Does the future of laparoscopic sleeve gastrectomy lie in the outpatient surgery center? A retrospective study of the safety of 3162 outpatient sleeve gastrectomies

doi:10.1016/j.soard.2018.05.027

Surgery for Obesity and Related Diseases

Volume 14, Issue 10, October 2018, Pages 1442-1447

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https://doi.org/10.1016/j.soard.2018.05.027 Get rights and content

Abstract

Background

Laparoscopic sleeve gastrectomy (LSG) is a safe and effective procedure that can be performed as an outpatient procedure.

Objectives

The aim of the study was to determine whether same-day discharge LSG is safe when performed in an outpatient surgery center.

Setting

Outpatient surgery centers.

Methods

The medical records of 3162 patients who underwent primary LSG procedure by 21 surgeons at 9 outpatient surgery centers from January 2010 through February 2018 were retrospectively reviewed.

Results

Three thousand one hundred sixty-two patients were managed with enhanced recovery after surgery protocol and were included in this analysis. The mean age and preoperative body mass index were 43.1 ± 10.8 years and 42.1 ± 7.1 kg/m², respectively. Sleep apnea, type 2 diabetes, gastroesophageal reflux disease, hypertension, and hyperlipidemia were seen in 14.4%, 13.5%, 24.7%, 30.4%, and 17.6% patients, respectively. The mean total operative time was 56.4 ± 16.9 minutes (skin to skin). One intraoperative complication (.03%) occurred. The hospital transfer rate was .2%. The 30-day follow-up rate was 85%. The postoperative outcomes were analyzed based on the available data. The 30-day readmission, reoperation, reintervention, and emergency room visit rates were .6%, .6%, .2%, and .1%, respectively. The 30-day mortality rate was 0%. The total short-term complication rate was 2.5%.

Conclusions

Same-day discharge seems to be safe when performed in an outpatient surgery center in selected patients. It would appear that outpatient surgery centers are a viable option for patients with minimal surgical risks.

Section snippets

Methods

In this multi-institutional retrospective study, the medical records of 3162 patients who had undergone primary LSG procedure by 21 surgeons from January 2010 through February 2018 at 9 independent outpatient surgery centers were reviewed from each institution's prospectively collected database. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki

Results

Three thousand one hundred sixty-two patients were identified. The study involved patients with a mean age of 43.1 ± 10.8 years and had 1524 (48.1%) to 1638 (51.8%) male to female ratio. The mean preoperative BMI and weight were 42.1 ± 7.1 kg/m² and 263.5 ± 53 lbs, respectively. Of the 3162 patients, preoperative co-morbidity data were available for 2057 patients. Of the 2057 patients, 14.4%, 13.5%, 24.7%, 30.4%, and 17.6% of patients had preexisting sleep apnea, type 2 diabetes,

Discussion

This is the first multi-institutional study on primary LSG at outpatient surgical centers. Additionally, this is the largest cohort studied on primary LSG at an outpatient surgery center. The results are consistent with conclusions from other studies that outpatient LSG can be safely performed with a low complication rate. Our readmission, reoperation, and reintervention rates after outpatient SG were similar to those of the same procedures performed during hospital admission [14], [15], [16].

Conclusions

LSG for select patients can be performed safely on an outpatient basis. The exact reasons for early discharge and low readmission rates have yet to be elucidated.

Disclosure

D.C., the corresponding author, reports personal fees and other from Medtronic outside the submitted work. All other authors have no conflicts of interest to declare.

Reference (32)

PS Billing et al.
Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: first 250 cases
Surg Obes Relat Dis
(2014)
S Lalezari et al.
Laparoscopic sleeve gastrectomy as a viable option for an ambulatory surgical procedure: our 52-month experience
Surg Obes Relat Dis
(2018)
M Sippey et al.
30-day readmissions after sleeve gastrectomy versus Roux-en-Y gastric bypass
Surg Obes Relat Dis
(2016)
R Badaoui et al.
Outpatient laparoscopic sleeve gastrectomy: first 100 cases
J Clin Anesth
(2016)
M Sethi et al.
Thirty-day readmission after laparoscopic sleeve gastrectomy—a predictable event?
J Gastrointest Surg
(2016)
EF Elli et al.
Four-year experience with outpatient laparoscopic adjustable gastric banding
Surg Obes Relat Dis
(2013)
P Billing et al.
High acuity sleeve gastrectomy patients in a free-standing ambulatory surgical center
Surg Obes Relat Dis
(2017)
Z Khorgami et al.
Fast track bariatric surgery: safety of discharge on the first postoperative day after bariatric surgery
Surg Obes Relat Dis
(2017)
Z Khorgami et al.
Cost of bariatric surgery and factors associated with increased cost: an analysis of national inpatient sample
Surg Obes Relat Dis
(2017)
MJ Mark
Minimally invasive and robotic surgery
JAMA
(2001)

EJ Reddick et al.

