Defining Benchmarks in Bariatric Surgery (BBenchmarks)

Defining Benchmarks in Bariatric Surgery - A Global Analysis of Laparoscopic Roux-en-Y Gastric Bypass and Sleeve Gastrectomy

Aim: To define benchmark outcomes in minimally-invasive primary bariatric surgery.

Design: Multicenter retrospective cohort study.

Assessed outcomes: Morbidity as defined by the Clavien-Dindo classification for surgical complications, the Comprehensive Complication Index® (CCI®) at discharge, at 3 months and at latest follow-up. Evolution of body mass index (BMI) will be also analyzed.

Hospital eligibility: High volume centers (> 200 bariatric operations per year) from at least three continents, maintaining a prospective database, as well as having published previously critically on their outcome.

Study population: Adult patients who underwent primary minimally invasive (laparoscopic / robotic) Roux-en-Y gastric bypass or sleeve gastrectomy from 1st of June 2012 to 31st of May 2017.

Patient Exclusion criteria: detailed later.

Data collection Deadline: 1st September 2017 - 30 April 2018

Study Overview

• Status: Completed
• Conditions: Complications; Bariatric Surgery; Sleeve Gastrectomy; Roux-en-y Gastric Bypass; Benchmark
• Intervention / Treatment: Procedure: bariatric surgery (RYGB or SG)

Detailed Description

Background With the growing complexity and cost of modern surgical practice, quality assessment becomes mandatory. The notion of quality and quality assessment is widely recognized and used in the world of business and manufacturing. A possible tool of quality assessment is benchmarking. Benchmarking is a process of measuring performance by comparison to the outcomes achieved by the best "service provider" in a specific domain. Usually, a benchmark describes the ''best possible'' outcome of a benchmarking subject to whom comparison can be performed. In the surgical community, however, such benchmarks - best possible outcomes - for specific procedures, not just the pooled overall performance, are lacking.

In 2016, a first landmark study defining benchmark outcomes for liver resection was published in Annals of Surgery by a group of international authors invited and guided by our department. More recently, further surgical outcomes (liver transplantation, minimally invasive esophagectomy) have been benchmarked and have been accepted for publication.

Since laparoscopic bariatric surgery has become a standardized and widely performed procedure worldwide, quality assessment is of major importance. To identify the best possible outcomes (i.e. the benchmarks), data from high-volume centers (based on official IFSO criteria) in low risk patients will be analyzed. These benchmarks will serve as "optimal outcomes" for comparison with single center outcomes, high-risk patients and future developments.

Aim The primary aim is to define benchmark outcomes based on assessment of post procedural complications according to the Clavien-Dindo classification for surgical complications and the comprehensive complication index CCI™ at discharge and at 90-days. The CCI® expresses morbidity on a continuous numeric scale from 0 (no complications) to 100 (death) by weighing all postoperative complications according to the Clavien-Dindo classification for their respective severity. Secondary outcome measure are patient survival and excess BMI loss (EBMIL).

Data Security This multicenter international study is designed to harvest prospectively collected retrospective data via an encrypted (i.e. Secure Sockets Layer (SSL) protocol) online platform (https://bbenchmarks.org/) that meets Food and Drug Administration (FDA) standards and is accessible only by secured login membership.

Confidential center specific data: Centers' outcomes will be individually analyzed in a first step to screen for center-specific differences. Benchmarks will be computed from each center's results in a second step. No center-specific data will be published. Instead, all complications or adverse outcomes will be anonymously reported, as fractions of the total study population. Each center, of course, will be free to publish their own data, as they wish.

Further use of cohort data: Future studies based on the collected data may emerge from this multicenter study, such as comparing outcomes in patients with or without specific comorbidities with benchmark outcomes. For further data usage, additional ethics approval may be required.

