp. S1550-S7289
[20]
A. Baltasar, C. Serra, R. Bou, M. Bengochea, N. Perez, F. Borrás, et al.
Índice de masa corporal esperable tras cirugía bariátrica.
Cir Esp, 85 (2009), pp. 308-312
[21]
A. Baltasar, N. Perez, C. Serra, R. Bou, M. Bengochea, F. Borrás.
Weight loss reporting: predicted body mass index after bariatric surgery.
Obes Surg, 21 (2011), pp. 367-372
[22]
L. Sjöström, K. Narbro, C.D. Sjöström, K. Karason, B. Larsson, H. Wedel, et al.
Effects of bariatric surgery on mortality in Swedish obese subjects.
N Engl J Med, 357 (2007), pp. 741-752
[23]
N.V. Christou, J.S. Sampalis, M. Liberman, D. Look, S. Auger, A.P. McLean, et al.
Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients.
Ann Surg, 240 (2004), pp. 416-423
[24]
H. Buchwald, Y. Avidor, E. Braunwald, M.D. Jensen, W. Pories, K. Fahrbach, et al.
Bariatric surgery: a systematic review and meta-analysis.
JAMA, 292 (2004), pp. 1724-1737
[25]
J.L. Colquitt, J. Picot, E. Loveman, A.J. Clegg.
Surgery for obesity.
Cochrane Database Syst Rev, 2 (2009), pp. CD003641
[26]
N.J. Switzer, S. Prasad, E. Debru, N. Church, P. Mitchell, R.S. Gill.
Sleeve gastrectomy and type 2 diabetes mellitus: a systematic review of long-term outcomes.
Obes Surg, 26 (2016), pp. 1616-1621
[27]
A. Sánchez-Pernaute, M.A. Herrera, M.E. Pérez-Aguirre, P. Talavera, L. Cabrerizo, P. Matía, et al.
Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S). One to three-year follow-up.
Obes Surg, 20 (2010), pp. 1720-1726
[28]
D. Arterburn, A. Bogart, K.J. Coleman, S. Haneuse, J.V. Selby, N.E. Sherwood, et al.
Comparative effectiveness of bariatric surgery vs nonsurgical treatment of type 2 diabetes among severely obese adults.
Obes Res Clin Pract, 7 (2013), pp. e258-e268
[29]
G. Mingrone, S. Panunzi, A. De Gaetano, C. Guidone, A. Iaconelli, G. Nanni, et al.
Bariatric-metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre, randomised controlled trial.
[30]
C. Ricci, M. Gaeta, E. Rausa, E. Asti, F. Bandera, L. Bonavina.
Long-term effects of bariatric surgery on type II diabetes, hypertension and hyperlipidemia: a meta-analysis and meta-regression study with 5-year follow-up.
Obes Surg, 25 (2015), pp. 397-405
[31]
J.B. Dixon, C.W. le Roux, F. Rubino, P. Zimmet.
Bariatric surgery for type 2 diabetes.
Lancet, 379 (2012), pp. 2300-2311
[32]
S. Ikramuddin, C.J. Billington, W.J. Lee, J.P. Bantle, A.J. Thomas, J.E. Connett, et al.
Roux-en-Y gastric bypass for diabetes (the Diabetes Surgery Study): 2-year outcomes of a 5-year, randomised, controlled trial.
Lancet Diabetes Endocrinol, 3 (2015), pp. 413-422
[33]
P.R. Schauer, D.L. Bhatt, J.P. Kirwan, K. Wolski, S.A. Brethauer, S.D. Navaneethan, et al.
Bariatric surgery versus intensive medical therapy for diabetes – 3-year outcomes.
N Engl J Med, 370 (2014), pp. 2002-2013
[34]
A. Mas-Lorenzo, D. Benaiges, J.A. Flores-Le-Roux, J. Pedro-Botet, J.M. Ramon, A. Parri, et al.
Impact of different criteria on type 2 diabetes remission rate after bariatric surgery.
Obes Surg, 24 (2014), pp. 1881-1887
[35]
American Diabetes Association.
Standards of medical care in diabetes.
Diabetes Care, 36 (2013), pp. S11-S66
[36]
D.C. Goff Jr., D.M. Lloyd-Jones, G. Bennett.
2013 ACC/AHA. Guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
[37]
J.M. Baena Díez, J.L. del Val Garcia, L. Salas Gaetgens, R. Sánchez Pérez, E. Altes Vaques, B. Deixens Martínez, et al.
