Surgical Endoscopy

, Volume 25, Issue 8, pp 2613–2625 | Cite as

Determinants of resource utilization and outcomes in laparoscopic Roux-en-Y gastric bypass: a multicenter analysis of 14,251 patients

  • Prateek K. Gupta
  • Weldon J. Miller
  • Jyothsna Sainath
  • R. Armour Forse



Outcomes for patients who undergo laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery have improved, but a subset of patients who significantly utilize more resources exists. We identified preoperative variables that increase resource utilization in patients who undergo LRYGB.


Patients who underwent LRYGB in 2007 and 2008 were identified from the NSQIP database. Variables that indicated resource utilization were operative time (OT), length of stay (LOS), and occurrence of postoperative complications. Analyses were performed by using multivariate analysis of variance and logistic regression.


Of 14,251 patients with a mean age of 44.6 (±11.1) years, 19.4% were men. The national 30-day morbidity and mortality were 4.5% and 0.17%, respectively. The median OT was 128 min (interquartile range (IQR), 100–167), and the median LOS was 2 days (IQR, 2–3). Bleeding disorder, male gender, African American race, increasing weight, and age were significantly associated with increased OT (p < 0.05 for all). Severe chronic obstructive pulmonary disease, bleeding disorder, increasing age, and anesthesia time were associated with increased length of stay (p < 0.05). Preoperative dialysis dependence (odds ratio (OR), 8.5; 95% confidence interval (CI), 2.3–32.3) and dyspnea at rest (OR, 3.3; 95% CI, 1.7–6.3) were the greatest predictors of postoperative complications. Emergency case, bleeding disorder, prior percutaneous coronary intervention, and increasing operative time also were significantly associated with increased postoperative complications on multivariate logistic regression analysis (p < 0.05 for all).


Age, sex, race, obesity, and some medical comorbidities affect outcomes and increase resource utilization. Optimization of modifiable factors and careful patient selection are needed to facilitate further improvement in outcomes and resource utilization.


