Volume-Outcome Association in Bariatric Surgery: A Systematic Review

Objective: To systematically examine the association between annual hospital and surgeon case volume and patient outcomes in bariatric surgery. Background: Bariatric surgery remains a technically demanding field with significant risk for morbidity and mortality. To mitigate this risk, minimum annual hospital and surgeon case volume requirements are being set and certain hospitals are being designated as “Bariatric Surgery Centers of Excellence.” The effects of these interventions on patient outcomes remain unclear. Methods: A comprehensive systematic review on volume-outcome association in bariatric surgery was conducted by searching MEDLINE, Cochrane Database of Systematic Reviews, and Evidence Based Medicine Reviews databases. Abstracts of identified articles were reviewed and pertinent full-text versions were retrieved. Manual search of bibliographies was performed and relevant studies were retrieved. Methodological quality assessment and data extraction were completed in a systematic fashion. Pooling of results was not feasible due to the heterogeneity of the studies. A qualitative summary of results is presented. Results: From a total of 2928 unique citations, 24 studies involving a total of 458,032 patients were selected for review. Two studies were prospective cohorts (level of evidence [LOE] 1), 3 were retrospective cohorts (LOE 3), 2 were retrospective case controls (LOE 3), and 17 were retrospective case series (LOE 4). The overall methodological quality of the reviewed studies was fair. A positive association between annual surgeon volume and patient outcomes was reported in 11 of 13 studies. A positive association between annual hospital volume and patient outcomes was reported in 14 of 17 studies. Conclusions: There is strong evidence of improved patient outcomes in the hands of high-volume surgeons and high-volume centers. This study supports the concept of “Bariatric Surgery Center of Excellence” accreditation; however, future research into the quality of care characteristics of successful bariatric programs is recommended. Understanding the characteristics of high-volume surgeons, which lead to improved patient outcomes, also requires further investigation.

[1]  K. Steele.  Hospital complication rates with bariatric surgery in Michigan centers of excellence: the emperor's new clothes. , 2011, Archives of surgery.

[2]  E. Livingston.  High case volumes and bariatric surgery outcomes. , 2010, Journal of the American College of Surgeons.

[3]  E. Livingston.  Relationship between surgeon volume and adverse outcomes after Roux-en-Y gastric bypass in Longitudinal Assessment of Bariatric Surgery (LABS) study. , 2010, Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery.

[4]  E. Livingston.  The incidence of bariatric surgery has plateaued in the U.S. , 2010, American journal of surgery.

[5]  J. Birkmeyer,et al.  Hospital complication rates with bariatric surgery in Michigan. , 2010, JAMA.

[6]  V. Pate,et al.  Baseline data from American Society for Metabolic and Bariatric Surgery-designated Bariatric Surgery Centers of Excellence using the Bariatric Outcomes Longitudinal Database. , 2010, Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery.

[7]  E. Livingston.  Bariatric surgery centers of excellence do not improve outcomes. , 2010, Archives of surgery.

[8]  J. Galanko,et al.  High case volumes and surgical fellowships are associated with improved outcomes for bariatric surgery patients: a justification of current credentialing initiatives for practice and training. , 2010, Journal of the American College of Surgeons.

[9]  E. Livingston.  Surgical volume impacts bariatric surgery mortality: a case for bariatric surgery centers of excellence. , 2010, Surgery.

[10]  B. Wolfe,et al.  Relationship between surgeon volume and adverse outcomes after RYGB in Longitudinal Assessment of Bariatric Surgery (LABS) study. , 2010, Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery.

[11]  Y. Young-Xu,et al.  Racial, Socioeconomic, and Rural–Urban Disparities in Obesity-Related Bariatric Surgery , 2010, Obesity surgery.

[12]  Justin B Dimick,et al.  Variation in hospital mortality associated with inpatient surgery. , 2009, The New England journal of medicine.

[13]  J. Birkmeyer,et al.  Identifying high-quality bariatric surgery centers: hospital volume or risk-adjusted outcomes? , 2009, Journal of the American College of Surgeons.

[14]  J. Birkmeyer,et al.  Composite measures for predicting surgical mortality in the hospital. , 2009, Health affairs.

[15]  S. Barreto,et al.  Mortality and Hospital Stay After Bariatric Surgery in 2,167 Patients: Influence of the Surgeon Expertise , 2009, Obesity surgery.

[16]  Daniel B. Jones,et al.  Expert Panel on Weight Loss Surgery: Executive Report Update , 2009, Obesity.

[17]  C. Steiner,et al.  Recent Improvements in Bariatric Surgery Outcomes , 2009, Medical care.

[18]  Daniel B. Jones,et al.  Best Practice Updates for Surgical Care in Weight Loss Surgery , 2009, Obesity.

[19]  J. Tseng,et al.  Surgeon Volume Impacts Hospital Mortality for Pancreatic Resection , 2009, Annals of surgery.

[20]  W. Pories,et al.  Demographics and outcomes at American Society for Metabolic and Bariatric Surgery Centers of Excellence , 2009, Surgical Endoscopy.

[21]  L. Sjöström.  Bariatric surgery and reduction in morbidity and mortality: experiences from the SOS study , 2008, International Journal of Obesity.

[22]  C. Hollenbeak,et al.  Surgical volume impacts bariatric surgery mortality: a case for centers of excellence. , 2008, Surgery.