Comparison of the SCORE and REGICOR models for calculating cardiovascular risk in cardiovascular disease-free individuals at a healthcare center in Barcelona, Spain.
Rev Esp Salud Pública, 79 (2005), pp. 453-464
[38]
A. Torquati, K. Wright, W. Melvin, W. Richards.
Effect of gastric bypass operation on Framingham and actual risk of cardiovascular events in class II to III obesity.
J Am Coll Surg, 204 (2007), pp. 776-782
[39]
J.A. Vogel, B.A. Franklin, K.C. Zalesin, J.E. Trivax, K.R. Krause, D.L. Chengelis, et al.
Reduction in predicted coronary heart disease risk after substantial weight reduction after bariatric surgery.
Am J Cardiol, 99 (2007), pp. 222-226
[40]
J. Lynch, A. Belgaumkar.
Bariatric surgery is effective and safe in patients over 55: a systematic review and meta-analysis.
Obes Surg, 22 (2012), pp. 1507-1516
[41]
L. Sjöström, A.K. Lindroos, M. Peltonen, J. Torgerson, C. Bouchard, B. Carlsson, et al.
Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery.
N Engl J Med, 351 (2004), pp. 2683-2693
[42]
P. Hallersund, L. Sjöström, T. Olbers, H. Lönroth, P. Jacobson, V. Wallenius, et al.
Gastric bypass surgery is followed by lowered blood pressure and increased diuresis. Long term results from the Swedish Obese Subjects (SOS) study.
[43]
P. Anagnostis, V.G. Athyros, F. Adamidou, M. Florentin, A. Karagiannis.
Vitamin D and cardiovascular disease: a novel agent for reducing cardiovascular risk?.
Curr Vasc Pharmacol, 8 (2010), pp. 720-730
[44]
V.G. Athyros, K. Tziomalos, A. Karagiannis, D.P. Mikhailidis.
Cardiovascular benefits of bariatric surgery in morbidly obese patients.
[45]
S.A. Brethauer, J. Kim, M. el Chaar, P. Papasavas, D. Eisenberg, A. Rogers, ASMBS Clinical Issues Committee, et al.
Standardized outcomes reporting in metabolic and bariatric surgery.
Surg Obes Relat Dis, 11 (2015), pp. 489-506
[46]
S.F. Noria, T. Grantcharov.
Biological effects of bariatric surgery on obesity-related comorbidities.
Can J Surg, 56 (2013), pp. 47-57
[47]
J.B. Segal, J.M. Clark, A.D. Shore, F. Dominici, T. Magnuson, T.M. Richards, et al.
Prompt reduction in use of medications for comorbid conditions after bariatric surgery.
Obes Surg, 19 (2009), pp. 1646-1656
[48]
L. Delling, K. Karason, T. Olbers, D. Sjöström, B. Wahlstrand, B. Carlsson, et al.
Feasibility of bariatric surgery as a strategy for secondary prevention in cardiovascular disease: a report from the Swedish obese subjects trial.
J Obes, (2010),
pii:102341
[49]
K.G. Alberti, R.H. Eckel, S.M. Grundy, P.Z. Zimmet, J.I. Cleeman, K.A. Donato, et al.
Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; International Association for the Study of Obesity.
Circulation, 120 (2009), pp. 1640-1645
[50]
M.A. Rubio, S. Monereo, A. Lecube, J. Resa, C. Masdevall, F. de la Cruz Vigo, et al.
Joint Position Statement of the SEEN-SECO-SEEDO-SED Societies on metabolic surgery for type 2 diabetes mellitus.
Endocrinol Nutr, 60 (2013), pp. 547-548
[51]
G. Del Genio, P. Limongelli, F. Del Genio, G. Motta, L. Docimo, D. Testa.
Sleeve gastrectomy improves obstructive sleep apnea syndrome (OSAS): 5 year longitudinal study.
Surg Obes Relat Dis, 12 (2016), pp. 70-74
[52]
C.A. Kushida, M.R. Littner, T. Morgenthaler, C.A. Alessi, D. Bailey, J. Coleman Jr., et al.
Practice parameters for the indications for polysomnography and related procedures: an update for 2005.
Sleep, 28 (2005), pp. 499-521
[53]
D.L. Greenburg, C.J. Lettieri, A.H. Eliasson.
Effects of surgical weight loss on measures of obstructive sleep apnea: a meta-analysis.
Am J Med, 122 (2009), pp. 535-542
[54]
T. Young, L. Finn, P.E. Peppard, M. Szklo-Coxe, D. Austin, F.J. Nieto, et al.
Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort.
