Laparoscopic Roux-En-Y Gastric Bypass and Adjustable Gastric Band with concomitant Hiatal Hernia Repair in the Nationwide Inpatient Sample

Benjamin J al-Haddad, MSc, Robert B Dorman, MD, PhD, Nikolaus F Rasmus, BA, Yong Y Kim, MD, PhD, Sayeed Ikramuddin, MD, Daniel B Leslie, MD

Division of Gastrointestinal Surgery, University of Minnesota

Introduction: We aimed to discover whether patients undergoing concomitant hiatal hernia repair (HHR) with either laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic adjustable gastric band (LAGB) had increased risk of prolonged length of stay (PLOS) or peri-operative adverse events.

Methods and Procedures: Using the Nationwide Inpatient Sample (NIS) between 2004 and 2009, we included all LRYGB and LAGB discharges where the patient was obese, aged 19 to 85 years and underwent the procedure on admission date. We defined PLOS as greater than 70th percentile (>=3 days) for LRYGB and greater than 90th percentile for LAGB (>=2 days). Hospital volume was categorized as <50, 50-100 and >100 procedures per year. Differences in pre-operative patient characteristics and co-morbidities were examined. Binomial and logistic regression models were fit comparing risk and odds of outcomes between patients undergoing only LRYGB or LAGB to patients undergoing these procedures with HHR.

Results: In the LRYGB group, there were a total of 42,272 records corresponding to 206,559 discharges after weighting. Similarly, there were 1945 records and 9060 discharges after weighting for the LRYGB+HHR group. Among patients undergoing LRYGB only, the average age was 43.6 (95% CI: 43.2, 43.9) years while those undergoing concomitant HHR had an average age of 47.4 (46.1, 48.7) years. Women comprised 80.1% (79.4%, 80.9%) of LRYGB only patients, while they were 87.6% (84.9%, 90.3%) of patients undergoing the combined procedure. The two groups were not different in terms of race or household zipcode median income levels. Approximately 38.5% (36.4, 40.5) of LRYGB patients and 54.6% (50.5, 58.7) of LRYGB+HHR patients had GERD prior to surgery. In regression analysis, patients undergoing HHR had 35.6% (10.1, 61.2) absolute lower risk of PLOS compared to LRYGB only after controlling for confounding variables. The LRYGB+HHR were not at higher risk of the combined adverse event, but had 79.9% (5.3, 154.4) absolute higher risk of pleural effusion and 65.9% (6.9, 124.9) absolute higher risk of adjacent structure injury in similar regressions. Lastly, patients in the LRYGB+HHR group had 5.6 (OR 95% CI: 1.344, 23.56) times higher odds of post-operative fistula after controlling for confounders.

Considering the LAGB alone patients, there were 10,578 discharge records corresponding to 52,997 discharges after weighting and 1963 and 9912 in the LAGB+HHR group. The average age of those undergoing the LAGB only was 45.3 years (44.5, 46.1) and 49.2 years (47.8, 50.5) for the LAGB+HHR. Patient groups did not differ on sex, race or household zipcode median income. GERD was present in 43.7% (38.2, 49.2) of the LAGB+HHR and 30.7% (27.8, 33.5) of those in the LAGB only group. In regression analysis, there were no differences in risk of PLOS or combined adverse events.

Conclusions: Using this nationally representative inpatient database, it appears that although patients undergoing concomitant HHR are older than those undergoing LRYGB alone, these former patients appear to be at reduced risk of PLOS but at increased risk for specific adverse post-operative events. There does not appear to be any significant excess risk associated with LAGB+HHR compared to LAGB alone.

Session: Poster Presentation

Program Number: P447

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