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Immobile Patients Have More Bariatric Surgery Woes

Immobile Patients Have More Bariatric Surgery Woes
Those confined to wheelchairs or scooters had higher mortality rate after surgery

by Ed Susman, Contributing Writer, MedPage Today
November 01, 2017
This article is a collaboration between MedPage Today® and: Medpage Today
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NATIONAL HARBOR, Maryland – Patients who are immobile – spending much of their day in a wheelchair or getting around on a scooter – are far more likely to have complications after bariatric surgery than overweight individuals who are up and about, researchers reported here.
Compared to those who can ambulate, immobile individuals had a higher risk of overall complications, readmission to the hospital, need for reoperation, and higher mortality within 30 days from the time of the initial operation, said Rana Higgins, MD, of the Medical College of Wisconsin in Milwaukee.

In an oral presentation here at Obesity Week, Higgins said she and her colleagues accessed the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015 dataset and identified 148,710 patients who underwent various bariatric surgery procedures – about 66% of them being sleeve gastrectomies. Another 30% of those procedures were Roux-en-Y gastric bypass operations.
Of those, 2,969 fit the MBSAQIP definition of immobility: limited ambulation, requires assistive devices (scooter, wheelchair, etc.) for ambulation most or all of the time; requires a home lift or elevator to negotiate stairs.
Compared to the mobile population, these people who were unable to move about without assistive devices:
Had a longer hospital stay: a mean of 2.3 days compared to 1.5 days for mobile patients (P<0.0001).
Had longer operative times: a mean of 101.6 minutes compared with 90.9 minutes for mobile patients (P<0.0001).
Were readmitted to the hospital more often: a mean of 7.3% compared with 4.3% for mobile patients (P<0.0001).
Required more reoperations: a mean of 2.6% compared with 1.4% for mobile patients (P<0.0001).
Had a greater mortality: a mean of 0.5% compared with a mean of 0.1% for mobile patients (P<0.0001). Higgins noted that the odds ratio for mortality was 4.5-fold greater for the immobile patients compared with those who were able to get around.
When Higgins scrutinized the complication rate, she found that being immobile resulted in more problems – including a 6.42-fold increased risk of acute renal failure compared with mobile patients; a 4.47-fold increased risk of wound disruption; a 4.33-fold increased risk of unplanned intubation; a 4.32-fold increased risk of developing sepsis (P<0.05 for all comparisons).
"Pretty much every single perioperative complication was elevated in the immobile patients compared with the mobile population," Higgins said.

The litany of complications with an odds ratio of 2-fold or greater for the immobile patients included urinary tract infections, renal insufficiency, pulmonary embolism, the need for blood transfusions, pneumonia, surgical site infections, septic shock and a 2.81-fold increased risk of cardiac arrest (P<0.05 for all).
"I think this study really highlights the need to focus on quality initiatives to improve the safety and complication profile for immobile patients undergoing bariatric surgery," Higgins said.
In further analyzing their patient population, she said the immobile population was, as expected, a more adverse group with a higher body mass index and other factors. The higher risk patients preoperatively correlated with the higher complication rate in the perioperative setting, she said.
Higgins, in answering questions about what to do with these patients to reduce their risk prior to surgery, said she now begins a program of "prehabilitation."
"It's sort of like a cardiac rehabilitation program and pulmonary rehabilitation. There has not been much research on prehabilitation for this patient population. I think this could be an intervention that could significantly help," she said.

"I would agree that a program of prehabilitation would be useful for these patients," session co-moderator Dana Telem, MD, of the University of Michigan at Ann Arbor, told MedPage Today.
She said the increased complication rate among these patients "is not a surprising finding, but the real question is: What can we do to change these outcomes?"

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