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RELEVANCE OF THE OBESITY SURGERY MORTALITY RISK SCORE IN PATIENTS UNDERGOING ROUX-EN-Y GASTRIC BYPASS.
A STUDY IN THE UNITED KINGDOM
S Mansour, V Kaur, G Vasilikostas, KM Reddy, A Wan
St George’s Healthcare NHS Trust, London, UK
BARIATRIC SURGERY Obesity is a leading cause of
death worldwideMokdad AH et al, JAMA 2004
Bariatric surgery is currently, the only treatment available for sustained weight loss in the morbidly obese• Reduction in relative risk of death by up to 89%
Colquitt JL et al Cochrane Database Systematic Review 2009Christou NV et al Annals of Surgery 2004
Good safety profile• Overall, 90-day MR* = 0.35% = lap chole 90-day MR*
Pories WJ Journal of Clin Endo & Met 2008*MR – Mortality rate
ROUX-EN-Y GASTRIC BYPASS (RYGB) Overall, reported MR for patients
undergoing primary RYGB 0 – 1.5%
DeMaria EJ et al Ann Surg 2002, Schauer PR et al Ann Surg 2000Wittgrove AC et al Am J Surg 2000, Buchwald H et al JAMA 2004
Published data on MR in ‘high-risk’ patients 0 – 1.0% Usually addressed a single risk factor
Age >60 yrs BMI >50 kg/m2
Wittgrove et al Obes Surg 2009, Adeles D et al J Am
Figure 1: RYGB
RISK STRATIFICATION Important component of surgical
decision – making
Risk stratification tools in surgery APACHE P – POSSUM O – POSSUM NSQIP Surgical APGAR
Does not recognise factors specific to bariatric patients
Surgical scores - not designed as a pre-operative predictive tool
IDENTIFYING RISK FACTORS Recent publications have attempted to identify risk
factors for morbidity and mortality in bariatric surgery
Fernandez AZ et al Ann Surg 2004, Livingston EH et al Ann Surg 2002
Sapala JA et al Obes Surg 2003, Jamal MK et al SOARD 2005
Courcoulas A et al Surgery 2003, Nguyen NT et al Ann Surg 2004Patient factors
Super obeseMale gender
Advanced ageCo-morbidities
Surgical complication
sAnastomotic leak
Pulmonary embolism
Surgeon experience
/ case volume
OBESITY SURGERY MORTALITY RISK SCORE (OS-MRS)
Developed from a single centre's experience with 2075 primary open and laparoscopic RYGB during a 10 year period Analysed multiple pre-op factors of potential significance Determined 5 pre-operative factors correlating with mortality Derived a pre-op scoring system for risk stratification
OS-MRS DeMaria EJ et al SOARD 2007
… Applied to a large (n=4431) multi-centre cohort
accurately predicted mortality risk DeMaria EJ et al Annals Surg 2007
OS-MRS is the first validated stratified scoring system for predicting post-op mortality in bariatric surgery Easy to use Pre-operative
AIM
To assess the utility of OS-MRS in patients undergoing primary laparoscopic RYGB in
a hospital in the United Kingdom
METHODS All patients undergoing elective primary roux-en-Y gastric
bypass surgery from June 2008 – Dec 2009
Planned laparoscopic approach
Exclusion criteria – revision surgery
Prospectively maintained database demographic & pre-op clinical data
90 day procedure-related mortality
Eligibility for surgery – NICE guidelines BMI* >40 kg/m2 or BMI* >35 kg/m2 with obesity-related co-
morbidities
Assessed by a multidisciplinary team
Patients have to display appropriate understanding of procedure
METHODS 5 OS-MRS variables (1 point each)
SBP= systolic blood pressure, DBP = diastolic blood pressure, VTE = venous thromboembolism, IVC = inferior vena cava, HF = heart failure
Variable Definition
Age >45 years
Gender Male
BMI > 50 kg/m2
Hypertension (HT)
• resting SBP >150mmHg or
DBP > 90mmHg at initial visit
• the use of antihypertensive medications
PE risk Previous VTE event
Pre-op IVC filter
Right HF
Pulmonary HT
Venous stasis
Obesity hypoventilatory syndrome
METHODS
OS-MRS points are grouped into 3 categories
Class Points Risk (MR%)
Class A 0-1 Low (0.31)
Class B 2-3 Intermediate (1.9)
Class C 4-5 High (7.56)
RESULTS 18 month period
Total =116 patients
No mortalities
All procedures were completed laparoscopically
F= Female, M= Male, ASA = American Society of Anesthesiologists
Parameter Value
Mean age (years) 43.15 +/- 9.47
Gender F:M (%) 93:23 (80:20)
Mean BMI (kg/m2) 49.45 +/- 7.76
Mode ASA grade 2
RESULTS
OS-MRS variables
Variable n (%)
Age >45 yrs 32 (28%)
Male 23 (20%)
BMI> 50 kg/m 23 (20%)
HT 41 (35%)
PE risk 0 (0%)
RESULTS
OS-MRS points
Points n (%)
0 28 (24.1)
1 41 (35.3)
2 25 (21.6)
3 18 (15.6)
4 4 (3.4)
5 0 (0)
RESULTS
OS-MRS classes (96.6%)
Class n (%)
A 69 (59.5)
B 43 (37.1)
C 4 (3.4)
RESULTS
OS-MRS mortalities
No significant difference seen between the observed and expected mortality OS-MRS was a valid tool for predicting mortality
risk in our cohort
Class Observed MR (%)
Expected MR (%)
A 0 (0) 0.2 (0.31)
B 0 (0) 0.8 (1.90)
C 0 (0) 0.3 (7.56)
OS-MRS RISK FACTORS
0
10
20
30
40
50
60
Our cohort
DeMariaDeMaria EJ et al SOARD 2007
UTILITY OF OS-MRS Provide objectivity
Aid informed consent Risk prediction Understanding prognosis / severity
Pre-op optimisation especially in high risk patients Risk reduction strategies – decreasing BMI, optimise BP
Aid surgical decision making in high-risk patients use alternative lower risk or staged procedures
Planned critical care admission post-operatively
Allow standardisation of outcome comparisons between different units
Instigate ‘new and improved’ risk-stratification scores in bariatric surgery
CONCLUSION
Mortality risk in RYGB can be stratified based on independent variables that can be identified pre-operatively
OS-MRS is a clinically relevant and valid scoring system for predicting mortality risk in our medium volume cohort
OS-MRS may help contribute in surgical decision making in bariatric surgery
THANK YOU FOR LISTENING
QUESTIONS & ANSWERS
RELEVANCE OF THE OBESITY SURGERY MORTALITY RISK SCORE IN PATIENTS UNDERGOING ROUX-EN-Y GASTRIC BYPASS.
Presenter’s name: Ms Vasha Kaur
As previously disclosed I do not have a financial or other relationship with any company.