Sleep, 31 (2008), pp. 1071-1078
[55]
NIH conference. Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel.
Ann Intern Med, 115 (1991), pp. 956-961
[56]
N.T. Nguyen, J. Root, K. Zainabadi, A. Sabio, S. Chalifoux, C.M. Stevens, et al.
Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery.
Arch Surg, 140 (2005), pp. 1198-1202
[57]
J.F. Finks, K.L. Kole, P.R. Yenumula, W.J. English, K.R. Krause, A.M. Carlin, et al.
Predicting risk for serious complications with bariatric surgery: results from the Michigan Bariatric Surgery Collaborative.
Ann Surg, 254 (2011), pp. 633-640
[58]
P. Benotti, G.C. Wood, D.A. Winegar, A.T. Petrick, C.D. Still, G. Argyropoulos, et al.
Risk factors associated with mortality after Roux-en-Y gastric bypass surgery.
Ann Surg, 259 (2014), pp. 123-130
[59]
P.K. Gupta, C. Franck, W.J. Miller, H. Gupta, R.A. Forse.
Development and validation of a bariatric surgery morbidity risk calculator using the prospective, multicenter NSQIP dataset.
J Am Coll Surg, 212 (2011), pp. 301-309
[60]
N.T. Nguyen, H. Masoomi, K. Laugenour, Y. Sanaiha, K.M. Reavis, S.D. Mills, et al.
Predictive factors of mortality in bariatric surgery: data from the Nationwide Inpatient Sample.
Surgery, 150 (2011), pp. 347-351
[61]
M. Hutter, B. Schirmer, D. Jones, C. Ko, M. Cohen, R. Merkow, et al.
First report from the American College of Surgeons – Bariatric Surgery Center Network: Laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass.
Ann Surg, 254 (2011), pp. 410-422
[62]
T.D. Adams, T.S. Mehta, L.E. Davidson, S.C. Hunt.
All-cause and cause-specific mortality associated with bariatric surgery: a review.
Curr Atheroscler Rep, 17 (2015), pp. 74
[63]
A. Lazzati, E. Audureau, F. Hemery, A.S. Schneck, J. Gugenheim, D. Azoulay, et al.
Reduction in early mortality outcomes after bariatric surgery in France between 2007 and 2012: a nationwide study of 133,000 obese patients.
Surgery, 159 (2016), pp. 467-474
[64]
T.D. Adams, R.E. Gress, S.C. Smith, R.C. Halverson, S.C. Simper, W.D. Rosamond, et al.
Long-term mortality after gastric bypass surgery.
N Engl J Med, 357 (2007), pp. 753-761
[65]
M.D. Smith, E. Patterson, A.S. Wahed, S.H. Belle, P.D. Berk, A.P. Courcoulas, et al.
Thirty-day mortality after bariatric surgery: independently adjudicated causes of death in the longitudinal assessment of bariatric surgery.
Obes Surg, 21 (2011), pp. 1687-1692
[66]
A. Csendes, F. Maluenda.
Morbimortalidad de la cirugía bariátrica: experiencia chilena en 10 instituciones de salud.
Rev Chil Cir, 58 (2006), pp. 208-212
[67]
N. Nguyen, M. Silver, M. Robinson, B. Needleman, G. Hartley, R. Cooney, et al.
Result of a national audit of bariatric surgery performed at academic centers.
Arch Surg, 141 (2006), pp. 445-450
[68]
D. Flum, L. Salem, J. Elrod, E. Dellinger, A. Cheadle, L. Chan.
Early mortality among medicare beneficiaries undergoing bariatric surgical procedures.
JAMA, 294 (2005), pp. 1903-1908
[69]
R. Sánchez-Santos, S. Estévez, C. Tomé, S. González, A. Brox, R. Nicolás, et al.
Training programs influence in the learning curve of laparoscopic gastric bypass for morbid obesity: a systematic review.
Obes Surg, 22 (2012), pp. 34-41
[70]
A.Z. Fernandez Jr., E.J. Demaria, D.S. Tichansky, J.M. Kellum, L.G. Wolfe, J. Meador, et al.
Multivariate analysis of risk factors for death following gastric bypass for treatment of morbid obesity.
Ann Surg, 239 (2004), pp. 698-702
[71]
S.R. Markar, M. Penna, A. Karthikesalingam, M. Hashemi.
The impact of hospital and surgeon volume on clinical outcome following bariatric surgery.
Obes Surg, 22 (2012), pp. 1126-1134
[72]
H. Buchwald, R. Estok, K. Fahrbach, D. Banel, I. Sledge.
Trends in mortality in bariatric surgery: a systematic review and meta-analysis.