Laparoscopic laser cholecystectomy: a comparison with minilap cholecystectomy

Surg Endosc

(1989)

Davis CJ, Filipi CJ. A history of endoscopic surgery. In: Arregui ME, Fitzgibbons RJ, Jr., Katkhouda N, McKernan JB,...

Hooper EA, Farhad B, Kim JJ. Bariatric surgery in elderly. In: Schauer PR, Schirmer BD, Brethauer S, editors. Minimally...

EL Munnich et al.

Returns to specialization: evidence from the outpatient surgery market

J Health Econ

(2017)

P Małczak et al.

Enhanced recovery after bariatric surgery: systematic review and meta-analysis

Obes Surg

(2017)

KC Sasse et al.

Outpatient weight loss surgery: initiating a gastric bypass and gastric banding ambulatory weight loss surgery center

JSLS

(2009)

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Making lemonade with lemons: a multicenter effort to improve outpatient sleeve gastrectomy amid the COVID-19 pandemic
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The COVID-19 pandemic impacted healthcare delivery worldwide. Resource limitations prompted a multicenter quality initiative to enhance outpatient sleeve gastrectomy workflow and reduce the inpatient hospital burden.
This study aimed to determine the efficacy of this initiative, as well as the safety of outpatient sleeve gastrectomy and potential risk factors for inpatient admission.
A retrospective analysis of sleeve gastrectomy patients was conducted from February 2020 to August 2021.
Inclusion criteria were adult patients discharged on postoperative day 0, 1, or 2. Exclusion criteria were body mass index ≥60 kg/m² and age ≥65 years. Patients were divided into outpatient and inpatient cohorts. Demographic, operative, and postoperative variables were compared, as well as monthly trends in outpatient versus inpatient admission. Potential risk factors for inpatient admission were assessed, as well as early Clavien-Dindo complications.
Analysis included 638 sleeve gastrectomy surgeries (427 outpatient, 211 inpatient). Significant differences between cohorts were age, co-morbidities, surgery date, facility, operative duration, and 30-day emergency department (ED) readmission. Monthly frequency of outpatient sleeve gastrectomy rose as high as 71% regionally. An increased number of 30-day ED readmissions was found for the inpatient cohort (P = .022). Potential risk factors for inpatient admission included age, diabetes, hypertension, obstructive sleep apnea, pre–COVID-19 surgery date, and operative duration.
Outpatient sleeve gastrectomy is safe and efficacious. Administrative support for extended postanesthesia care unit recovery was critical to successful protocol implementation for outpatient sleeve gastrectomy within this large multicenter healthcare system, demonstrating potential applicability nationwide.
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Citation Excerpt :
This was considerably higher than the rest of the studies, which ranged from .6% to 8.5%. Reasons for readmission after SDD SG were reported in 9 of 10 studies [14–17,19,23–25,27]. Nausea and vomiting constituted 23.5%–65% of the reasons for readmission in 5 of the studies [14,15,19,23,27], while it was not a cause for readmission in the remaining 4.
Length of stay after bariatric surgery has progressively shortened. Same-day discharge (SDD) has been reported for the 2 most common bariatric procedures, Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). The aim of this study is to evaluate the safety and success of SDD following SG and RYGB. Systematic literature search on SDD after bariatric surgery was conducted in Medline, Cochrane library, Google Scholar, and Embase. SDD was defined as discharging the patient during the day of the bariatric operation, without an overnight stay. The primary outcomes of interest were successful SDD, readmission, and morbidity rates. The secondary endpoints included reoperation and mortality rates. A proportion meta-analysis was performed to assess the outcomes of interest. A total of 14 studies with 33,403 patients who underwent SDD SG (32,165) or RYGB (1238) were included in the qualitative synthesis. Seven studies with 5000 patients who underwent SDD SG were included in the quantitative analysis, and pooled proportions (PPs) were calculated for the outcomes of interest. The SDD success rate was 63%–100% (PP: 99%) after SG and 88%–98.1% after RYGB. The readmission rate ranged from .6% to 20.8% (PP: 4%) after SDD SG and 2.4%–4% after SDD RYGB. Overall morbidity, reoperation, and mortality were 1.1%–10% (PP:4%), .3%–2.1% (PP: 1%), and 0%–.1% (PP: 0%), respectively, for SDD SG, and 2.5%–4%,1.9%–2.5%, and 0%–.9%, respectively, for SDD RYGB. SDD after SG seems feasible and safe. The outcomes of SDDRYGB seem promising, but the evidenceis stilllimitedto draw definitive conclusions. Selection criteria and perioperative protocolsmust be standardized to adequately introduce this practice.
