Feasibility of Same-Day Discharge After Laparoscopic Roux-en-Y Gastric Bypass Using Remote Monitoring

Patient Satisfaction and Experience with Same-Day Discharge After Laparoscopic Roux-en-Y Gastric Bypass: A Mixed-Methods study

INTRODUCTION

Same-day discharge (SDD) after laparoscopic Roux-en-Y gastric bypass (RYGB) is a safe and effective healthcare pathway. However, there is limited understanding of the patient perspective on SDD. The aim of this study was to explore patient satisfaction and experience with SDD after RYGB.

METHODS

A mixed-methods study with a concurrent design was conducted in a Dutch teaching hospital, using questionnaires and interviews. Patients who underwent RYGB and were discharged on the day of the surgery completed four questionnaires of the BODY-Q (satisfaction with the surgeon, satisfaction with the medical team, satisfaction with the office staff, and satisfaction with information provision) ± 4 months postoperative. The results of the questionnaires were compared with pre-existing data from a cohort of patients who stayed overnight after surgery (i.e., control group). A subset of patients was individually interviewed for an in-depth understanding of the patient perspective on SDD.

RESULTS

In the questionnaires, median scores for the control group (n = 158) versus the present group of patients (n = 51) were as follows: 92/100 vs. 92/100 (p = 0.331) for the surgeon, 100/100 vs. 92/100 (p = 0.775) for the medical team, 100/100 vs. 100/100 (p = 0.616) for the office staff, and 90/100 vs. 73/100 (p = 0.015) for information provision. Interviews with 14 patients revealed seven themes, describing high satisfaction, along with several points of interest.

CONCLUSIONS

Patient satisfaction with SDD after RYGB is high, although information provision regarding the day of surgery could be improved. However, not every medically eligible patient might be suitable for this healthcare pathway, as responsibilities are shifted.

Ambulatory bariatric surgery: a prospective single-center experience

BACKGROUND

Ambulatory bariatric surgery has recently gained interest especially as a potential way to improve access for eligible patients with severe obesity. Building on our previously published research, this follow-up study delves deeper in the evolving landscape of ambulatory bariatric surgery over a 3-year period, focusing on predictors of success/failure.

METHODS

In a prospective single-center follow-up study, we conducted a descriptive assessment of all eligible patients as per our established protocol, who underwent a planned same-day discharge (SDD) primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) between 03/01/2021 and 02/29/2024. Trends in SDD surgeries over time were assessed over six discrete 6 month intervals. Primary endpoint was defined as a successful discharge on the day of surgery without emergency department visit or readmission within 24 h. Secondary outcomes included 30-day postoperative morbidity.

RESULTS

A total of 811 primary SG and 325 RYGB procedures were performed during the study period. Among them, 30% (n = 244) were SDD-SGs and 6% (n = 21) were SDD-RYGBs, respectively. At baseline, median age of the entire SDD cohort was 43 years old, 81% were females, and body mass index (BMI) was 44.5 kg/m2. The planned SDD approach was successful in 89% after SG (n = 218/244) and in 90% after RYGB (n = 19/21). Nausea/vomiting was the main reason for a failed SDD approach after SG (46%). The 30-day readmission rate was 1.5% (n = 4) for the entire SDD cohort including only one readmission in the first 24 h. The percentage of SDD-SGs performed as a proportion of total SGs increased over the initial five consecutive six-month intervals (14%, 25%, 24%, 38%, and 49%).

CONCLUSION

Our SDD protocol for bariatric surgery demonstrates a favorable safety profile, marked by high success rate and low postoperative morbidity. These outcomes have led to a continued increase in ambulatory procedures performed over time especially SG.

Cost-effectiveness and safety of continuous pulse oximetry for management of undiagnosed obstructive sleep apnea in bariatric surgery: a nationwide cohort study

BACKGROUND

Undetected obstructive sleep apnea (OSA) is highly prevalent in patients undergoing bariatric surgery and increases perioperative risks. Screening for OSA using preoperative polygraphy (PG) with subsequent continuous positive airway pressure (CPAP) is costly and time-consuming. Postoperative continuous pulse oximetry (CPOX) is less invasive, and is hypothesized to be a safe and cost-effective alternative.

OBJECTIVES

This nationwide multicenter prospective observational cohort study compared CPOX monitoring with OSA-screening using PG.