• Study Type: Observational
• Enrollment (Actual): 5741

Contacts and Locations

Study Locations

• Switzerland
  • Zurich
    • Zürich, Zurich, Switzerland, 8091
      • University Hospital Zürich

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years to 63 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Adult patients with severe obesity with a lower risk profile who undergo bariatric surgery

Description

Inclusion Criteria:

• Adult patients of 18-65 years
• Low risk profile (please read "exclusion criteria"),
• Maximum preoperative BMI of 50 kg/m2
• Primary laparoscopic/robotic proximal Roux-en-Y gastric bypass or sleeve gastrectomy
• Documented follow-up of at least 90 days

Exclusion Criteria:

• Open surgery
• Previous intra-abdominal surgery (including previous bariatric surgery)
• Pre-operative BMI over 50 kg/m2
• Age over 65 years
• Cardiovascular disease (e.g. cardiac arrhythmia, stroke, coronary artery disease) (Hypertension is allowed)
• History of thromboembolic events and/or therapeutic anticoagulation
• Diabetes mellitus (Type I and Type II, as defined by the American Diabetes Association)
• Obstructive sleep apnea (recurrent episodes of upper airway collapse during sleep)
• Chronic obstructive pulmonary disease (FEV1/FVC<0.7)
• Chronic kidney disease (eGFR < 30ml/min/1.72 m2)
• Inflammatory bowel disease (ulcerative colitis, Crohn's)
• Immunosuppression therapy (e.g. steroids, calcineurin inhibitors, etc)
• Patients who underwent associated procedures (for example: cholecystectomy, hiatoplasty, liver biopsy)
• ASA score > 2

Study Plan

How is the study designed?

Design Details

• Observational Models: Case-Only
• Time Perspectives: Retrospective

Number of groups / cohorts

19

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
University Hospital Zurich	Procedure: bariatric surgery (RYGB or SG); laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy for severe obesity
St Pierre University Hospital, Brussels, Belgium	Procedure: bariatric surgery (RYGB or SG); laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy for severe obesity
Sana Klinikum, Offenbach, Germany	Procedure: bariatric surgery (RYGB or SG); laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy for severe obesity
Complutense University of Madrid, Spain	Procedure: bariatric surgery (RYGB or SG); laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy for severe obesity
Musgrove Park Hospital, Taunton, UK	Procedure: bariatric surgery (RYGB or SG); laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy for severe obesity
University of Gothenburg, Sweden	Procedure: bariatric surgery (RYGB or SG); laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy for severe obesity
AZ Sint-Jan Hospital in Bruges, Belgium	Procedure: bariatric surgery (RYGB or SG); laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy for severe obesity
Bristol	Procedure: bariatric surgery (RYGB or SG); laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy for severe obesity
Cleveland Clinic, Weston, Florida, USA	Procedure: bariatric surgery (RYGB or SG); laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy for severe obesity
Oswaldo Cruz German Hospital, Sao Paolo, Brazil	Procedure: bariatric surgery (RYGB or SG); laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy for severe obesity
Clínica Las Condes, Santiago, Chile	Procedure: bariatric surgery (RYGB or SG); laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy for severe obesity
Brown University, Providence Rhode Island	Procedure: bariatric surgery (RYGB or SG); laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy for severe obesity
Fresno Bariatric, CA, USA	Procedure: bariatric surgery (RYGB or SG); laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy for severe obesity
Rijnstate Hospital, Arnhem, The Netherlands	Procedure: bariatric surgery (RYGB or SG); laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy for severe obesity
CHU Nice, France	Procedure: bariatric surgery (RYGB or SG); laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy for severe obesity
Claraspital Basel, Switzerland	Procedure: bariatric surgery (RYGB or SG); laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy for severe obesity
Gastro-Obeso-Center Advanced Med Inst, Brazil	Procedure: bariatric surgery (RYGB or SG); laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy for severe obesity
Hospital Dipreca Santiago Región Metropolitana , Chile	Procedure: bariatric surgery (RYGB or SG); laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy for severe obesity
Medical University Wien, Austria	Procedure: bariatric surgery (RYGB or SG); laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy for severe obesity

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Benchmark outcomes (best achievable outcomes after bariatric surgery)	Comprehensive Complication Index (http://www.assessurgery.com/calculator_single/)	30 days postoperatively
Benchmark outcomes (best achievable outcomes after bariatric surgery)	Comprehensive Complication Index (http://www.assessurgery.com/calculator_single/)	90 days postoperatively
Benchmark outcomes (best achievable outcomes after bariatric surgery)	Comprehensive Complication Index (http://www.assessurgery.com/calculator_single/)	180 days postoperatively
Major complications after bariatric surgery	Clavien-Dindo grade > IIIa	30 days postoperatively
Major complications after bariatric surgery	Clavien-Dindo grade > IIIa	90 days postoperatively
Major complications after bariatric surgery	Clavien-Dindo grade > IIIa	180 days postoperatively