Surgery, 142 (2007), pp. 621-632
[73]
R.T. Lancaster, M.M. Hutter.
Bands and bypasses: 30-day morbidity and mortality of bariatric surgical procedures as assessed by prospective, multi-center, risk-adjusted ACS-NSQIP data.
Surg Endosc, 22 (2008), pp. 2554-2563
[74]
A.I. Sarela, S.P.L. Dexter, M.J. McMahon.
Use of the obesity surgery mortality risk score to predict complications of laparoscopic bariatric surgery.
Obes Surg, 21 (2011), pp. 1698-1703
[75]
N. Birkmeyer, J. Dimick, D. Share, A. Hawasli, W. English, J. Genaw, et al.
Hospital complication rates with bariatric surgery in Michigan.
JAMA, 304 (2010), pp. 435-442
[76]
K.J. Neff, C.W. le Roux.
Bariatric surgery: a best practice article.
J Clin Pathol, 66 (2013), pp. 90-98
[77]
H. Thomas, S. Agrawal.
Systematic review of obesity surgery mortality risk score-preoperative risk stratification in bariatric surgery.
Obes Surg, 22 (2012), pp. 1135-1140
[78]
E.J. DeMaria, M. Murr, T.K. Byrne, R. Blackstone, J.P. Grant, A. Budak, et al.
Validation of the obesity surgery mortality risk score in a multicenter study proves it stratifies mortality risk in patients undergoing gastric bypass for morbid obesity.
Ann Surg, 246 (2007), pp. 578-582
[79]
The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium.
Perioperative safety in the longitudinal assessment of bariatric surgery.
N Engl J Med, 361 (2009), pp. 445-454
[80]
R.P. Blackstone, M.C. Cortes.
Metabolic acuity score: effect on major complications after bariatric surgery.
Surg Obes Relat Dis, 6 (2010), pp. 267-273
[81]
J. Dimick, L. Nicholas, A. Ryan, J. Thumma, J. Birkmeyer.
Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence.
JAMA, 309 (2013), pp. 792-799
[82]
A. Carlin, T. Zeni, W. English, A. Hawasli, J. Genaw, K. Krause, For the Michigan Bariatric Surgery Collaborative, et al.
The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures for the treatment of morbid obesity.
Ann Surg, 257 (2013), pp. 791-797
[83]
J.B. Dimick, L.H. Nicholas, A.M. Ryan, J.R. Thumma, J.D. Birkmeyer.
Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence.
JAMA, 309 (2013), pp. 792-799
[84]
C.J. Magee, J. Barry, S. Javed, R. Macadam, D. Kerrigan.
Extended thromboprophylaxis reduces incidence of postoperative venous thromboembolism in laparoscopic bariatric surgery.
Surg Obes Relat Dis, 6 (2010), pp. 322-325
[85]
R. Gonzalez, K. Haines, L.G. Nelson, S.F. Gallagher, M.M. Murr.
Predictive factors of thromboembolic events in patients undergoing Roux-en-Y gastric bypass.
Surg Obes Relat Dis, 2 (2006), pp. 30-35
discussion 35–6
[86]
P.D. Stein, F. Matta.
Pulmonary embolism and deep venous thrombosis following bariatric surgery.
Obes Surg, 23 (2013), pp. 663-668
[87]
E.H. Livingston.
Complications of bariatric surgery.
Surg Clin North Am, 85 (2005), pp. 853-868
[88]
G. Curro, T. Centorrino, C. Musolino, G. Sarra, G. Navarra.
Incisional hernia prophylaxis in morbidly obese patients undergoing biliopancreatic diversion.
Obes Surg, 21 (2011), pp. 1559-1563
[89]
M. Owens, M. Barry, A.Z. Janjua, D.C. Winter.
A systematic review of laparoscopic port site hernias in gastrointestinal surgery.
[90]
A.R. Ahmed, G. Rickards, S. Husain, J. Johnson, T. Boss, W. O’Malley.
Trends in internal hernia incidence after laparoscopic Roux-en-Y gastric bypass.
Obes Surg, 17 (2007), pp. 1563-1566
[91]
A. Iannelli, E. Facchiano, J. Gugenheim.
Internal hernia after laparoscopic Roux-en-Y gastric bypass for morbid obesity.
Obes Surg, 16 (2006), pp. 1265-1271
[92]
K.E. Steele, G.P. Prokopowicz, T. Magnuson, A. Lidor, M. Schweitzer.