SETTING

High-volume bariatric centers.

METHODS

Patients were either postoperatively monitored using CPOX without preoperative OSA-screening, or underwent preoperative PG and CPAP treatment when OSA was diagnosed. Cohort placement was based on local hospital protocols. Cost-effectiveness was analyzed using quality adjusted life years (QALYs) and healthcare costs. Surgical outcomes were also analyzed. Propensity score matching was used in sensitivity analyses.

RESULTS

A total of 1390 patients were included. QALYs were similar between groups at baseline and 1-year postoperatively. Postoperative complications, intensive care unit (ICU)-admissions and admissions, particularly OSA-related, did not differ between groups. Mean costs per patient/year in the CPOX group was €3094 versus €3680 in the PG group; mean difference €-586 (95% CI €-933-€-242). Following propensity score matching, 1090 of 1390 included patients remained, and similar findings for cost-effectiveness, complications, and ICU admissions were observed.

CONCLUSION

CPOX monitoring without preoperative OSA-screening was not associated with higher complication or readmission rates compared to PG. CPOX resulted in lower costs from a healthcare perspective and can therefore be considered a cost-effective alternative to routine OSA-screening in patients undergoing bariatric surgery.

Patient experience and satisfaction after same-day discharge radical prostatectomy using a personalized, digital perioperative programme

PURPOSE

To assess the patient experience and satisfaction after the implementation in routine of a personalized, digital programme before and after same-day discharge (SDD) robot-assisted radical prostatectomy (RARP).

METHODS

The study is a pre/post-interventional, multi-surgeon, unicentre, prospective study. All consecutive patients undergoing SDD RARP were included during a 6-month period. After a pre-interventional assessment of the satisfaction rate (n = 26), all patients (n = 46) were introduced to the Betty. Care platform and followed the BETTY COACHING programme which included a specific radical prostatectomy module. The primary endpoint was patient satisfaction 6 weeks after SDD RARP. Secondary endpoints were hospital stay, readmission and complications rates, unplanned visits, and remote monitoring data.

RESULTS

Median age and PSA were 66 years and 7.0 ng/ml. Lymph node-dissection and nerve-sparing procedures were performed in 41.3 and 87.0% of patients, respectively. Median operative time and blood loss were 80 min and 150 ml, respectively. The 90-day rates of unplanned visits, readmission and complications were improved after the digital tool implementation (2.2, 2.2, and 8.7%, respectively). Mean satisfaction score was 9.6 out of 10 (8.0 before implementation). Median duration of pain was 2 days after discharge, with median pain intensity of 2/10. Median duration of daily active use of remote monitoring was 34 days. The urinary continence rate was 91.3% 6 weeks after surgery in the postinterventional cohort.

CONCLUSIONS

The implementation of a personalized, surgery-specific, digital programme combining prehabilitation, patient education, rehabilitation, patient-reported outcome measurement and remote monitoring, improves patient experience and satisfaction and could help promoting early discharge even after a major surgery.

Safety of Same-Day Discharge after Bariatric Surgery: Retrospective 6-Year North American Analysis

BACKGROUND

With increasing implementation of Enhanced Recovery After Surgery protocols and rising demand for inpatient hospital beds accentuated by COVID-19, there has been interest in same-day discharge (SDD) for bariatric surgery. The aim of this study was to determine the national trends, safety profile, and risk factors for complications of SDD for minimally invasive bariatric surgery.

STUDY DESIGN

We analyzed the MBSAQIP database from 2016 to 2021 to characterize trends in SDD for minimally invasive bariatric operation. Multivariate logistic regression was performed on preoperative patient characteristics predictive of increased complications associated with SDD. A comparative analysis of postoperative outcomes within 30 days was performed for SDD and admission after 1:1 nearest neighbor propensity score matching for patient demographics and preoperative comorbidities.

RESULTS

SDD increased from 2.4% in 2016 to 7.4% in 2021. Major preoperative factors associated with increased complications for SDD included Black race, history of MI, renal insufficiency, deep vein thrombosis, and smoking. SDD for Roux-en-Y gastric bypass had 72% increased risk of postoperative complications compared with sleeve gastrectomy. The overall major complications were lower in SDD cohort vs admission cohort (odds ratio [OR] 0.62, p < 0.01). However, there was a significant increase in deaths within 30 days (OR 2.11, p = 0.01), cardiac arrest (OR 2.73; p < 0.01), and dehydration requiring treatment (OR 1.33; p < 0.01) in SDD cohort compared with admission cohort.

CONCLUSIONS

Nationally, there has been a rise in SDD for bariatric operation from 2016 to 2021. Matched analysis demonstrates that SDD is associated with a significantly higher mortality rate. Additionally, the risk of complications with SDD is higher for RYGB compared with sleeve gastrectomy. Therefore, further studies are required to appropriately select patients for whom bariatric surgery can be safely performed as an outpatient.

Patient's Preference for Same-Day Discharge or Hospitalization After Bariatric Surgery

PURPOSE

Enhanced Recovery After Bariatric Surgery protocols have proven to be effective in reducing complication rates and length of stay. Guidelines do not include a recommendation on the length of hospital stay whereas same-day discharge is currently widely investigated on safety and feasibility. However, none of these studies takes patient preferences into account. The study aimed to reveal the patient's preference for outpatient surgery (OS) in patients who underwent primary bariatric surgery.

MATERIALS AND METHODS

A single-center preference-based randomized trial was performed between March and December of 2021. Adult patients planned for primary bariatric surgery were able to choose their care pathway, either OS with remote heart and respiratory rate monitoring by a wearable data logger or standard care with at least one-night hospitalization.

RESULTS

Out of the 202 patients, nearly everyone (98.5%) had a preference. Of 199 patients, 99 (49.7%) chose inpatient surgery. Of the 100 with a preference for OS, 23 stayed in the hospital due to medical reasons and 12 patients changed their preference. Based on both initial preference and changed preference, there were no differences between sex, age, body mass index, and co-morbidities such as diabetes mellitus, hypertension, and atrial fibrillation, nor in the use of anticoagulants or type of surgery.

CONCLUSION

Patients seemed to have a strong preference for their stay after a bariatric procedure. The preference is equally divided between outpatient and inpatient surgery and is not influenced by any patient characteristics.

Feasibility of same-day discharge after laparoscopic sleeve gastrectomy in the Netherlands

BACKGROUND

There is a trend towards laparoscopic sleeve gastrectomy (SG) with same-day discharge (SDD), as an efficient healthcare pathway to alleviate the burden on clinical capacity. This approach seems to be safe, if patients are carefully selected. In our bariatric center, a protocol for Roux-en-Y gastric bypass with SDD has already been successfully implemented. The aim of this study was to evaluate feasibility of applying the same SDD protocol for SG.

METHODS

A single-center prospective feasibility study was conducted at a high-volume bariatric center. Low-risk patients who were scheduled for primary SG were included. Strict criteria were used for approval upon SDD. The primary outcome was the rate of successful SDD without readmission within 48 h. Secondary outcomes included short-term complications, emergency department visits, readmissions, and mortality.

RESULTS

Fifty patients were included in the study, of whom 45 were successfully discharged on the same day of the surgery. Nausea and vomiting were the most common reasons for overnight hospitalization (three patients). One patient was readmitted within the first 48 h due to a mild complication related to bleeding, resulting in a success rate of 88% for SDD without readmission within 48 h. No severe complications or mortality were reported in the cohort.

CONCLUSION

Our SDD protocol for SG has demonstrated feasibility, with a high success rate of SDD and no severe complications. Strict conditions should be met for the safe implementation of a SDD protocol, including careful patient selection and the establishment of a safety net to detect early complications.

Implementation of a same-day discharge bariatric surgery program and follow-up with a telemonitoring platform

INTRODUCTION

Some groups have initiated outpatient bariatric surgery programs in selected patients, publishing good results after sleeve gastrectomy. Recent studies show that outpatient surgery is also feasible and safe in Roux-en-Y gastric bypass. The aim of this paper is to describe and analyze the results of our initial experience after the implementation of a same-day discharge bariatric surgery program using a telemonitoring system.

METHODS

We have completed a prospective, observational study with 14 consecutive, selected patients undergoing primary bariatric surgery (sleeve gastrectomy or Roux-en-Y gastric bypass) at a single center from April 2021 to February 2023, with home follow-up using the REVITA® telemonitoring platform (HI Iberia, S.A.) and the Home Hospitalization Unit.