Gastric bypass Laparoscopic Resource Outcomes Morbidity Length of stay 


  1. 1.
    Angus DC, Linde-Zwirble WT, Sirio CA, Rotondi AJ, Chelluri L, Newbold RC III, Lave JR, Pinsky MR (1996) The effect of managed care on ICU length of stay: implications for medicare. JAMA 276:1075–1082PubMedCrossRefGoogle Scholar
  2. 2.
    Luft HS, Hunt SS (1986) Evaluating individual hospital quality through outcome statistics. JAMA 255:2780–2784PubMedCrossRefGoogle Scholar
  3. 3.
    Hebel JR, Kessler II, Mabuchi K, McCarter RJ (1982) Assessment of hospital performance by use of death rates. A recent case history. JAMA 248:3131–3135PubMedCrossRefGoogle Scholar
  4. 4.
    Collins TC, Daley J, Henderson WH, Khuri SF (1999) Risk factors for prolonged length of stay after major elective surgery. Ann Surg 230:251–259PubMedCrossRefGoogle Scholar
  5. 5.
    Gedaly R, McHugh PP, Johnston TD, Jeon H, Ranjan D, Davenport DL (2009) Obesity, diabetes, and smoking are important determinants of resource utilization in liver resection: a multicenter analysis of 1029 patients. Ann Surg 249:414–419PubMedCrossRefGoogle Scholar
  6. 6.
    Hawn MT, Bian J, Leeth RR, Ritchie G, Allen N, Bland KI, Vickers SM (2005) Impact of obesity on resource utilization for general surgical procedures. Ann Surg 241:821–826PubMedCrossRefGoogle Scholar
  7. 7.
    Lang M, Niskanen M, Miettinen P, Alhava E, Takala J (2001) Outcome and resource utilization in gastroenterological surgery. Br J Surg 88:1006–1014PubMedCrossRefGoogle Scholar
  8. 8.
    Trakas K, Lawrence K, Shear NH (1999) Utilization of health care resources by obese Canadians. CMAJ 160:1457–1462PubMedGoogle Scholar
  9. 9.
    Thomas EJ, Goldman L, Mangione CM, Marcantonio ER, Cook EF, Ludwig L, Sugarbaker D, Poss R, Donaldson M, Lee TH (1997) Body mass index as a correlate of postoperative complications and resource utilization. Am J Med 102:277–283PubMedCrossRefGoogle Scholar
  10. 10.
    Fry DE, Pine M, Jones BL, Meimban RJ (2010) Patient characteristics and the occurrence of never events. Arch Surg 145:148–151PubMedCrossRefGoogle Scholar
  11. 11.
    Ferraris VA, Ferraris SP, Singh A (1998) Operative outcome and hospital cost. J Thorac Cardiovasc Surg 115:593–602PubMedCrossRefGoogle Scholar
  12. 12.
    Khan NA, Quan H, Bugar JM, Lemaire JB, Brant R, Ghali WA (2006) Association of postoperative complications with hospital costs and length of stay in a tertiary care center. J Gen Intern Med 21:177–180PubMedGoogle Scholar
  13. 13.
    Cooney RN, Haluck RS, Ku J, Bass T, MacLeod J, Brunner H, Miller CA (2003) Analysis of cost outliers after gastric bypass surgery: what can we learn? Obes Surg 13:29–36PubMedCrossRefGoogle Scholar
  14. 14.
    Mosti M, Dominguez G, Herrera MF (2007) Calculating surgical costs: how accurate and predictable is the cost of a laparoscopic Roux-en-Y gastric bypass? Obes Surg 17:1555–1557PubMedCrossRefGoogle Scholar
  15. 15.
    Mehrotra C, Serdula M, Naimi TS, Khan LK, Miller J, Dietz W (2005) Population-based study of trends, costs, and complications of weight loss surgeries from 1990 to 2002. Obes Res 13:2029–2034PubMedCrossRefGoogle Scholar
  16. 16.
  17. 17.
    Khuri SF, Daley J, Henderson W, Barbour G, Lowry P, Irvin G, Gibbs J, Grover F, Hammermeister K, Stremple JF (1995) The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care. J Am Coll Surg 180:519–531PubMedGoogle Scholar
  18. 18.
    Khuri SF, Daley J, Henderson W, Hur K, Gibbs JO, Barbour G, Demakis J, Irvin G III, Stremple JF, Grover F, McDonald G, Passaro E Jr, Fabri PJ, Spencer J, Hammermeister K, Aust JB (1997) Risk adjustment of the postoperative mortality rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. J Am Coll Surg 185:315–327PubMedGoogle Scholar
  19. 19.
    Daley J, Khuri SF, Henderson W, Hur K, Gibbs JO, Barbour G, Demakis J, Irvin G III, Stremple JF, Grover F, McDonald G, Passaro E Jr, Fabri PJ, Spencer J, Hammermeister K, Aust JB, Oprian C (1997) Risk adjustment of the postoperative morbidity rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. J Am Coll Surg 185:328–340PubMedGoogle Scholar