Laparoscopic antecolic Roux-en-Y gastric bypass with closure of internal defects leads to fewer internal hernias than the retrocolic approach.
Surg Endosc, 22 (2008), pp. 2056-2061
[93]
K.D. Higa, T. Ho, K.B. Boone.
Internal hernias after laparoscopic Roux-en-Y gastric bypass: incidence, treatment and prevention.
Obes Surg, 13 (2003), pp. 350-354
[94]
K. Higa, K. Boone, I. Arteaga González, E. López-Tomassetti Fernández.
Mesenteric closure in laparoscopic gastric bypass: surgical technique and literature.
Cir Esp, 82 (2007), pp. 77-88
[95]
M. Cho, D. Pinto, L. Carrodeguas, C. Lascano, F. Soto, O. Whipple, et al.
Frequency and management of internal hernias after laparoscopic antecolic antegastric Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: review of 1400 consecutive cases.
Surg Obes Relat Dis, 2 (2006), pp. 87-91
[96]
J. Ortega, N. Cassinello, D. Sánchez, C. Sebastián, F. Martínez.
Anatomical basis for the low incidence of internal hernia after a laparoscopic Roux-en-Y gastric bypass without mesenteric closure.
Obes Surg, 23 (2013), pp. 1273-1280
[97]
N. Geubbels, N. Lijftogt, M. Fiocco, N.J. van Leersum, M.W. Wouters, L.M. de Brauw.
Meta-analysis of internal herniation after gastric bypass surgery.
Br J Surg, 102 (2015), pp. 451-460
[98]
C. Bakhos, F. Alkhoury, T. Kyriakides, R. Reinhold, G. Nadzam.
Early postoperative hemorrhage after open and laparoscopic Roux-en-Y gastric bypass.
Obes Surg, 19 (2009), pp. 153-157
[99]
H.M. Heneghan, S. Meron-Eldar, P. Yenumula, T. Rogula, S.A. Brethauer, P.R. Schauer.
Incidence and management of bleeding complications after gastric bypass surgery in the morbidly obese.
Surg Obes Relat Dis, 8 (2012), pp. 729-735
[100]
K.J. Neff, T. Olbers, C.W. le Roux.
Bariatric surgery: the challenges with candidate selection, individualizing treatment and clinical outcomes.
[101]
S. Driscoll, D.M. Gregory, J.M. Fardy, L.K. Twells.
Long-term health-related quality of life in bariatric surgery patients: a systematic review and meta-analysis.
Obesity (Silver Spring), 24 (2016), pp. 60-70
[102]
R. Tayyem, A. Ali, J. Atkinson, C.R. Martin.
Analysis of health-related quality-of-life instruments measuring the impact of bariatric surgery: systematic review of the instruments used and their content validity.
[103]
H.E. Oria.
How to use the bariatric analysis and reporting outcome system.
Surg Obes Relat Dis, 8 (2012), pp. 130-131
[104]
H.E. Oria, M.K. Moorehead.
Updated Bariatric Analysis and Reporting Outcome System (BAROS).
Surg Obes Relat Dis, 5 (2009), pp. 60-66
[105]
E.H. Livingston, A.S. Fink.
Quality of life: cost and future of bariatric surgery.
Arch Surg, 138 (2003), pp. 383-388
[106]
B. McLeod, G. Beban, J. Sanderson, A. McKillop, A. Jull.
Bariatric surgery makes dramatic difference to health-related quality of life.
N Z Med J, 125 (2012), pp. 46-52
[107]
A.B. Al Harakeh, C.J. Larson, M.A. Mathiason, K.J. Kallies, S.N. Kothari.
BAROS results in 700 patients after laparoscopic Roux-en-Y gastric bypass with subset analysis of age, gender, and initial body mass index.
Surg Obes Relat Dis, 7 (2011), pp. 94-98
[108]
M. Suter, A. Donadini, S. Romy, N. Demartines, V. Giusti.
Laparoscopic Roux-en-Y gastric bypass: significant long-term weight loss, improvement of obesity-related comorbidities and quality of life.
Ann Surg, 254 (2011), pp. 267-273
[109]
J.C. Gould, M.J. Garren, V. Boll, J.R. Starling.
Laparoscopic gastric bypass: risks vs benefits up to two years following surgery in super-super obese patients.
Surgery, 140 (2006), pp. 524-529
discussion 529–31
[110]
M. Suter, J.M. Calmes, A. Paroz, S. Romy, V. Giusti.
Results of Roux-en-Y gastric bypass in morbidly obese vs superobese patients: similar body weight loss, correction of comorbidities, and improvement of quality of life.