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Case-mix within centers	proportion of benchmark cases	5 years
Excess weight loss after bariatric surgery	Body-mass index (kg/m2)	1-year postoperatively
Excess weight loss after bariatric surgery	Body-mass index (kg/m2)	3-years postoperatively
Excess weight loss after bariatric surgery	Body-mass index (kg/m2)	5-years postoperatively

Collaborators and Investigators

• Sponsor: Marco Bueter
• Collaborators: Dr. med. Daniel Gero; Dr. med. Dimitri A. Raptis, PhD; Dr. med. Henner Schmidt

Publications and helpful links

General Publications

• Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004 Aug;240(2):205-13. doi: 10.1097/01.sla.0000133083.54934.ae.
• Slankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA. The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg. 2013 Jul;258(1):1-7. doi: 10.1097/SLA.0b013e318296c732.
• Rossler F, Sapisochin G, Song G, Lin YH, Simpson MA, Hasegawa K, Laurenzi A, Sanchez Cabus S, Nunez MI, Gatti A, Beltrame MC, Slankamenac K, Greig PD, Lee SG, Chen CL, Grant DR, Pomfret EA, Kokudo N, Cherqui D, Olthoff KM, Shaked A, Garcia-Valdecasas JC, Lerut J, Troisi RI, De Santibanes M, Petrowsky H, Puhan MA, Clavien PA. Defining Benchmarks for Major Liver Surgery: A multicenter Analysis of 5202 Living Liver Donors. Ann Surg. 2016 Sep;264(3):492-500. doi: 10.1097/SLA.0000000000001849.
• Muller X, Marcon F, Sapisochin G, Marquez M, Dondero F, Rayar M, Doyle MMB, Callans L, Li J, Nowak G, Allard MA, Jochmans I, Jacskon K, Beltrame MC, van Reeven M, Iesari S, Cucchetti A, Sharma H, Staiger RD, Raptis DA, Petrowsky H, de Oliveira M, Hernandez-Alejandro R, Pinna AD, Lerut J, Polak WG, de Santibanes E, de Santibanes M, Cameron AM, Pirenne J, Cherqui D, Adam RA, Ericzon BG, Nashan B, Olthoff K, Shaked A, Chapman WC, Boudjema K, Soubrane O, Paugam-Burtz C, Greig PD, Grant DR, Carvalheiro A, Muiesan P, Dutkowski P, Puhan M, Clavien PA. Defining Benchmarks in Liver Transplantation: A Multicenter Outcome Analysis Determining Best Achievable Results. Ann Surg. 2018 Mar;267(3):419-425. doi: 10.1097/SLA.0000000000002477.
• Gero D, Raptis DA, Vleeschouwers W, van Veldhuisen SL, Martin AS, Xiao Y, Galvao M, Giorgi M, Benois M, Espinoza F, Hollyman M, Lloyd A, Hosa H, Schmidt H, Garcia-Galocha JL, van de Vrande S, Chiappetta S, Menzo EL, Aboud CM, Luthy SG, Orchard P, Rothe S, Prager G, Pournaras DJ, Cohen R, Rosenthal R, Weiner R, Himpens J, Torres A, Higa K, Welbourn R, Berry M, Boza C, Iannelli A, Vithiananthan S, Ramos A, Olbers T, Sepulveda M, Hazebroek EJ, Dillemans B, Staiger RD, Puhan MA, Peterli R, Bueter M. Defining Global Benchmarks in Bariatric Surgery: A Retrospective Multicenter Analysis of Minimally Invasive Roux-en-Y Gastric Bypass and Sleeve Gastrectomy. Ann Surg. 2019 Nov;270(5):859-867. doi: 10.1097/SLA.0000000000003512.

Helpful Links

• Related Info

Study record dates

Study Major Dates

• Study Start (Actual): October 17, 2017
• Primary Completion (Actual): September 10, 2018
• Study Completion (Actual): September 17, 2019

Study Registration Dates

• First Submitted: February 7, 2018
• First Submitted That Met QC Criteria: February 13, 2018
• First Posted (Actual): February 20, 2018

Study Record Updates

• Last Update Posted (Actual): September 19, 2019
• Last Update Submitted That Met QC Criteria: September 18, 2019
• Last Verified: September 1, 2019

More Information

Terms related to this study

• Other Study ID Numbers: BASECnr_2017-01652

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No
• IPD Plan Description: the study is based on de-anonymised data, so it is impossible to backtrack it to a patient. only overall data will be shared, not individual data

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No