  20. 20.
  21. 21.
    Gupta PK, Franck C, Miller WJ, Gupta H, Forse RA (2011) Development and validation of a bariatric surgery morbidity risk calculator using the prospective, multicenter NSQIP dataset. J Am Coll Surg 212:301–309PubMedCrossRefGoogle Scholar
  22. 22.
    Kelly JJ, Shikora S, Jones DB, Hutter MH, Robinson MK, Romanelli J, Buckley F, Lederman A, Blackburn GL, Lautz D (2009) Best practice updates for surgical care in weight loss surgery. Obesity (Silver Spring) 17:863–870CrossRefGoogle Scholar
  23. 23.
    Belle SH, Berk PD, Courcoulas AP, Flum DR, Miles CW, Mitchell JE, Pories WJ, Wolfe BM, Yanovski SZ (2007) Safety and efficacy of bariatric surgery: longitudinal assessment of bariatric surgery. Surg Obes Relat Dis 3:116–126PubMedCrossRefGoogle Scholar
  24. 24.
    Santry HP, Gillen DL, Lauderdale DS (2005) Trends in bariatric surgical procedures. JAMA 294:1909–1917PubMedCrossRefGoogle Scholar
  25. 25.
    Flum DR, Belle SH, King WC, Wahed AS, Berk P, Chapman W, Pories W, Courcoulas A, McCloskey C, Mitchell J, Patterson E, Pomp A, Staten MA, Yanovski SZ, Thirlby R, Wolfe B (2009) Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med 361:445–454PubMedCrossRefGoogle Scholar
  26. 26.
    Hutter MM, Randall S, Khuri SF, Henderson WG, Abbott WM, Warshaw AL (2006) Laparoscopic versus open gastric bypass for morbid obesity: a multicenter, prospective, risk-adjusted analysis from the National Surgical Quality Improvement Program. Ann Surg 243:657–662PubMedCrossRefGoogle Scholar
  27. 27.
    Lancaster RT, Hutter MM (2008) Bands and bypasses: 30-day morbidity and mortality of bariatric surgical procedures as assessed by prospective, multi-center, risk-adjusted ACS-NSQIP data. Surg Endosc 22:2554–2563PubMedCrossRefGoogle Scholar
  28. 28.
    Buchwald H, Estok R, Fahrbach K, Banel D, Sledge I (2007) Trends in mortality in bariatric surgery: a systematic review and meta-analysis. Surgery 142:621–632PubMedCrossRefGoogle Scholar
  29. 29.
    Nguyen NT, Rivers R, Wolfe BM (2003) Factors associated with operative outcomes in laparoscopic gastric bypass. J Am Coll Surg 197:548–555PubMedCrossRefGoogle Scholar
  30. 30.
    Ballantyne GH, Svahn J, Capella RF, Capella JF, Schmidt HJ, Wasielewski A, Davies RJ (2004) Predictors of prolonged hospital stay following open and laparoscopic gastric bypass for morbid obesity: body mass index, length of surgery, sleep apnea, asthma, and the metabolic syndrome. Obes Surg 14:1042–1050PubMedCrossRefGoogle Scholar
  31. 31.
    Mehrotra C, Serdula M, Naimi TS, Khan LK, Miller J, Dietz W (2005) Population-based study of trends, costs, and complications of weight loss surgeries from 1990 to 2002. Obes Res 13:2029–2034PubMedCrossRefGoogle Scholar
  32. 32.
    Huerta S, Heber D, Sawicki MP, Liu CD, Arthur D, Alexander P, Yip I, Li ZP, Livingston EH (2001) Reduced length of stay by implementation of a clinical pathway for bariatric surgery in an academic health care center. Am Surg 67:1128–1135PubMedGoogle Scholar
  33. 33.
    Weller WE, Rosati C, Hannan EL (2006) Predictors of in-hospital postoperative complications among adults undergoing bariatric procedures in New York state, 2003. Obes Surg 16:702–708PubMedCrossRefGoogle Scholar
  34. 34.
    Livingston EH (2004) Procedure incidence and in-hospital complication rates of bariatric surgery in the United States. Am J Surg 188:105–110PubMedCrossRefGoogle Scholar
  35. 35.
    Dindo D, Muller MK, Weber M, Clavien PA (2003) Obesity in general elective surgery. Lancet 361:2032–2035PubMedCrossRefGoogle Scholar
  36. 36.
    Zizza C, Herring AH, Stevens J, Popkin BM (2004) Length of hospital stays among obese individuals. Am J Public Health 94:1587–1591PubMedCrossRefGoogle Scholar
  37. 37.
    Tafti BA, Haghdoost M, Alvarez L, Curet M, Melcher ML (2009) Recovery of renal function in a dialysis-dependent patient following gastric bypass surgery. Obes Surg 19:1335–1339PubMedCrossRefGoogle Scholar