[23]  J. Richter,et al.  Trends of Heller Myotomy Hospitalizations for Achalasia in the United States, 1993–2005: Effect of Surgery Volume on Perioperative Outcomes , 2008, The American Journal of Gastroenterology.

[24]  R. F. Capella,et al.  Bariatric Surgery: Low Mortality at a High-Volume Center , 2008, Obesity surgery.

[25]  M. Morino,et al.  Mortality After Bariatric Surgery: Analysis of 13,871 Morbidly Obese Patients From a National Registry , 2007, Annals of surgery.

[26]  M. Robinson,et al.  Pathophysiology of Obesity: Why Surgery Remains the Most Effective Treatment , 2007, Obesity surgery.

[27]  E. Livingston,et al.  When policy meets statistics: the very real effect that questionable statistical analysis has on limiting health care access for bariatric surgery. , 2007, Archives of surgery.

[28]  E. Vittinghoff,et al.  Spectrum and risk factors of complications after gastric bypass. , 2007, Archives of surgery.

[29]  H. Eckstein,et al.  The relationship between volume and outcome following elective open repair of abdominal aortic aneurysms (AAA) in 131 German hospitals. , 2007, European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery.

[30]  B. Zilberstein,et al.  Follow-up of Roux-en-Y Gastric Bypass Patients at 5 or more Years Postoperatively , 2007, Obesity surgery.

[31]  M. Murr,et al.  A State-wide Review of Contemporary Outcomes of Gastric Bypass in Florida: Does Provider Volume Impact Outcomes? , 2007, Annals of surgery.

[32]  E. Yatco,et al.  Predictors of outcome after obesity surgery in New York state from 1991 to 2003 , 2007, Surgical Endoscopy.

[33]  E. Hannan,et al.  Relationship between surgeon and hospital volume and readmission after bariatric operation. , 2007, Journal of the American College of Surgeons.

[34]  L. Flancbaum,et al.  Factors Affecting Morbidity and Mortality of Roux-en-Y Gastric Bypass for Clinically Severe Obesity: An Analysis of 1,000 Consecutive Open Cases by a Single Surgeon , 2007, Journal of Gastrointestinal Surgery.

[35]  E. Hannan,et al.  Relationship between provider volume and postoperative complications for bariatric procedures in New York State. , 2006, Journal of the American College of Surgeons.

[36]  P. Benotti,et al.  Perioperative outcomes and risk factors in gastric surgery for morbid obesity: a 9-year experience. , 2006, Surgery.

[37]  B. Diggs,et al.  Perioperative morbidity associated with bariatric surgery: an academic center experience. , 2006, Archives of surgery.

[38]  M. Curet,et al.  Laparoscopic Roux-en-Y gastric bypass at a Veterans Affairs and high-volume academic facilities: a comparison of institutional outcomes. , 2005, American journal of surgery.

[39]  D. Flum,et al.  Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures. , 2005, JAMA.

[40]  B. Heniford,et al.  National Study of the Effect of Patient and Hospital Characteristics on Bariatric Surgery Outcomes , 2005, The American surgeon.

[41]  D. Flum,et al.  Impact of gastric bypass operation on survival: a population-based analysis. , 2004, Journal of the American College of Surgeons.

[42]  N. Nguyen,et al.  The Relationship Between Hospital Volume and Outcome in Bariatric Surgery at Academic Medical Centers , 2004, Annals of surgery.

[43]  H. Sugerman,et al.  Experience with over 3,000 open and laparoscopic bariatric procedures: Multivariate analysis of factors related to leak and resultant mortality , 2004, Surgical Endoscopy And Other Interventional Techniques.

[44]  Guido G. Gatti,et al.  The relationship of surgeon and hospital volume to outcome after gastric bypass surgery in Pennsylvania: a 3-year summary. , 2003, Surgery.

[45]  E. Livingston,et al.  Characterizing the Performance and Outcomes of Obesity Surgery in California , 2003, The American surgeon.

[46]  B. Wolfe,et al.  Factors associated with operative outcomes in laparoscopic gastric bypass. , 2003, Journal of the American College of Surgeons.

[47]  A. Voitk,et al.  Impartial Long-Term Review of Vertical Banded Gastroplasty in a Low Volume Community Hospital Practice , 2001, Obesity surgery.

[48]  A. Wittgrove,et al.  Laparoscopic Gastric Bypass, Roux-en-Y: Preliminary Report of Five Cases , 1994, Obesity surgery.

[49]  Sankey V. Williams,et al.  Hospital and Patient Characteristics Associated With Death After Surgery: A Study of Adverse Occurrence and Failure to Rescue , 1992, Medical care.

[50]  D. Reinharth.  The quality of care: how can it be assessed? , 1989, JAMA.

[51]  P. Tugwell,et al.  The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses , 2014 .

[52]  K. Behrns.  Bariatric Surgery Outcomes at Designated Centers of Excellence vs Nondesignated Programs , 2010 .

[53]  E. Livingston.  Development of bariatric surgery-specific risk assessment tool. , 2007, Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery.

[54]  American Society for Bariatric Surgery's guidelines for granting privileges in bariatric surgery. , 2006, Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery.

[55]  N. Nguyen,et al.  Improving the quality of care in bariatric surgery: the volume and outcome relationship. , 2005, Advances in surgery.