Optimizing outcomes in bariatric surgery: outpatient laparoscopic gastric bypass

Bariatric Surgery Before and After the SARS-CoV-2 Pandemic: a Comparative Study of Cases Before the Onset of the Pandemic in a High-Volume Academic Center

INTRODUCTION

At the beginning of the pandemic, studies showed a higher risk of severe surgical complications and mortality among patients with perioperative SARS-CoV-2 infection, which led to the suspension of elective surgery. Confinement and lockdown measures were shown to be associated with weight gain and less access to medical and surgical care in patients with obesity, with negative health consequences. To evaluate the safety of bariatric surgery during the pandemic, we compared 30-day complications between patients who underwent bariatric surgery immediately before with those who underwent bariatric surgery during the opening phase of the pandemic.

METHODS

Observational analytical study of a non-concurrent cohort of patients who underwent bariatric surgery in 2 periods: pre-pandemic March 1 to December 31, 2019, and pandemic March 1 to December 31, 2020. Surgical complications were defined using the Clavien-Dindo classification.

RESULTS

Pre-pandemic and pandemic groups included 256 and 202 patients who underwent primary bariatric surgery, respectively. The mean age was 37.6 + 10.3 years. The overall complication rate during the first 30 days of discharge was 7.42%. No differences between groups were observed in severe complications (pre-pandemic 1.56% vs. pandemic 1.98%, p: 0.58). No mortality was reported. Overall 30-day readmission was 3.28% with no differences between groups.

CONCLUSION

The findings of this study did not find a difference in the rate of severe complications, nor also we report severe COVID-19 complications in this high-risk population. During the pandemic, with appropriately implemented protocol, the resumption of bariatric surgery is possible with no increased risk for patients.

Difference in 30-Day Readmission Rates After Laparoscopic Sleeve Gastrectomy Versus Laparoscopic Roux-En-Y Gastric Bypass: a Propensity Score Matched Study Using ACS NSQIP Data (2015-2019)

PURPOSE

There are very few studies that have compared the short-term outcomes of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). Among short-term outcomes, hospital readmission after these procedures is an area for quality enhancement and cost reduction. In this study, we compared 30-day readmission rates after LSG and LRYGB through analyzing a nationalized dataset. In addition, we identified the reasons of readmission.

MATERIALS AND METHODS

The current study was a retrospective analysis of data from National Surgical Quality Improvement Program (NSQIP) All adult patients, ≥ 18 years of age and who had LSG or LRYGB during 2014 to 2019 were included. Current Procedural Terminology (CPT) codes were used to identify the procedures. Multivariate logistic regressions were used to calculate propensity score adjusted odds ratios (ORs) for all cause 30-day re-admissions.

RESULTS

There were 109,900 patients who underwent laparoscopic bariatric surgeries (67.5% LSG and 32.5% LRYGB). Readmissions were reported in 4168 (3.8%) of the patients and were more common among RYGB recipients compared to LSG (5.6% versus 2.9%, P < 0.001). The odds of 30-day readmissions were significantly higher among LRYGB group compared to LSG group (AOR, 2.20; 95% CI; 1.83, 2.64). In addition, variables such as age, chronic obstructive pulmonary disease, hypertension, bleeding disorders, blood urea nitrogen, SGOT, alkaline phosphatase, hematocrit, and operation time were significantly predicting readmission rates.

CONCLUSIONS

Readmission rates were significantly higher among those receiving LRYGB, compared to LSG. Readmission was also affected by many patient factors. The factors could help patients and providers to make informed decisions for selecting appropriate procedures.

S136-operationalizing an enhanced recovery protocol after bariatric surgery: single institutional pilot experience forging data-driven standard work

BACKGROUND

Enhanced recovery protocols (ERPs) after metabolic and bariatric surgery (MBS) may help decrease length of stay (LOS) and postoperative nausea/vomiting but implementation is often fraught with challenges. The primary aim of this pilot study was to standardize a MBS ERP with a real-time data support dashboard and checklist and assess impact on global and individual element compliance. The secondary aim was to evaluate 30 day outcomes including LOS, hospital readmissions, and re-operations.

METHODS AND PROCEDURES

An ERP, paper checklist, and virtual dashboard aligned on MBS patient care elements for pre-, intra-, and post-operative phases of care were developed and sequentially deployed. The dashboard includes surgical volumes, operative times, ERP compliance, and 30 day outcomes over a rolling 18 month period. Overall and individual element ERP compliance and outcomes were compared pre- and post-implementation via two-tailed Student's t-tests.

RESULTS

Overall, 471 patients were identified (pre-implementation: 193; post-implementation: 278). Baseline monthly average compliance rates for all patient care elements were 1.7%, 3.7%, and 6.2% for pre-, intra-, and post-operative phases, respectively. Following ERP integration with dashboard and checklist, the intra-operative phase achieved the highest overall monthly average compliance at 31.3% (P < 0.01). Following the intervention, pre-operative acetaminophen administration had the highest monthly mean compliance at ≥ 99.1%. Overall TAP block use increased 3.2-fold from a baseline mean rate of 25.4-80.8% post-implementation (P < 0.01). A significant decrease in average intra-operative monthly morphine milligram equivalents use was noted with a 56% drop pre- vs. post-implementation. Average LOS decreased from 2.0 to 1.7 days post-implementation with no impact on post-operative outcomes.

CONCLUSION

Implementation of a checklist and dashboard facilitated ERP integration and adoption of process measures with many improvements in compliance but no impact on 30 day outcomes. Further research is required to understand how clinical support tools can impact ERP adoption among MBS patients.

Incidence and risk factors for early gastrojejunostomy anastomotic stricture requiring endoscopic intervention following laparoscopic Roux-en-Y gastric bypass: a MBSAQIP analysis

BACKGROUND

Gastrojejunostomy (GJ) stricture is one of the most commonly recognized complications following laparoscopic Roux-en-Y gastric bypass (LRYGB). The risks involving the formation of early GJ stomal stenosis are largely unknown. The aims of this study are to evaluate the rate and risk factors associated with GJ stricture in patients requiring esophagogastroduodenoscopy (EGD) within 30 days after LRYGB.