Arch Surg, 144 (2009), pp. 312-318
[111]
J. Himpens, A. Verbrugghe, G.B. Cadière, W. Everaerts, J.W. Greve.
Long-term results of laparoscopic Roux-en-Y Gastric bypass: evaluation after 9 years.
Obes Surg, 22 (2012), pp. 1586-1593
[112]
J. Himpens, J. Dobbeleir, G. Peeters.
Long-term results of laparoscopic sleeve gastrectomy for obesity.
Ann Surg, 252 (2010), pp. 319-324
[113]
M. D’Hondt, S. Vanneste, H. Pottel, D. Devriendt, F. van Rooy, F. Vansteenkiste.
Laparoscopic sleeve gastrectomy as a single-stage procedure for the treatment of morbid obesity and the resulting quality of life, resolution of comorbidities, food tolerance, and 6-year weight loss.
Surg Endosc, 25 (2011), pp. 2498-2504
[114]
E. Mohos, E. Schmaldienst, M. Prager.
Quality of life parameters, weight change and improvement of co-morbidities after laparoscopic Roux Y gastric bypass and laparoscopic gastric sleeve resection: comparative study.
Obes Surg, 21 (2011), pp. 288-294
[115]
G.W. Strain, L. Faulconbridge, R.D. Crosby, R.L. Kolotkin, L. Heacock, M. Gagner, et al.
Health-related quality of life does not vary among patients seeking different surgical procedures to assist with weight loss.
Surg Obes Relat Dis, 6 (2010), pp. 521-525
[116]
J.B. Alley, S.J. Fenton, M.C. Harnisch, D.N. Tapper, J.M. Pfluke, R.M. Peterson.
Quality of life after sleeve gastrectomy and adjustable gastric banding.
Surg Obes Relat Dis, 8 (2012), pp. 31-40
[117]
P. Kaly, S. Orellana, T. Torrella, C. Takagishi, L. Saff-Koche, M.M. Murr.
Unrealistic weight loss expectations in candidates for bariatric surgery.
Surg Obes Relat Dis, 4 (2008), pp. 6-10
[118]
J.K. Smiertka, B.H. MacPerson.
Bariatric surgery postoperative behavioral change: the importance of ongoing assessment and teaching.
Obes Surg, 5 (1995), pp. 337-340
[119]
Z. Pataky, I. Carrard, A. Golay.
Psychological factors and weight loss in bariatric surgery.
Curr Opin Gastroenterol, 27 (2011), pp. 167-173
[120]
T. Rutledge, L.M. Groesz, M. Savu.
Psychiatric factors and weight loss patterns following gastric bypass surgery in a veteran population.
Obes Surg, 21 (2011), pp. 29-35
[121]
S. Leite, E. de Oliveira, O. Pereira, M. Kiyomi.
Snack-eating patients experience lesser weight loss after Roux-en-Y gastric bypass surgery.
Obes Surg, 19 (2009), pp. 1293-1296
[122]
J. Odom, K.C. Zalesin, T.L. Washington, W.W. Miller, B. Hakmeh, D.L. Zaremba.
Behavioral predictors of weight regain after bariatric surgery.
Obes Surg, 20 (2010), pp. 349-356
[123]
B. Sarwer, R.J. Dilks, L. West-Smith.
Dietary intake and eating behavior after bariatric surgery: threats to weight loss maintenance and strategies for success.
Surg Obes Rel Dis, 7 (2011), pp. 644-651
[124]
J.M. Campoy, M.L. Collazo-Clavell, A.F. Spitz.
American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient.
Surg Obes Relat Dis, (2008), pp. 109-184
[125]
R.E. Brolin.
Weight gain after short- and long-limb gastric bypass in patients followed for longer than 10 years.
Ann Surg, 246 (2007), pp. 163-164
[126]
M.D. Kofman, M.R. Lent, C. Swencionis.
Maladaptive eating patterns, quality of life, and weight outcomes following gastric bypass: results of an Internet survey.
Obesity, 18 (2010), pp. 1938-1943
[127]
E.M. Nesset, M.L. Kendrick, S.G. Houghton.
A two-decade spectrum of revisional bariatric surgery at a tertiary referral center.
Surg Obes Relat Dis, 3 (2007), pp. 25-30
[128]
C. Spyropoulos, I. Kehagias, S. Panagiotopoulos.
Revisional bariatric surgery: 13-year experience from a tertiary institution.
