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Surgery for Obesity and Related Diseases ] (2014) 00–00

Editorial comment

Comment on: three-year weight outcomes from a bariatric surgery registry in a large integrated healthcare system Received March 6, 2014; accepted March 6, 2014

In 1990, 12.7% of Americans were considered obese. Currently, over 35% of the U.S. population is obese, and the numbers are expected to grow over the next 2 decades with prevalence projected to reach 42% by 2030 [1]. Along with the dramatic increase in obesity, bariatric surgery saw a similar rise with over 200,000 procedures being performed annually in the United States by the end of 2007. This exponential growth in bariatric surgery led to significant concerns about the quality and safety of the operations. Indeed, the discipline faced intense scrutiny in the mid-2000s by the media and our peers [2,3]. To answer these concerns, as well as to set standards and establish evidence-based guidelines for best clinical practices and quality improvement, the American Society for Metabolic and Bariatric Surgery and the Surgical Review Corporation launched Bariatric Outcomes Longitudinal Database (BOLD) in 2007. Around the same time, American College of Surgeons developed the Bariatric Surgery Center Network (BSCN) data collection system, with similar goals in mind. Today, these 2 databases represent the largest repositories of bariatric surgery patients, with 4500,000 patients in BOLD database and over 113,000 patients in the BSCN database. In this issue of the journal, Coleman et al. have compared the Kaiser Permanente Southern California (KPSC) bariatric registry with BOLD and BSCN, and offer 3-year weight loss outcomes. What makes the KPSC bariatric registry unique is its composition. Besides being one of the largest cohorts of bariatric surgery patients (n = 20,296), the KPSC database contains a much larger percentage of ethnic minorities (450%) than BOLD or BSCN. Additionally, the KPSC database has a breakdown of procedures similar to today’s bariatric surgery trends, with 58% of the patients undergoing Roux-en-Y gastric bypass (RYGB), 40% having sleeve gastrectomy (SG), and only 2% having a banding procedure. The analysis by Coleman et al. of the KPSC registry has reconfirmed, albeit in a more diverse patient population, what was already known in respect to percent excess weight loss (%EWL) for each procedure (i.e., RYGB patients

experience a higher %EWL than SG patients, and banded patients have the lowest %EWL.) However, in-depth analysis by the authors has revealed some interesting findings. For instance, we see that black patients undergoing RYGB experience less weight loss than their Caucasian counterparts at 1, 2, and 3 years, but these differences are not apparent when comparing patients who undergo SG. Additionally, we see that men experience less weight loss than women, regardless of the operation performed. What variables are associated with successful weight loss? What characteristics correlate with failure of the operation? Who will benefit the most from a bariatric procedure? And what procedure is best for what person? One of the biggest unknowns in bariatric surgery is the ability to predict success or failure of the operation, based just on preoperative factors. The authors report a very wide range of weight loss for all 3 procedures. At 3 years, %EWL for RYGB ranged from 60% to 136%, 73% to 121% for banding procedures, and 87.5% to 145% for SG. What was unique about the patients who lost 4100% of their excess weight? What characteristics were common among individuals who not only regained all of their excess weight but also continued to gain weight beyond their preoperative starting weight? These are only some of the questions that might be answered by further analysis of the KPSC registry. Another unique feature of the KPSC bariatric registry is that it represents patients from an integrated healthcare system, which consists of a healthcare insurance, hospitals, and medical offices to deliver patient care and a partnership of physicians and surgeons. Due to this unique enterprise, the registry should provide access to unparalleled socioeconomic data, which can also make significant contributions to our understanding of what makes bariatric surgery a success versus a failure. Implementation of the BOLD and BSCN databases has set benchmarks for perioperative morbidity and mortality, hospital length of stay, resolution of co-morbidities, and long-term efficacy of the procedures [4,5]. Access to these databases by participants in the American College of

http://dx.doi.org/10.1016/j.soard.2014.03.006 1550-7289/r 2014 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.

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Surgeons or American Society for Metabolic and Bariatric Surgery accreditation programs or outside investigators has enabled researchers to answer intriguing questions and provide further insight into the mechanisms of bariatric surgery [6–8]. The KPSC registry holds a tremendous wealth of information, and we hope that the authors and other Kaiser physicians and surgeons will utilize this unique database and shed light on some of the important questions that still perplex the bariatric surgery community. Disclosures xx Umer I. Chaudhry, M.D., F.A.C.S., Bradley J. Needleman, M.D., F.A.C.S. The Ohio State University Wexner Medical Center Columbus, Ohio References [1] Finkelstein EA, Khavjou OA, Thompson H, et al. Obesity and severe obesity forecasts through 2030. Am J Prev Med 2012;42:563–70.

[2] Flum DR, Salem L, Elrod JA, et al. Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures. JAMA 2005;294:1903–8. [3] Livingston EH, Langert J. The impact of age and Medicare status on bariatric surgical outcomes. Arch Surg 2006;141:1115–20; discussion 1121. [4] DeMaria EJ, Pate V, Warthen M, et al. Baseline data from American Society for Metabolic and Bariatric Surgery-designated Bariatric Surgery Centers of Excellence using the Bariatric Outcomes Longitudinal Database. Surg Obes Relat Dis 2010;6:347–55. [5] Hutter MM, Schirmer BD, Jones DB, 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 2011;254: 410–20. (discussion 420–2). [6] Maciejewski ML, Winegar DA, Farley JF, et al. Risk stratification of serious adverse events after gastric bypass in the Bariatric Outcomes Longitudinal Database. Surg Obes Relat Dis 2012;8:671–7. [7] Pallati PK, Shaligram A, Shostrom VK, et al. Improvement in gastroesophageal reflux disease symptoms after various bariatric procedures: review of the Bariatric Outcomes Longitudinal Database. Surg Obes Relat Dis. Epub 2013 Aug 29. [8] Winegar DA, Sherif B, Pate V, et al. Venous thromboembolism after bariatric surgery performed by Bariatric Surgery Center of Excellence Participants: analysis of the Bariatric Outcomes Longitudinal Database. Surg Obes Relat Dis 2011;7:181–8.

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Comment on: Three-year weight outcomes from a bariatric surgery registry in a large integrated healthcare system.

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