METHODS

This is a retrospective study of patients who underwent EGD for GJ stricture following LRYGB. Data were retrieved from MBSAQIP database from 2015 to 2018. Descriptive, bivariate, and logistic regression analyses were performed. Those who had reoperation, readmission, and intervention for other indications rather than GJ stricture were excluded from the risk factor analysis.

RESULTS

760,076 patients underwent bariatric surgery. Of these, 184,660 (24.3%) underwent LRYGB and 875 had GJ stricture within 30 days postoperatively. The overall incidence of early GJ stricture after LRYGB was 4.7 per 1000 person-years. The incidence decreased from 6.2 to 3.4 per 1000 person-years during the 4-year period. 85% of patients with GJ stricture required therapeutic intervention. Median (IQR) day to the first endoscopic intervention was 25 (21-28) days. The overall 30-day readmission rate was 40%. 30-day reoperation rate due to GJ stricture was 5.6%. No 30-day mortality occurred. Factors independently associated with an increased risk for early GJ stricture include concurrent hiatal hernia repair (Adjusted Odds Ratio-AOR 1.8, 95% CI 1.5-2.2), revision case (AOR 1.4, 95% CI 1.1-1.6), African American (AOR 1.4, 95% CI 1.2-1.7), gastroesophageal reflux disease-GERD (AOR 1.4, 95% CI 1.2-1.5), drain placement (AOR 1.3, 95% CI1.1-1.4), and routine postoperative swallow study (AOR 1.3, 95% CI 1.1-1.50).

CONCLUSION

The incidence of early GJ stricture following LRYGB decreased at MBSAQIP-accredited centers over the review period. Patients having additional manipulation at or around GJ were at risk of developing early GJ stricture after LRYGB.

Anesthesia and Enhanced Recovery After Surgery in Bariatric Surgery

The Enhanced Recovery After Surgery Society published guidelines for bariatric surgery reviewing the evidence and providing specific care recommendations. These guidelines emphasize preoperative nutrition, multimodal analgesia, postoperative nausea and vomiting prophylaxis, anesthetic technique, nutrition, and mobilization. Several studies have since evaluated these pathways, showing them to be safe and effective at decreasing hospital length of stay and postoperative nausea and vomiting. This article emphasizes anesthetic management in the perioperative period and outlines future directions, including the application of Enhanced Recovery After Surgery principles in patients with extreme obesity, diabetes, and metabolic disease and standardization of the pathways to decrease heterogeneity.

Risk Factors for Readmission After Same-Day Discharge Sleeve Gastrectomy: a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Database Analysis

Background

Same-day discharge after sleeve gastrectomy (SG) is gaining popularity. We aimed to determine risk factors associated with readmission in patients who underwent same-day discharge SG.

Methods

We performed a retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for the period 2015–2018. Patients who underwent SG and were discharged the same day of the operation were included in the analysis. Multivariable logistic regression analysis was performed to determine risk factors for readmission.

Results

A total of 466,270 SG were performed during the study period; 14,624 (3.1%) patients were discharged the same day and were included in the analysis. Mean age was 43.4 (14.7–80) years and 11,718 (80.1%) were female. Mean preoperative BMI was 43.7 ± 7.4 kg/m². Mean operative time was 58.3 ± 32.4 min. Thirty-day reoperation, reintervention, and mortality rates were 0.7%, 0.7%, and 0.1%, respectively. Readmission rates were similar in same-day discharge and inpatient SG (2.9% vs. 3%, p = 0.5). Female sex (OR 1.52, 95% CI 1.15–2.00), preoperative gastroesophageal reflux disease (OR 1.33, 95% CI 1.08–1.64), renal insufficiency (OR 3.06, 95% CI 1.01–9.32), and intraoperative drain placement (OR 1.78, 95% CI 1.37–2.31) were independent risk factors for readmission following same-day discharge SG.

Conclusions

Same-day discharge SG appears to be safe and is associated with low readmission rates. However, the identification of preoperative and intraoperative variables associated with higher risk of readmission might help defining safer and more effective same-day discharge protocols.

Graphical abstract

Factors that Hinder 24-Hour Discharge After Laparoscopic Roux-en-Y Gastric Bypass: a Retrospective Analysis at a Low-Volume Center

Purpose

This study aimed to identify factors that hinder 24-h patient discharge after laparoscopic Roux-en-Y gastric bypass (LRYGB) in a low-volume practice.

Material and Methods

Consecutive patients who fulfilled regional criteria and underwent primary LRYGB from 2018 to 2020 were retrospectively analyzed. Patients were discharged on the morning of the first postoperative day (POD1) after meeting the predefined criteria. The assessed outcome measures (POD1 vital signs, laboratory findings, pain scores and nausea/vomiting) and 30-day postoperative complications were compared between the early (stay ≤ 24 h) and delayed (>24 h) groups.

Results

For 107 patients who fulfilled the inclusion criteria, 48 (44.9%) were discharged within 24 h. There were no differences in the baseline demographics, except that the early group was more likely to have a previous abdominal operation (35.4% vs. 16.9%). Both groups had similar operation durations (89 min vs. 92 min), but the early group had a markedly shortened length of stay (23 (24–22) h vs. 27 (47–26) h). The POD1 parameters were the same between the groups, except that the delay group had a significantly higher visual analog scale score, with fewer patient scores of 0. Patients who were younger and female were more likely to need additional IV analgesics. No POD1 antiemesis was required throughout the study. There was no increase in the 30-day complications.

Conclusion

Patient discharge at 24 h post-LRYGB is feasible and safe in a low-volume practice. A more comprehensive pain relief strategy may be required before generalizing this approach.