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Laparoscopic hiatal hernia repair is commonly performed with 1 night hospitalization. The aim was to assess repairs as same-day-surgery (SDS).
Costs/short-term outcomes of SDS were compared to hospital-stay < 24-h: observation (OBS) and hospital-stay ≥ 24-h: inpatient (INP). Outcomes were assessed by postoperative 30-day ER visits/readmissions.
There were 262 procedures, excluding 50 reoperative repairs, 212 procedures were included: There were 66 SDS, 65 OBS and 81 INP. SDS vs. OBS: OBS were older, had higher ASA, less type I and more type III and IV hernias. Costs were significantly less in the SDS group with no difference in post-operative ER visits/post-discharge readmissions. SDS vs. INP: INP were older, had higher ASA, less type I and more type III and IV hernias. Costs were significantly less in the SDS group with no difference in post-operative ER visits/post-discharge readmissions.
Laparoscopic hiatal hernia repair can be performed as SDS in majority of elective repairs with good short-term outcomes and reduced cost.
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Enhanced recovery after surgery (ERAS) protocols have been successfully implemented in several surgical fields; however, the application of ERAS in the pediatric population is still limited.
The aim was to determine if implementation of an ERAS protocol can improve outcomes of laparoscopic sleeve gastrectomy (LSG) in adolescents.
University Hospital, United States.
A retrospective analysis of 112 adolescent patients who underwent LSG from February 2011 to July 2019 was conducted. An ERAS protocol was instituted in June 2016. Conventional care patients (n = 51) were compared with ERAS patients (n = 61). Comparisons were made using Χ² tests or Fisher’s exact for categoric data and Wilcoxon-rank sum tests for continuous data. Multiple linear regression was used to adjust length of stay for patient characteristics.
The 2 cohorts were similar in age, sex, race, number of co-morbidities, and preoperative body mass index. The volume of intraoperative fluid, intraoperative and postoperative opioids were significantly reduced in the ERAS group (P < .0001). The number of ERAS elements received per patient increased from a median of 9 to 15 (P < .0001). ERAS group had more discharges on postoperative day 1 (48% versus 6 %, respectively). Length of stay was significantly lower in the ERAS group (2.34 versus 2.04 median d, respectively). Difference was still significant after adjusting for age, sex, race/ethnicity, payor status, American Society of Anesthesiologists score, preoperative body mass index, and the duration of surgery (P < .0001). There were no differences in postoperative complications and 30-day readmissions.
An LSG ERAS protocol is associated with significant reduction in perioperative opioid use and length of stay with no increase in complications or readmission rates.
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Surgery for anorectal disease is thought to cause significant postoperative pain. Our previous work demonstrated that most opioids prescribed after anorectal surgery are not used. We aimed to evaluate a standardized protocol for pain control after anorectal surgery.
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Original articleDoes the future of laparoscopic sleeve gastrectomy lie in the outpatient surgery center? A retrospective study of the safety of 3162 outpatient sleeve gastrectomies

Abstract

Background

Objectives

Setting

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Conclusions

Disclosure

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

J Clin Anesth

J Gastrointest Surg

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Minimally invasive and robotic surgery

JAMA

Laparoscopic laser cholecystectomy: a comparison with minilap cholecystectomy

Surg Endosc

Returns to specialization: evidence from the outpatient surgery market

J Health Econ

Enhanced recovery after bariatric surgery: systematic review and meta-analysis

Obes Surg

Outpatient weight loss surgery: initiating a gastric bypass and gastric banding ambulatory weight loss surgery center

JSLS

Original article
Does the future of laparoscopic sleeve gastrectomy lie in the outpatient surgery center? A retrospective study of the safety of 3162 outpatient sleeve gastrectomies