Arch Surg, 145 (2010), pp. 173-177
[129]
M. Gagner, P. Gentileschi, J. de Csepel.
Laparoscopic reoperative bariatric surgery: experience from 27 consecutive patients.
Obes Surg, 12 (2002), pp. 254-260
[130]
R. Cohen, J.S. Pinheiro, J.L. Correa.
Laparoscopic revisional bariatric surgery: myths and facts.
Surg Endosc, 19 (2005), pp. 822-825
[131]
J.T. McCormick, P.K. Papasavas, P.F. Caushaj.
Laparoscopic revision of failed open bariatric procedures.
Surg Endosc, 17 (2003), pp. 413-415
[132]
B. Deylgat, M. D’Hondt, H. Pottel.
Indications, safety, and feasibility of conversion of failed bariatric surgery to Roux-en-Y gastric bypass: a retrospective comparative study with primary laparoscopic Roux-en-Y gastric bypass.
Surg Endosc, 26 (2012), pp. 1997-2002
[133]
C.S. Hollenbeak, A. Rogers, B. Barrus, I. Wadiwala, R. Cooney.
Surgical volume impacts bariatric surgery mortality: a case for centers of excellence.
Surgery, 144 (2008), pp. 736-743
[134]
R.E. Brolin, R.P. Cody.
Impact of technological advances on complications of revisional bariatric operations.
J Am Coll Surg, 206 (2008), pp. 1137-1144
[135]
K.K. Mahawar, Y. Graham, W.R. Carr, N. Jennings, N. Schroeder, S. Balupuri, et al.
Revisional Roux-en-Y gastric bypass and sleeve gastrectomy: a systematic review of comparative outcomes with respective primary procedures.
Obes Surg, 25 (2015), pp. 1271-1280
[136]
R. Schouten, D.C. Wiryasaputra, F.M. van Dielen.
Long-term results of bariatric restrictive procedures: a prospective study.
Obes Surg, 20 (2010), pp. 1617-1626
[137]
D.J. Gagné, E. Dovec, J.E. Urbandt.
Laparoscopic revision of vertical banded gastroplasty to Roux-en-Y gastric bypass: outcomes of 105 patients.
Surg Obes Relat Dis, 7 (2011), pp. 493-499
[138]
U. Zingg, A. McQuinn, D. DiValentino.
Revisional vs primary Roux-en-Y gastric bypass—a case-matched analysis: less weight loss in revisions.
Obes Surg, 20 (2010), pp. 1627-1632
[139]
C.S. Lim, V. Liew, M.L. Talbot.
Revisional bariatric surgery.
Obes Surg, 19 (2009), pp. 827-832
[140]
J.F. Radtka, F.J. Puleo, L. Wang.
Revisional bariatric surgery: who, what, where, and when?.
Surg Obes Relat Dis, 6 (2010), pp. 635-642
[141]
D. Nguyen, F. Dip, J.A. Huaco, R. Moon, H. Ahmad, E. LoMenzo, et al.
Outcomes of revisional treatment modalities in non-complicated Roux-en-Y gastric bypass patients with weight regain.
Obes Surg, 25 (2015), pp. 928-934
[142]
N.R. Obeid, W. Malick, S.J. Concors, G.A. Fielding, M.S. Kurian, C.J. Ren-Fielding.
Long-term outcomes after Roux-en-Y gastric bypass: 10- to 13-year data.
Surg Obes Relat Dis, 12 (2016), pp. 11-20
[143]
D. Cheung, N.J. Switzer, R.S. Gill, X. Shi, S. Karmali.
Revisional bariatric surgery following failed primary laparoscopic sleeve gastrectomy: a systematic review.
Obes Surg, 24 (2014), pp. 1757-1763
[144]
F.B. Langer, A. Bohdjalian, S. Shakeri-Leidenmuhler.
Conversion from sleeve gastrectomy to Roux-en-Y gastric bypass-indications and outcome.
Obes Surg, 20 (2010), pp. 835-840
[145]
A. Iannelli, A.S. Schneck, P. Topart, M. Carles, X. Hébuterne, J. Gugenheim.
Laparoscopic sleeve gastrectomy followed by duodenal switch in selected patients versus single-stage duodenal switch for superobesity: case–control study.
Surg Obes Relat Dis, 9 (2013), pp. 531-538
[146]
K.B. Jones.
Revisional bariatric surgery-potentially safe and effective.
Surg Obes Rel Dis, 1 (2005), pp. 599-603
[147]
P. O’Brien, L. MacDonald, M. Anderson, L. Brennan, W. Brown.
Long-term outcomes after bariatric surgery. Fifteen-year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature.