Graphical abstract

Successful Implementation of Enhanced Recovery After Surgery in a Single-Surgeon Bariatric Practice

The feasibility and safety of unselectively applying an enhanced recovery after surgery (ERAS) protocol in a low-volume bariatric unit were determined. Retrospectively, review patients undergoing bariatric surgeries between 2015 and 2018 were included, and those receiving non-primary procedures or with BMI <32.5 kg/m² were excluded. Demographics and 30-day outcomes were collected and compared between the ERAS (2017-2018) and control (2015-2016) groups. 62 (40.8%) were treated before and 90 (59.2%) were treated after ERAS. No differences in baseline demographics, except ERAS group had more Roux-en-Y gastric bypass procedures (58.9% vs. 12.9%). A markedly reduced operation time (101 min vs. 147 min) and shortened length of stay (2.6 days vs. 3.3 days) were observed with no increment of ER visits, readmissions (1.1% vs. 4.8%), or total complications between the groups (5.5% vs. 9.7%). Unselective ERAS implementation in low-volume units is feasible and safe, with significantly reduced operation times and shortened LOS without increased complications.

Advancing the Time to the Initiation of Adjuvant Chemotherapy and Improving Postoperative Outcome: Enhanced Recovery after Surgery in Pancreaticoduodenectomy

Early initiation of chemotherapy could improve overall survival after pancreaticoduodenectomy (PD). The concept of enhanced recovery after surgery (ERAS), which aims to reduce the stress response to surgery and accelerate recovery, is relatively limited in PD. The aim of the study was to retrospectively analyze the relationships of ERAS with the time of initiation of postoperative chemotherapy and recovery in PD patients. Between January 1, 2008 and December 31, 2017, all patients who underwent open PD for malignant tumor at our unit were studied retrospectively. Patients were divided into ERAS and conventional groups. The time to initiation of adjuvant chemotherapy and postoperative outcomes were analyzed. There were 344 consecutive patients in this study, with 203 patients in the ERAS group. There were no significant differences between the ERAS and conventional groups in morbidity, mortality, and readmission. The median time of initiation of adjuvant chemotherapy in the ERAS group (54.1 days) was significantly shorter than that of initiation of adjuvant chemotherapy in the conventional group (67.8 days). The ERAS group had a shorter postoperative length of stay than the conventional group (14.9 vs 19.3 days). The ERAS program is safe and feasible in PD. These protocols improve postoperative recovery and advance the time of initiation of adjuvant chemotherapy.

Postoperative Remote Monitoring with a Transcutaneous Biosensing Patch: Preliminary Evaluation of Data Collection

Introduction. Connected systems transmitting vital parameters could well represent a tool to shorten postoperative hospital stay while providing continuous remote patient monitoring and potentially detect the onset of complications. Our aim was to analyze the functionality of a transcutaneous biosensing data collection patch in morbidly obese patients. Materials and Methods. An adhesive patch (The HealthPatch MD™) was applied to patients' chests postoperatively. The patch was connected to a tablet via a bluetooth network to collect the heart rate, respiratory rate, skin temperature, and posture recognition data. The tablet conveyed data to a secure health data central server by means of a WiFi or 3G/4G transmission. Data were stored in a digital health platform to which health care professionals could connect. The evaluation focused on the volume, quality, and security of data transmission. A pilot phase involved 10 patients. Thirty-three additional patients undergoing bariatric surgery were included in the experimental phase. Results. The mean length of stay was 2.28 days (range: 2-5 days). The mean time of patch application was 51 ± 25.2 hours per patient (range: 19-139 hours), totalizing 1,683 hours of recording for the 33 patients included. During this time, a total of 7.562.531 data measurement points were collected and transmitted to the e-health platform via the patch. Two total disconnections and two partial disconnections were observed. The acquisition of patient postural data was unreliable. Conclusions. Connected telemetry for remote postoperative monitoring is promising. However, it is still limited by data transmission problems.

Fast Track Program in Conversion Bariatric Surgery, as Safe as in Primary Bariatric Surgery?

OBJECTIVES

Evaluate the safety of fast track (FT) surgery program in patients undergoing primary and revisional bariatric surgery (conversion from one procedure to another); identify limiting factors for early discharge and predictive factors for readmission.

METHODS

This is a retrospective review of 730 consecutive morbidly obese patients who underwent bariatric surgery between January 2016 and December 2017. Fast track protocol was applied on all patients. Target discharge was after one-night stay. The primary end point is length of stay. The secondary end point is frequency of hospital contact after discharge, readmissions and reinterventions within 30 days.

RESULTS

Primary procedures (n = 633) were banded Roux-en-Y gastric bypass (BRYGB, 79.3%), sleeve gastrectomy (10.7%), gastric band (4.7%) and others (5.3%). Mean age (± SD) was 44.32 ± 11.26 years, and mean BMI (± SD) was 43.58 ± 6.12 kg/m². Conversion procedures (n = 97) were gastric band to BRYGB (40.2%), or to adjustable BRYGB (39.2%), Mason to BRYGB (11.3%), sleeve to BRYGB (4.1%) and others (5.2%). Mean age (± SD) was 47.22 ± 9.1 years, and mean BMI (± SD) was 37.9 ± 7.27 kg/m². Mean LOS in primary patients was 1.3 ± 0.99, and that in conversion patients was 1.5 ± 1.4. Successful discharge at one night or less was achieved in 650 cases (573 primary and 77 conversion). After one-night discharge, incidence of contact to the hospital, readmission and reintervention was 23.9%, 5.9% and 1.9%, in the primary group and 31.2%, 13% and 5.2% in the conversion group.

CONCLUSION

One-night discharge in FT managed conversion procedures is safe, compared to primary procedures. It is associated with higher readmission rates; however, the postdischarge hospital contacts and surgical complications were not statistically significant different.

A Single-center Experience Examining the Length of Stay and Safety of Early Discharge After Laparoscopic Roux-en-Y Gastric Bypass Surgery

PURPOSE

This study's objective was to describe our experience and evaluate the safety of early discharge (ED) following laparoscopic Roux-en-Y gastric bypass (LRYGB) in a specific patient population.

MATERIALS AND METHODS

Patients undergoing LRYGB at Montefiore Medical Center were retrospectively reviewed. Patients readmitted in the first 30 days following surgery were compared to those patients who were not readmitted. Data analysis was used to compare groups and to determine factors associated with readmission. In addition to patient demographics, length of stay (LOS) was analyzed as an independent risk factor for readmission.

RESULTS

A total of 630 LRYGB were performed during this period. There were 5.1% (n = 32) of patients that required readmission within 30 days of discharge. Readmitted patients had a higher BMI (50.0 vs. 45.8; p = 0.006) and there was a trend for them to be younger (38.4 years vs. 42.0; p = 0.07). There was an increased rate of ED in 2015 (36.7%, n = 121) compared to 2014 (29.9%, n = 90). The readmission rate for ED for the study period was 4.7% (n = 10). There were no observed mortalities in our early discharge group of patients.

CONCLUSIONS

Discharge on post-operative day 1 following a LRYGB is safe and is not associated with an increased likelihood of being readmitted within 30 days of discharge. Our single-center experience helps to better characterize current patient profiles and length of stay trends within the field and can be used to establish a randomized controlled trial for discharging patients early after LRYGB.

Preoperative Clinical Factors Associated with Short-Stay Laparoscopic Appendectomy

BACKGROUND

Outpatient appendectomy for acute appendicitis is a feasible, yet not widely performed procedure, as there are no universally accepted criteria for patient selection. The aim of this study was to assess preoperative clinical factors associated with successful short-stay appendectomy (SSA) and establish a predictive score to help with patient selection.

METHODS

All consecutive laparoscopic appendectomies performed in our institution between January 2013 and June 2015 were retrospectively analyzed. Several preoperative clinical and biological variables were compared between patients with SSA, defined as a postoperative stay <24 h, and those needing inpatient care. Logistic regression analysis was used to identify variables independently associated with SSA, and these variables were then used to create a predictive score.

RESULTS

A total of 578 patients were included, 303 (53%) in the SSA group and 275 (48%) in the long-stay appendectomy (LSA) group. In multivariate analysis, male gender (OR 1.61, 95% CI 1.12-2.31, p = 0.010), ASA class I-II (OR 9.52, 95% CI 1.65-180.69, p = 0.037), absence of generalized guarding (OR 3.55, 95% CI 1.30-11.41, p = 0.019), C-reactive protein <100 mg/dl (OR 3.09, 95% CI 1.81-5.42, p < 0.001) and leukocyte count <20 g/l (OR 2.06, 95% CI 1.02-4.30, p = 0.046) were independently associated with SSA. These five parameters were used to construct a predictive score, whereby ≥17 (range 0-21) was defined as the optimal threshold to predict SSA with a high sensitivity (95.6%) and negative predictive value (82.2%).

CONCLUSIONS

A purely clinical predictive score based on five widely used preoperative parameters can be used to identify eligible patients for short-stay appendectomy.

Impact of Index Surgical Care Setting on Perioperative Outcomes and Cost Following Penile Prosthesis Surgery

BACKGROUND

Penile prosthesis surgery has witnessed a migration from the inpatient to ambulatory surgical care setting. However, little is known about the cost savings afforded by this change in care setting and whether or not these savings come at the expense of worse perioperative outcomes.

AIM

The aim of this study was to identify predictors of index penile prosthesis (PP) surgery care setting, and whether ambulatory vs inpatient surgery is associated with comparable perioperative outcomes and costs.

METHODS

This was a retrospective cohort study using all-payer claims data from the 2014 Healthcare Cost and Utilization Project State Databases from Florida and New York. Patient demographics, regional data, total charges (converted to costs), and 30-day revisit rates were abstracted for all patients undergoing index placement of an inflatable or malleable PP. Multivariable logistic and linear regression adjusted for facility clustering was utilized.

OUTCOMES

The outcomes were index surgical and 30-day postoperative costs, as well as 30-day revisit rates.

RESULTS

Of the 1,790 patients undergoing an index surgery, 394 (22.0%) received care in the inpatient setting compared to 1,396 (78.0%) in the ambulatory setting. Adjusted index procedural ($9,319.66 vs $ 10,191.35; P < .001) and 30-day acute care costs ($9,461.74 vs $10,159.42; P < .001) were lower in the ambulatory setting. The underinsured experienced lower odds of receiving surgery in the ambulatory setting (Medicaid vs private: odds ratio [OR] 0.19; 95% CI 0.06-0.55; P < .001). There was no difference in risk-adjusted odds of experiencing a 30-day revisit between patients undergoing surgery in the ambulatory vs inpatient settings (OR 1.31; 95% CI 0.78-2.21; P = .3).

CLINICAL TRANSLATION

Ambulatory PP surgery confers significant cost savings and is associated with comparable perioperative outcomes relative to inpatient-based surgery.

CONCLUSIONS

Both clinical and nonclinical factors predict the care setting of index PP surgery. Notably, underinsured patients experienced lower odds of undergoing ambulatory surgery. Ambulatory surgery was less costly with similar 30-day revisit rates relative to inpatient-based care. Berger A, Friedlander DF, Herzog P, et al. Impact of Index Surgical Care Setting on Perioperative Outcomes and Cost Following Penile Prosthesis Surgery. J Sex Med 2019;16:1451-1458.

Enhanced recovery after surgery (ERAS) in one-anastomosis gastric bypass surgery: a matched-cohort study

BACKGROUND

One-anastomosis gastric bypass (OAGB) is considered new from the bariatric standpoint.

OBJECTIVES

To assess the effectiveness and safety of the enhanced recovery after surgery protocol compared with the conventional approach in perioperative care of OAGB patients.

SETTING

Turkey.

METHODS

The prospectively collected data of 92 patients managed with standard care (group 1) were compared with 216 patients managed by the enhanced recovery after surgery pathway (group 2). All patients underwent OAGB by the same surgeon. The groups were compared in terms of mean postoperative length of stay; costs for surgery and recovery; and rates of complications, emergency room visits, and readmissions.

