Weight loss at 30-days post-surgery was superior in Black patients, but despite better outcomes, these patients had a 24% higher risk of serious morbidity and adverse events versus similar white patients, a researcher reported.
In patients undergoing Roux-en-Y (RYGB) and laparoscopic sleeve gastrectomy (SG), the mean comparative decrease in BMI was higher in Blacks at 2.68 versus 2.53 in whites (P<0.001) post-RYGB, and 2.64 versus 2.55 (P<0.001) post-SG at 30 days, according to Dilhana S. Badurdeen, MBBS, of Johns Hopkins Hospital in Baltimore, in a presentation at the Digestive Disease Week virtual meeting.
In univariate analysis, serious morbidity was defined as any of the following: surgical site infection, wound dehiscence, ventilator dependence of >48 hours, progressive or acute renal insufficiency (RI), cerebrovascular accidents, stroke, cardiac arrest, MI, bleeding requiring transfusion, pulmonary embolism (PE), sepsis, and septic shock. Variables significantly associated in univariate analysis were used in multivariate models.
For both bariatric procedures, Black patients had a greater 30-day risk of adverse events (AEs). For SG, their risk was higher for death, acute RI, venous thromboembolism (VTE), the need for anticoagulation, and PE. After RYGB, Black patients had a 30-day slightly increased risk of cerebrovascular accidents, VTE, need for anticoagulation, and PE. That risk held regardless of baseline comorbidities and surgery type or characteristics.
“Further studies are imperative to determine contributing factors, and to reduce healthcare disparity,” Badurdeen stated.
These findings came in the context of existing racial disparities in the access to, and utilization of, bariatric surgery, as well as the disproportionate prevalence of obesity in Black Americans.
The researchers identified patients undergoing RYGB and laparoscopic SG using the 2015-2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. This registry represent 150,000 cases per yer from more than 700 U.S. participating centers.
During the study period, 107,449 Black and 341,380 white patients underwent RYGB or SG. Blacks were slightly younger at age 42.56 versus 45 (,<0.001), and fewer Black patients were male (13.1% vs 22.9%, P<0.001).
At time of surgery, mean BMI was 46.66 in Blacks and 44.72 in whites (P<0.001). Black patients were less likely to be smokers (7.8% vs 8.9%, P<0.001).
Surgery characteristics such as utilization of laparoscopic, hand-assisted, natural orifice transluminal endoscopic versus single-incision surgery, did not differ between the two groups. Robotic-assisted surgery was utilized in 10.6% of Blacks and in 8.9% of whites, but robotic surgery did not predict serious morbidity or AEs.
However, factors that were predictive of a higher incidence of serious morbidity and AEs were:
- Gastroesophageal reflux disease
- Mobility device use
- History of MI
- Previous cardiac surgery
- History of deep VTE
- Therapeutic anticoagulation
- Type 2 diabetes
- Chronic obstructive pulmonary disease
- Sleep apnea
- Use of chronic steroids at baseline
“Blacks, however, had a 24% higher risk of serious morbidity and adverse outcomes even after correcting for these baseline risk factors, type of surgery or use of a robot,” Badurdeen said.
The national database revealed no relationship between geographic region and risk. She also noted that big data, such as those in the MBSAQIP, cannot delve into the detailed specifics of patients and treatment.
Badurdeen explained that one contributing factor to the discrepancy may be that patients are not currently assessed at baseline for risk of possible adverse outcomes, and treated prophylactically before surgery with anticoagulants, which might help forestall complications.
“We need to look at which patients have higher risk of complications based on phenotypical and lab variables,” she said. “In order to get into the details of why these patients are experiencing more adverse events, we probably need more prospective studies. And it would be really nice to see outcomes beyond 30 days.”
She also noted that time will tell if preoperative biases that prevent teams from recognizing complaints and issues in Black patients play a role in outcomes. Some differences in outcomes between Blacks and whites may be inherent to differences in genotype or phenotype, she added.
Moving forward, Badurdeen said she would like to see all patients have a thorough baseline work-up of personal medical history and risk assessment for adverse outcomes. She pointed out that some tools are under development to predict serious AEs and complications.
Samer G. Mattar, MD, of Baylor College of Medicine in Houston, said Black patients suffer “double bias and discrimination, that of being a minority, and also of being obese. We have known for years that for a variety of reasons, African Americans tend to experience higher levels of obesity and for far longer periods, when compared to non-African Americans.”
Mattar, who was not involved in the study, added that many Blacks first experience obesity as children or adolescents and continue to gain weight for the rest of their lives, accelerated by unhealthy food choices and lack of access to exercise facilities.
“We have also come to recognize that, also for a variety of socioeconomic reasons, African-American patients tend to seek medical advice later in life, or when life-threatening comorbid conditions associated with severe obesity have advanced to dangerous levels,” he said.
Mattar called for referring obese patients earlier to clinical care. “The earlier patients are referred, the more reserve they will have and the better chance of receiving life-saving therapies with minimal adverse events,” he said, adding that would require the full participation of healthcare providers and community leaders at all levels of society.
Badurdeen and Matter disclosed no relevant relationships with industry.