High-risk bariatric candidates: does red-flagging predict the post-operative course?

Background: Standards for preoperative bariatric patient selection include a thorough psychological evaluation. Using patients "red-flagged" during preoperative evaluations, this study aims to identify trends in long-term follow-up and complications to further optimize bariatric patient selection.

Methods: A multidisciplinary team held a case review conference (CRC) to discuss red-flagged patients. A retrospective chart review compared CRC patients to control patients who underwent bariatric surgery in the same interval. Patients under 18 years old, undergoing revisional bariatric surgery, or getting band placement were excluded. High-risk characteristics causing CRC inclusion, preoperative demographics, percent follow-up and other postoperative outcomes were collected up to 5 years postoperatively. If univariate analysis revealed a significant difference between cohorts, multivariable analysis was performed.

Results: Two hundred and fifty three patients were red-flagged from 2012 to 2013, of which 79 underwent surgery. After excluding 21 revisions, 3 non-adult patients, and 6 band patients, 55 red-flagged patients were analyzed in addition to 273 control patients. Patient age, sex, initial BMI, ASA, and co-morbidities were similar between groups, though flagged patients underwent RYGB more frequently than control patients. Notably, percent excess BMI loss and percent follow-up (6 months-5 years) were similar. In multivariable analysis, minor complications were more common in flagged patients; and marginal ulcers, endoscopy, and dilation for stenosis were more common in flagged versus control patients who underwent RYGB. Perforation, reoperation, revision, incisional hernia, and internal hernia were statistically similar in both groups, though reoperation was significantly more common in patients with multiple reasons to be flagged compared to controls.

Conclusion: Bariatric patients deemed high risk for various psychosocial issues have similar follow-up, BMI loss, and major complications compared to controls. High-risk RYGB patients have greater minor complications, warranting additional counseling of high-risk patients.