  38. 38.
    Alexander JW, Goodman HR, Hawver LR, Cardi MA (2009) Improvement and stabilization of chronic kidney disease after gastric bypass. Surg Obes Relat Dis 5:237–241PubMedCrossRefGoogle Scholar
  39. 39.
    Alexander JW, Goodman H (2007) Gastric bypass in chronic renal failure and renal transplant. Nutr Clin Pract 22:16–21PubMedCrossRefGoogle Scholar
  40. 40.
    Arozullah AM, Daley J, Henderson WG, Khuri SF (2000) Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program. Ann Surg 232:242–253PubMedCrossRefGoogle Scholar
  41. 41.
    Gupta H, Gupta PK, Kaushik M, Miller WJ, Wichman TO, Schuller D, Morrow LE (2009) Risk factors predicting postoperative pneumonia in surgical patients. Chest 136:6S–6eCrossRefGoogle Scholar
  42. 42.
    Gupta PK, Gupta H, Miller WJ, Cemaj S, Forse RA, Morrow LE (2009) Risk factors predicting postoperative respiratory failure in surgical patients. Chest 136:31S–31bCrossRefGoogle Scholar
  43. 43.
    Chumillas S, Ponce JL, Delgado F, Viciano V, Mateu M (1998) Prevention of postoperative pulmonary complications through respiratory rehabilitation: a controlled clinical study. Arch Phys Med Rehabil 79:5–9PubMedCrossRefGoogle Scholar
  44. 44.
    McGlinch BP, Que FG, Nelson JL, Wrobleski DM, Grant JE, Collazo-Clavell ML (2006) Perioperative care of patients undergoing bariatric surgery. Mayo Clin Proc 81:S25–S33PubMedGoogle Scholar
  45. 45.
    Huerta S, DeShields S, Shpiner R, Li Z, Liu C, Sawicki M, Arteaga J, Livingston EH (2002) Safety and efficacy of postoperative continuous positive airway pressure to prevent pulmonary complications after Roux-en-Y gastric bypass. J Gastrointest Surg 6:354–358PubMedCrossRefGoogle Scholar
  46. 46.
    Dixon BJ, Dixon JB, Carden JR, Burn AJ, Schachter LM, Playfair JM, Laurie CP, O’Brien PE (2005) Preoxygenation is more effective in the 25 degrees head-up position than in the supine position in severely obese patients: a randomized controlled study. Anesthesiology 102:1110–1115PubMedCrossRefGoogle Scholar
  47. 47.
    Liu JH, Zingmond D, Etzioni DA, O’Connell JB, Maggard MA, Livingston EH, Liu CD, Ko CY (2003) Characterizing the performance and outcomes of obesity surgery in California. Am Surg 69:823–828PubMedGoogle Scholar
  48. 48.
    DeMaria EJ, Murr M, Byrne TK, Blackstone R, Grant JP, Budak A, Wolfe L (2007) Validation of the obesity surgery mortality risk score in a multicenter study proves it stratifies mortality risk in patients undergoing gastric bypass for morbid obesity. Ann Surg 246:578–582PubMedCrossRefGoogle Scholar
  49. 49.
    Davenport DL, Holsapple CW, Conigliaro J (2009) Assessing surgical quality using administrative and clinical data sets: a direct comparison of the University Health System Consortium Clinical Database and the National Surgical Quality Improvement Program data set. Am J Med Qual 24:395–402PubMedCrossRefGoogle Scholar
  50. 50.
    Poirier P, Alpert MA, Fleisher LA, Thompson PD, Sugerman HJ, Burke LE, Marceau P, Franklin BA (2009) Cardiovascular evaluation and management of severely obese patients undergoing surgery: a science advisory from the American Heart Association. Circulation 120:86–95PubMedCrossRefGoogle Scholar
  51. 51.
    Schumann R, Jones SB, Ortiz VE, Connor K, Pulai I, Ozawa ET, Harvey AM, Carr DB (2005) Best practice recommendations for anesthetic perioperative care and pain management in weight loss surgery. Obes Res 13:254–266PubMedCrossRefGoogle Scholar
  52. 52.
    Kuruba R, Koche LS, Murr MM (2007) Preoperative assessment and perioperative care of patients undergoing bariatric surgery. Med Clin North Am 91:339–351, ixPubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Prateek K. Gupta
    • 1
  • Weldon J. Miller
    • 2
  • Jyothsna Sainath
    • 3
  • R. Armour Forse
    • 1
  1. 1.Department of SurgeryCreighton University Medical CenterOmahaUSA
  2. 2.University of VirginiaCharlottesvilleUSA
  3. 3.Department of StatisticsUniversity of NebraskaLincolnUSA

Personalised recommendations