RESULTS

Length of stay was always 5 days in group 1 and had a mean of 1.2 ± 1.3 days in group 2 (P < .001). The mean total cost for surgery and recovery was 858.6 ± 33.1 USD in group 1 and 625.2 ± 289.1 USD in group 2 (P < .001). Specific complications (Clavien-Dindo IIIa) occurred in 1 patient (1.1%) in group 1 and in 3 patients (1.4 %) in group 2 (P = 1.000). Fifty-seven patients (61.9%) in group 1 and 45 (20.9%) in group 2 visited the emergency room within 1 month of being discharged (P < .001). Two patients (.9%) in group 2 needed hospital readmission; there was no need for rehospitalization in group 1 (P < .001).

CONCLUSION

The enhanced recovery after surgery pathway significantly reduces length of stay and cost after OAGB, with no significant difference in terms of surgical outcomes. It also reduces postdischarge resource utilization.

Same-Day Discharge after Laparoscopic Roux-en-Y Gastric Bypass: An Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Database

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been performed with successful discharge on postoperative day 1 (POD1). There are limited studies on same-day discharge after LRYGB. The objective of this study was to examine the frequency and outcomes of same-day discharge after LRYGB.

STUDY DESIGN

The 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was analyzed for adult patients who underwent elective LRYGB cases with same-day vs POD1 discharge. Open and revisional cases were excluded. Multivariate analysis was performed to compare risk-adjusted 30-day mortality, overall morbidity, readmission, and reoperation.

RESULTS

There were 354 (0.9%) patients who were discharged on the same day as surgery after LRYGB. After exclusion criteria, 319 patients with same-day discharge and 9,402 patients with POD1 discharge were examined. For same-day vs POD1 discharge groups, mean ages were 45.0 and 44.5 years, respectively, and mean BMIs were 47.3 kg/m² and 45.9 kg/m², respectively. The unadjusted mortality rate was significantly higher for same-day compared with POD1 discharge (0.94% vs. 0.05%, respectively; p = 0.0017). Compared with POD1 discharge, same-day discharge had higher overall morbidity (3.76% vs 1.54%; adjusted odds ratio [AOR] 2.41; p = 0.0216), but no statistically significant differences for readmissions (3.45% vs. 3.66%; AOR 0.85; p = 0.9999) or reoperations (1.88% vs. 0.89%; AOR 2.33; p = 0.2428).

CONCLUSIONS

Same-day discharge after LRYGB is associated with increased morbidity and mortality compared with POD1 discharge. The practice of same-day discharge after LRYGB should be considered experimental until further studies confirm which patient characteristics will ensure safe same-day discharge.

Fast-Track in Bariatric and Metabolic Surgery: Feasibility and Cost Analysis Through a Matched-Cohort Study in a Single Centre

BACKGROUND

Due to the rise in severe obesity in Western countries and the increase in bariatric surgery, enhanced recovery (ER) pathways should be developed and promoted.

METHODS

A monocentric prospective series of 103 bariatric surgery patients managed with the ER pathway (group ER) was compared with a retrospective and immediately previous series of 103 patients managed with standard care (group CS). The aim of the present study was to assess and compare the differences in terms of mean postoperative length of stay (LOS), costs for surgery and recovery, and the differences in terms of complications, readmission, and reoperation rate in the short term between the ER and CS groups.

RESULTS

The mean LOS was 4.18 days in group CS and 1.79 days in group ER (p < 0.0001). The mean operative time (OT) per patient was 190.20 min in the group CS and 133.54 min in the group ER, resulting in an average cost of 7272.57€ per patient in group CS and 5424.09€ per patient in group ER. The average recovery cost was 1809.94€ for the group CS series and 775.07 for the group ER one. Overall complications (Clavien-Dindo up to II) occurred in 6 patients (5.8 %) in group CS and in 2 patients (1.9 %) in group ER (p = 0.149) and specific complications (Clavien-Dindo IIIb) occurred for 9 patients (8.7 %) in Group CS and for 14 patients (13.5 %) in group ER (p = 0.268) after hospital discharge within 1-month of follow-up. Twelve patients (11.5 %) in group CS and 13 (12.5 %) in group ER were readmitted after discharge (p = 0.831) within 1-month of follow-up; 8 patients (7.7 %) in group CS versus 9 patients (8.8 %) in group ER needed to be reoperated (p = 0.800) within 1-month follow-up.

CONCLUSIONS

Enhanced recovery pathway reduces significantly LOS in bariatric surgical patients and shortens the mean OT of the procedure, with no significant differences in terms of surgical outcomes. Furthermore, recovery charges were lower and operative time was shorter allowing for procedural cost reduction.

Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations

BACKGROUND

During the last two decades, an increasing number of bariatric surgical procedures have been performed worldwide. There is no consensus regarding optimal perioperative care in bariatric surgery. This review aims to present such a consensus and to provide graded recommendations for elements in an evidence-based "enhanced" perioperative protocol.

METHODS

The English-language literature between January 1966 and January 2015 was searched, with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded. After critical appraisal of these studies, the group of authors reached a consensus recommendation.

RESULTS

Although for some elements, recommendations are extrapolated from non-bariatric settings (mainly colorectal), most recommendations are based on good-quality trials or meta-analyses of good-quality trials.

CONCLUSIONS

A comprehensive evidence-based consensus was reached and is presented in this review by the enhanced recovery after surgery (ERAS) Society. The guidelines were endorsed by the International Association for Surgical Metabolism and Nutrition (IASMEN) and based on the evidence available in the literature for each of the elements of the multimodal perioperative care pathway for patients undergoing bariatric surgery.

Readmissions and Emergency Department Visits after Bariatric Surgery at Saudi Arabian Hospital: The Rates, Reasons, and Risk Factors

BACKGROUND

Saudi Arabian hospital readmissions and emergency department (ED) visits following bariatric surgery and discharge have never been investigated. This study aimed to evaluate the rates and reasons of hospital readmissions and ED visits related to surgical weight loss interventions at the King Abdulaziz Medical City - Riyadh.