[148]
D. Chiapaikeo, M. Schultheis, B. Protyniak, P. Pearce, F.J. Borao, S.J. Binenbaum.
Analysis of reoperations after laparoscopic adjustable gastric banding.
[149]
C. Boza, J. Salinas, N. Salgado, G. Pérez, A. Raddatz, R. Funke, et al.
Laparoscopic sleeve gastrectomy as a stand-alone procedure for morbid obesity: report of 1,000 cases and 3-year follow-up.
Obes Surg, 22 (2012), pp. 866-871
[150]
D. Cottam, F.G. Qureshi, S.G. Mattar, S. Sharma, S. Holover, G. Bonanomi, et al.
Laparoscopic sleeve gastrectomy as an initial weight loss procedure for high-risk patients with morbid obesity.
Surg Endosc, 20 (2006), pp. 859-863
[151]
A. Burgos, A. Csendes, I. Braghetto.
Gastric stenosis after laparoscopic sleeve gastrectomy in morbidly obese patients.
Obes Surg, 23 (2013), pp. 1481-1486
[152]
R. Rosenthal.
International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of 12,000 cases.
Surg Obes Relat Dis, 8 (2012), pp. 8-19
[153]
I. Braghetto, A. Csendes, E. Lanzarini, K. Papapietro, C. Cárcamo, J. Molina.
Is laparoscopic sleeve gastrectomy an acceptable primary bariatric procedure in obese patients? Early and 5-year postoperative results.
Surg Laparosc Endosc Percutan Tech, 22 (2012), pp. 479-486
[154]
M. Gagner, M. Deitel, T.L. Kalberer, A.L. Erickson, R.D. Crosby.
The Second International Consensus Summit for Sleeve Gastrectomy.
Surg Obes Relat Dis, 5 (2009), pp. 476-485
[155]
X. Shi, S. Karmali, A.M. Sharma, D.W. Birch.
A review of laparoscopic sleeve gastrectomy for morbid obesity.
Obes Surg, 20 (2010), pp. 1171-1177
[156]
S. Chiu, D. Birch, X. Shi, A. Sharma, S. Karmali.
Effect of sleeve gastrectomy on gastroesophageal reflux disease: a systematic review.
Surg Obes Relat Dis, 7 (2011), pp. 510-515
[157]
B. Ahmed, B. Ammori.
The safety of laparoscopic hand-sutured gastrojejunostomy in gastric bypass for the treatment of morbid obesity.
Obes Surg, 23 (2013), pp. 1487-1492
[158]
K.D. Higa, K.B. Boone, T. Ho.
Complications of the laparoscopic Roux-en-Y gastric bypass: 1040 patients—what have we learned?.
Obes Surg, 10 (2000), pp. 509-513
[159]
M. Penna, S.R. Markar, V. Venkat-Raman, A. Karthikesalingam, M. Hashemi.
Linear-stapled versus circular-stapled laparoscopic gastrojejunal anastomosis in morbid obesity: meta-analysis.
Surg Laparosc Endosc Percutan Tech, 22 (2012), pp. 95-101
[160]
S. Giordano, P. Salminen, F. Biancari, M. Victorzon.
Linear stapler technique may be safer than circular in gastrojejunal anastomosis for laparoscopic Roux-en-Y gastric bypass: a meta-analysis of comparative studies.
Obes Surg, 21 (2011), pp. 1958-1964
[161]
J.F. Finks, A. Carlin, D. Share, A. O’Reilly, Z. Fan, J. Birkmeyer, et al.
Effect of surgical techniques on clinical outcomes after laparoscopic gastric bypass results from the Michigan Bariatric Surgery Collaborative.
Surg Obes Relat Dis, 7 (2011), pp. 284-289
[162]
S.R. Markar, M. Penna, V. Venkat-Ramen, A. Karthikesalingam, M. Hashemi.
Influence of circular stapler diameter on postoperative stenosis after laparoscopic gastrojejunal anastomosis in morbid obesity.
Surg Obes Relat Dis, 8 (2012), pp. 230-235

Please cite this article as: Sabench Pereferrer F, Domínguez-Adame Lanuza E, Ibarzabal A, Socas Macias M, Valentí Azcárate V, García Ruiz de Gordejuela A, et al. Criterios de calidad en cirugía bariátrica: revisión de conjunto y recomendaciones de la Asociación Española de Cirujanos y de la Sociedad Española de Cirugía de la Obesidad. Cir Esp. 2017;95:4–16.

Copyright © 2016. AEC
Article options
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos