Background

Post-operative gastrointestinal (GI) bleeding, while infrequent, is the most common complication after bariatric surgery. We aimed to determine whether the GI bleeding rate in our MBSAQIP Center of Excellence had room for improvement and identify a process to actively monitor potential interventions using novel application of Lean Six Sigma quality improvement methodology.

Methods

Statistical Process Control (SPC) was used to analyze our GI bleed data. Patient demographic, procedure, and complication data were abstracted from our MBSAQIP database from July 2022 to August 2023. GI bleeds were categorized as intraluminal or extraluminal, by case type and time-to-bleed. A G-chart was constructed using number of operative cases between GI bleed events.

Results

Of 531 cases, 15 (2.8%) post-operative GI bleeds occurred within 30 days of operation. A total of 11 (73%) occurred after Roux-en-Y gastric bypass, 2 (13%) after sleeve gastrectomy, and 2 (13%) after conversions. Bleeds were predominantly intraluminal (n=11, 73%) and 4 (27%) were associated with therapeutic anticoagulation. Bleeds occurred between 0 and 25 days post-operatively (median 2, IQR 1-10). A G-Chart of cases between events (figure 1) demonstrated common cause variation. No special cause signals were identified.

Conclusions

The overall rate of GI bleeds and the variation identified in our G-Chart suggests that our GI bleed rate can be improved upon. Planned interventions include intra-operative normalization of blood pressure to evaluate for bleeding and adjustment of post-operative anticoagulation management. SPC methodology will allow active monitoring of outcomes and may be useful to other bariatric programs to improve outcomes.