METHODS

We conducted a retrospective cohort study on 301 patients who underwent bariatric surgery between January 2011 and July 2016. We reviewed patient medical records progressively to assess hospital readmission, ED visits, and complications.

RESULTS

Of the 301 patients analyzed, 67.1% were female and 93% had class II obesity. The readmission rate, ED visit rate after discharge and the rate of either of the two was 8%, 14%,and 18.3%, respectively. The most common causes of readmission were abdominal pain (37.5%), nausea/vomiting (29.2%), and site leak (25%), while the most common causes of ED visits were abdominal pain (59.5%) and nausea/vomiting (16.9%). Readmission rates tended to be higher in older patients (age of patients readmitted 42 ± 12.1 years vs. age of patients not readmitted 34.3 ± 11.8 years; p = 0.002). The rate of readmission tends to increase in patients with overweight or class I obesity (odds ratio (OR) = 20.15), diabetes (OR = 14.82), and obstructive sleep apnea (OR = 14.29). Dyslipidemia was positively associated with ED visits (p = 0.027, OR = 2.87). The rate of readmission or ED visits increased with age, while there were decreases in readmission and ED visits for those who had received gastric sleeve surgery.

CONCLUSIONS

The study reported high rates of readmission and ED visits, thus the effectiveness of different types of weight loss surgeries should be further evaluated, particularly in individuals with complicated medical issues such as diabetes, dyslipidemia, and obstructive sleep apnea.

Current Status of Bariatric and Metabolic Surgery in Korea

Bariatric surgery is considered to be the most effective treatment modality in maintaining long-term weight reduction and improving obesity-related conditions in morbidly obese patients. In Korea, surgery for morbid obesity was laparoscopic sleeve gastrectomy first performed in 2003. Since 2003, the annual number of bariatric surgeries has markedly increased, including adjustable gastric banding (AGB), Roux-en-Y gastric bypass, sleeve gastrectomy, mini-gastric bypass, and others. In Korea, AGB is much more common than in others countries. A large proportion of doctors, the public, and government misunderstand the necessity and effectiveness of bariatric surgery, believing that bariatric surgery has an unacceptably high morbidity, and that it is not superior to non-surgical treatments to improve obesity and obesity-related diseases. The effectiveness, safety, and cost-effectiveness of bariatric surgery have been well demonstrated. The Korean Society of Metabolic and Bariatric Surgery recommend bariatric surgery confining to morbidly obese patients (body mass index ≥40 or >35 in the presence of significant comorbidities).

Advanced Laparoscopic Surgery in a Free-Standing Ambulatory Setting

To decrease the impact and cost of surgery, there is a trend toward developing treatment models for complex conditions on a fully outpatient basis. This is a retrospective study of the initial experience of advanced laparoscopic procedures performed on a same-day outpatient basis in the ambulatory campus of a university hospital. Over 3 years, 55 patients underwent 50 Nissen fundoplications and 5 adrenalectomies. There were 2 intraoperative complications, with no mortality and no conversion. The median postoperative stay was 4.5 hours. Readmission at 1 month was 11%. Data on the nursing postoperative telephone follow-up were available for 50 patients; 34 (62%) were successfully contacted.Twenty four (70%) had no complaint. Preliminary high-level cost data indicate a cost advantage. Advanced laparoscopic procedures can be done safely in a pure ambulatory setting; the current readmission rate can be reduced with improved pain management and better telephone follow-up strategies. Cost savings are likely.

Fast track bariatric surgery: safety of discharge on the first postoperative day after bariatric surgery

BACKGROUND

Fast track recovery pathways have resulted in a multidisciplinary approach to enhance postoperative recovery.

OBJECTIVES

To assess feasibility and outcome of early discharge after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB).

SETTING

The American College of Surgeons National Surgical Quality Improvement Program database was analyzed to identify patients with body mass index≥35 kg/m² who underwent LSG or LRYGB in 2012 and 2013.

METHODS

Patients were allocated to early discharge (ED) when discharged on postoperative (POD) 1 and late discharge (LD) when discharged on POD 2 or 3. Baseline characteristics and 30-day outcomes were compared between the 2 groups.

RESULTS

Records of 15,468 LSG and 16,483 LRYGB patients were analyzed; 5220 patients with LSG (33.7%) and 2960 patients with LRYGB (18%) were discharged on POD 1. The early discharge group had significantly fewer co-morbidities and lower rate of complications and readmission. Thirty-day readmission rate in LSG was 2.8% in ED versus 3.6% in LD (P = .008), and in LRGYB, it was 4.3% in ED versus 5.8% in LD (P = .001). Based on multivariate analysis, early discharge was not an independent risk factor for a higher readmission rate after LSG or LRYGB. Predictors of late discharge were age>50 years, body mass index>50 kg/m², Hispanic or non-Hispanic black race/ethnicity, impaired functional status, diabetes on insulin, chronic steroid/immunosuppressant use, bleeding disorder, being on dialysis, chronic obstructive pulmonary disease, albumin<3.5 mg/dL, longer operative time, and concurrent cholecystectomy.

CONCLUSION

Discharge on POD 1 after LSG and LRYGB is feasible in a considerable proportion of patients. In this subgroup, early discharge is well tolerated and may be associated with lower complication and readmission rates.

Mechanism Underlying the Weight Loss and Complications of Roux-en-Y Gastric Bypass. Review

Various bariatric surgical procedures are effective at improving health in patients with obesity associated co-morbidities, but the aim of this review is to specifically describe the mechanisms through which Roux-en-Y gastric bypass (RYGB) surgery enables weight loss for obese patients using observations from both human and animal studies. Perhaps most but not all clinicians would agree that the beneficial effects outweigh the harm of RYGB; however, the mechanisms for both the beneficial and deleterious (for example postprandial hypoglycaemia, vitamin deficiency and bone loss) effects are ill understood. The exaggerated release of the satiety gut hormones, such as GLP-1 and PYY, with their central and peripheral effects on food intake has given new insight into the physiological changes that happen after surgery. The initial enthusiasm after the discovery of the role of the gut hormones following RYGB may need to be tempered as the magnitude of the effects of these hormonal responses on weight loss may have been overestimated. The physiological changes after RYGB are unlikely to be due to a single hormone, or single mechanism, but most likely involve complex gut-brain signalling. Understanding the mechanisms involved with the beneficial and deleterious effects of RYGB will speed up the development of effective, cheaper and safer surgical and non-surgical treatments for obesity.

