Laparoscopic sleeve gastrectomy at a new bariatric surgery centre in Canada: 30-day complication rates using the Clavien-Dindo classification.

Obesity, defined as a body mass index (BMI) of 30 or higher, has been associated with comorbidities, such as diabetes, obstructive sleep apnea, cardiovascular disease, hypertension and dyslipidemia, as well as an increased incidence of certain cancers.1 Although numerous treatment options exist for obesity, bariatric surgery has proven to be the only effective treatment resulting in substantial and sustainable weight loss, substantial improvement in comorbid conditions and quality of life, and reduction in the risk of death.2,3 According to Canadian guidelines, surgical treatment of adult obesity is indicated in medical refractory patients with a BMI of 40 or higher or with a BMI of 35 or higher combined with at least 1 comorbid condition.4 Newfoundland and Labrador (NL) has the highest rates of obesity in Canada, with estimated increases projected.5 In 2011, Eastern Health established a provincial bariatric surgery program in NL at the Health Science Centre. This multidisciplinary program consists of 3 surgeons, a nurse practitioner and a dietician, with referral to other allied health professionals if required. Laparoscopic sleeve gastrectomy (LSG) is the primary bariatric procedure (96%) performed at this centre. Laparoscopic sleeve gastrectomy originated as an initial step of a 2-step procedure known as the biliopancreatic bypass. It has gained popularity and is currently the second most commonly performed bariatric surgery in Canada.6 Its relatively short duration of surgery, shorter learning curve and lower complication rates make it an increasingly popular alternative to the laparoscopic Roux-en-Y gastric bypass (LRYGB).7 Current literature provides evidence that supports lower complication rates with LSG than with LRYGB.8,9 A 2010 systematic review of 15 studies including 940 patients analyzed the clinical outcomes and operational impact of LSG. The authors reported a major complication rate (e.g., staple line leakage and internal bleeding) ranging from 0% to 29%. The range was 0%–5.5% for leakage and 0%–15.8% for bleeding. Mortality ranged from 0% to 3.3%. In the systematic review some studies reported all minor complications (e.g., vomiting, nausea and diarrhea), and others did not, confounding the analysis.10 In a more recent systematic review and meta-analysis on the effectiveness and risks of bariatric surgery, Chang and colleagues2 reported complication rates associated with LSG from both randomized controlled trials (RCTs) and observational studies. The meta-analytic results from the 10 observational studies (n = 3647 patients) reported perioperative and postoperative mortality for LSG as 0.29% and 0.34%, respectively. The complication rate after LSG ranged from 8.9% (8 observational studies, n = 4987 patients) to 13% (2 RCTs, n = 137 patients).2 In response to a growing number of people living with obesity, specifically those with severe obesity (BMI ≥ 35), there has been an increase in the volume of bariatric surgeries performed in many Canadian provinces. In Canada, 28% of bariatric procedures performed between 2012 and 2013 were LSG.6 With the increasing number of LSG procedures being performed, outcome assessment is of utmost importance. The Surgical Review Corporation (SRC), American Society of Bariatric Surgery (ASBS) and Bariatric Surgery Center of Excellence (BSCOE) established guidelines to ensure patient safety and operative quality.11 While the NL program complies with some of the criteria (i.e., including a dedicated bariatric team and long-term patient follow-up) for a BSCOE, operative volumes are less than the minimum annual 125 bariatric procedures required to be classified as a COE.12 The purpose of this study was to assess 30-day complication rates and mortality in the first 209 consecutive patients undergoing LSG. We used the Clavien–Dindo classification system to grade and report surgical complications in a standard and comparable format to allow valid and reliable comparisons.13