Factors influencing 30-day emergency visits and readmissions after sleeve gastrectomy: results from a community bariatric center

INTRODUCTION

Bariatric surgery has proven safe and effective for long-term weight loss in morbidly obese patients. Readmissions within 30 days of discharge have become an important metric for quality of care. Sleeve gastrectomy is a common bariatric procedure, but data regarding early readmission is sparse. The purpose of this study is to determine what, if any, demographic or technical factors influence returns to the hospital or readmission following sleeve gastrectomy.

METHODS

All laparoscopic sleeve gastrectomies (n = 200) performed at a single community hospital from February 2009 to November 2012 were retrospectively reviewed. Demographic, technical, length of stay, return to Emergency Department (ED) and readmission data were gathered for each patient. The data were analyzed to determine what factors were related to early return to the Emergency Department or readmission.

RESULTS

Demographics were similar to other studies, with a male to female ratio of 1:4. Patients returning to the ED or readmitted within 30 days were statistically younger than those not returning. None of the other demographic, social, technical, or comorbid conditions considered were associated with a statistically significant risk of readmission or return to the ED within 30 days.

CONCLUSION

Although the only statistically significant difference among the groups studied was age, trends toward significance exist in minority ethnicity and comorbid asthma. These factors have been associated with increased complications in other types of surgery. Larger, multi-institutional studies are needed to further evaluate these and other risk factors for readmission following bariatric surgery.

Fast-track bariatric surgery improves perioperative care and logistics compared to conventional care

BACKGROUND

Due to the increased incidence of morbid obesity, the demand for bariatric surgery is increasing. Therefore, the methods for optimising perioperative care for the improvement of surgical outcome and to increase efficacy are necessary. The aim of this prospective matched cohort study is to objectify the effect of the fast-track surgery (FTS) programme in patients undergoing primary Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) surgery compared to conventional perioperative care (CPC).

METHODS

This study compared the perioperative outcome data of two groups of 75 consecutive morbid obese patients who underwent a primary LRYGB according to international guidelines in the periods January 2011-April 2011 (CPC group) and April 2012-June 2012 (FTS group). The two groups were matched for age and sex. Primary endpoints were surgery and hospitalisation time, while secondary endpoints were intraoperative medication use and complication rates.

RESULTS

Baseline patient characteristics for age, sex, weight and ASA classification were similar (p > 0.05) for CPC and FTS patients. BMI and waist circumference were significantly lower (p < 0.05) in the FTS compared to CPC. The total time from arrival at the operating room to the arrival at the recovery was reduced from 119 to 82 min (p < 0.001). Surgery time was reduced from 80 to 56 min (p < 0.001); mean hospital stay was reduced from 65 to 43 h (p < 0.001). Major complications occurred in 3 versus 4 % in the FTS and CPC, respectively.

CONCLUSIONS

The introduction of a fast-track programme after primary LRYGB improves short-term recovery and may reduces direct hospital-related resources.

Fast-Track Programs for Liver Surgery: A Meta-Analysis

BACKGROUND AND OBJECTIVES

Plentiful publications have inspected the feasibility of fast-track surgery programs during hepatic surgery, but the potency of these studies has not been discussed profoundly so far. Our goal was to assess the effects of fast-track programs on surgical outcomes compared with traditional surgical plans for liver surgery.

METHODS

The following databases were searched: PubMed, Cochrane library, Embase, Science Citation Index Expanded, etc. Studies meeting our inclusion criteria were included. All interrelated data and the methodological quality of included studies were extracted and assessed. We applied risk ratio and weighted mean difference as the estimated effect measures. Sensitivity analysis was performed to perceive the reliability of our findings.

RESULTS

Altogether, 14 studies with 1400 patients were analyzed. Meta-analysis of randomized controlled trials demonstrated that implementation of fast-track surgery programs could observably decrease the total length of hospital stay, complication rate, postoperative first flatus time, and hospitalization expense, and did not compromise mortality and readmission rate. The above findings were also in line with the results of case-control studies.

CONCLUSIONS

Fast-track surgery programs are feasible and effective for liver surgery. Future studies should optimize fast-track surgery programs catering to liver surgery.

The relationship between duration of stay and readmissions in patients undergoing bariatric surgery

BACKGROUND

Hospital readmissions are a quality indicator in bariatric surgery. In recent years, duration of stay after bariatric surgery has trended down greatly. We hypothesized that a shorter postoperative hospitalization does not increase the likelihood of readmission.

METHODS

The University HealthSystem Consortium (UHC) is an alliance of academic medical centers and affiliated hospitals. The UHC's clinical database contains information on inpatient stay and returns (readmissions) up to 30 days after discharge. A multicenter analysis of outcomes was performed by the use of data from the January 2009 to December 2013 for patients 18 years and older. Patients were identified by bariatric procedure International Classification of Diseases, Ninth Revision, codes and restricted by diagnosis codes for morbid obesity.

RESULTS

A total of 95,294 patients met inclusion criteria. The mean patient age was 45.4 (±0.11) years, and 73,941 (77.6%) subjects were female. There were 5,423 (5.7%) readmissions within the study period. Patients with hospitalizations of 3 days and more than 3 days were twice and four times as likely to be readmitted than those with hospitalizations of one day, respectively (P < .001).

CONCLUSION

Patients with longer postoperative hospitalizations were more likely to be readmitted after bariatric surgery. Early discharge does not appear to be associated with increased readmission rates.

Is there a role for enhanced recovery after laparoscopic bariatric surgery? Preliminary results from a specialist obesity treatment center

BACKGROUND

There has been a relative lack of research on the effect of enhanced recovery in the context of morbid obesity surgery.

OBJECTIVES

To determine if the application of enhanced recovery after surgery (ERAS) principles can contribute to reduce postoperative hospital length of stay after bariatric surgery, controlling for other factors that may influence safe discharge on the first postoperative day.

SETTING

University teaching hospital, United Kingdom.

METHODS

Between February 2011 and December 2014, prospectively collected data on all patients undergoing laparoscopic bariatric surgery under the care of a single surgeon were reviewed. From January 2012, all patients were enrolled in an ERAS protocol and were assessed for fitness for early discharge (within 24 hr from the operation). Baseline patient characteristics and additional concomitant procedures data were compared for patients treated before and after implementation of the ERAS protocol; 30-day readmission data were analyzed for patients discharged on the first postoperative day and those discharged later. The effect of the implementation of the ERAS protocol on discharge on the first postoperative day was analyzed using multivariate analysis, while taking into account the effects of potential confounders (e.g., age, gender, American Society of Anesthesiologists [ASA] grade, concomitant surgical procedures, etc.).

RESULTS

Two-hundred and eighty-eight consecutive patients underwent bariatric surgery. Of these, 278 (96.5%) were potentially suitable for early discharge, while 10 (3.5%) patients developed an acute postoperative complication that delayed discharge irrespective of the effect of ERAS. All these patients required a reoperation within 48 hours and therefore were not considered suitable for early discharge and were not included in the statistical analysis. During the entire study period, 100 of 278 (36%) patients were discharged on the first postoperative day, 28.5% after laparoscopic Roux-en-Y gastric bypass (LRYGB) and 60.9% after laparoscopic sleeve gastrectomy (LSG); 178 of 278 (64%) patients were discharged after ≥ 2 days (mean: 2.58, range: 2-5). After implementation of the ERAS protocol in January 2012, the rate of patients discharged on the first postoperative day increased significantly from 1.6% to 39.7% after LRYGB (P<.01). Early discharge increased from 50% to 67.5% after LSG; although this change did not reach statistical significance (P = .294), it nevertheless represents a clinically relevant result. Four (4%) patients were readmitted after having been discharged on the first postoperative day, 10 (5.3%) patients after having been discharged ≥ 2 postoperative days. This difference was not statistically significant (P = .620).

CONCLUSIONS

The implementation of an enhanced recovery program after bariatric surgery is feasible, well tolerated, and can significantly reduce the length of hospital stay without increasing readmission rates. Controlling for several possible confounders, implementation of the ERAS protocol remained the strongest predictor of discharge on the first postoperative day after laparoscopic bariatric surgery.

One hundred seventy-nine consecutive bariatric operations after introduction of protocol inspired by the principles of enhanced recovery after surgery (ERAS®) in bariatric surgery

Background

Obese patients are a very large high-risk group for complications after surgical procedures. In this group, optimized perioperative care and a faster recovery to full activity can contribute to a decreased rate of postoperative complications. The introduction of ERAS^®-based protocol is now even more important in bariatric surgery centers. The results of our study support the idea of implementation of ERAS^®-based protocol in this special group of patients.

Material/Methods

This analysis included 170 patients (62 male/108 female, mean BMI 46.7 kg/m²) who had undergone laparoscopic bariatric surgery, and whose perioperative care was conducted according to a protocol inspired by ERAS^® principles. Examined factors included oral nutrition tolerance, time until mobilization after surgery, requirements for opioids, duration of hospitalization, and readmission rate.

Results

During the first 24 postoperative hours, oral administration of liquid nutrition was tolerated by 162 (95.3%) patients and 163 (95.8%) were fully mobile. In 44 (25.8%) patients it was necessary to administer opioids to relieve pain. Intravenous liquid supply was discontinued within 24 hours in 145 (85.3%) patients. The complication rate was 10.5% (mainly rhabdomyolysis and impaired passage of gastric contents). The average time of hospitalization was 2.9 days and the readmission rate was 1.7%.

Conclusions

The introduction of an ERAS^® principles-inspired protocol in our center proved technically possible and safe for our patients, and allowed for reduced hospitalization times without increased rate of complications or readmissions.

Predicting potentially preventable hospital readmissions following bariatric surgery

BACKGROUND

Using hospital readmissions as a quality of care measure predicates that some readmissions were preventable.

OBJECTIVES

This study identifies predictors of potentially preventable readmissions (PPR) within 30 days of bariatric surgery discharge.

SETTING

New York State acute care hospitals.

METHODS

Adult inpatient surgical discharges, during 2012, with a principal diagnosis of overweight or obesity and a principal procedure for bariatric surgery were identified. Logistic regression was used to evaluate surgical approach, sex, age, race/ethnicity, payor, body mass index, complications and co-morbidities recorded during the surgical admission.

RESULTS

There were 10,448 surgeries studied for readmission of which 552 were followed by a PPR, for a statewide rate of 5.3 per 100 surgeries. Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) was the most common surgical approach (46.0%), then Sleeve Gastrectomy (SG) (41.3%), Laparoscopic Adjustable Gastric Band (LAGB) (8.1%), and Open Roux-en-Y Gastric Bypass (RYGB) (4.6%). RYGB had the highest PPR rate (8.8), followed by LRYGB (6.1), SG (4.3) and LAGB (3.3). Compared to LAGB, the odds of a PPR in patients with RYGB, LRYGB, and SG increased by 2.4 fold, 1.8 fold and 1.2 fold respectively. Black, non-Hispanic patients were at a greater risk of PPR (odds-ratio 2.0, P<.0001) compared to White, non-Hispanic patients while the risk of a PPR increased by 2-fold in patients with a surgical complication.

CONCLUSIONS

Taking all patient risk factors into account, the most significant predictors of a PPR were surgical approach, race and the presence of a surgical complication.