RESULTS

From April 2021 to February 2023, 14 patients were selected for this program, which meant 7.3% of the total of 191 patients who underwent bariatric surgery during this period. Ten out of the 14 patients selected completed the circuit (71.4%), 4 of whom consulted the emergency department within the first 24 h (40%). There were no serious complications, readmissions or re-operations typical of bariatric surgery. The estimated savings per patient who completed the circuit was 762.

CONCLUSION

Bariatric surgery without hospital admission is feasible and safe in selected patients using a telemonitoring platform and with the support of a home hospitalization unit.

Markers for Major Complications at Day-One Postoperative in Fast-Track Metabolic Surgery: Updated Metabolic Checklist

INTRODUCTION

In fast-track metabolic surgery, the window to identify complications is narrow. Postoperative checklists can be useful tools in the decision-making of safe early discharge. The aim of this study was to evaluate the predictive value of a checklist used in metabolic surgery.

METHODS

Retrospective data from June 2018 to January 2021 was collected on all patients that underwent metabolic surgery in a high-volume bariatric hospital in the Netherlands. Patients without an available checklist were excluded. The primary outcome was major complications and the secondary outcomes were minor complications, readmission, and unplanned hospital visits within 30 days postoperatively.

RESULTS

Major complications within 30 days postoperatively occurred in 62/1589 (3.9%) of the total included patients. An advise against early discharge was significantly more seen in patients with major complications compared to those without major complications (90.3% versus 48.1%, P < 0.001, respectively), and a negative checklist (advice for discharge) had a negative predictive value of 99.2%. The area under the curve for the total checklist was 0.80 (P < 0.001). Using a cut-off value of ≥3 positive points, the sensitivity and specificity were 65% and 82%, respectively. Individual parameters from the checklist: oral intake, mobilization, calf pain, willingness for discharge, heart rate, drain (>30 ml/24 h), hemoglobin, and leukocytes count were also significantly different between groups.

CONCLUSION

This checklist is a valuable tool to decide whether patients can be safely discharged early. Heart rate appeared to be the most predictive parameter for the development of major complications. Future studies should conduct prediction models to identify patients at risk for major complications.

Lessons Learned from Telemonitoring in an Outpatient Bariatric Surgery Pathway-Secondary Outcomes of a Patient Preference Clinical Trial

BACKGROUND

Remote monitoring is increasingly used to support postoperative care. This study aimed to describe the lessons learned from the use of telemonitoring in an outpatient bariatric surgery pathway.

MATERIALS AND METHODS

Patients were assigned based on their preference to an intervention cohort of same-day discharge after bariatric surgery. In total, 102 patients were monitored continuously for 7 days using a wearable monitoring device with a Continuous and Remote Early Warning Score-based notification protocol (CREWS). Outcome measures included missing data, course of postoperative heart and respiration rate, false positive notification and specificity analysis, and vital sign assessment during teleconsultation.

RESULTS

In 14.7% of the patients, data for heart rate was missing for > 8 h. A day-night-rhythm of heart rate and respiration rate reappeared on average on postoperative day 2 with heart rate amplitude increasing after day 3. CREWS notification had a specificity of 98%. Of the 17 notifications, 70% was false positive. Half of them occurred between day 4 and 7 and were accompanied with surrounding reassuring values. Comparable postoperative complaints were encountered between patients with normal and deviated data.

CONCLUSION

Telemonitoring after outpatient bariatric surgery is feasible. It supports clinical decisions, however does not replace nurse or physician care. Although infrequent, the false notification rate was high. We suggested additional contact may not be necessary when notifications occur after restoration of circadian rhythm or when surrounding reassuring vital signs are present. CREWS supports ruling out serious complications, what may reduce in-hospital re-evaluations. Following these lessons learned, increased patients' comfort and decreased clinical workload could be expected.

TRIAL REGISTRATION

ClinicalTrials.gov. Identifier: NCT04754893.

Evaluation of Postoperative Care Protocol for Roux-en-Y Gastric Bypass Patients with Same-Day Discharge

INTRODUCTION

Same-day discharge (SDD) after bariatric surgery is increasingly being performed and is safe with careful patient selection. However, detecting early complications during the first postoperative days can be challenging. We developed a postoperative care protocol for these patients and aimed to evaluate its effectiveness in detecting complications and monitoring patient recovery.

METHODS

A single-center retrospective observational study was conducted with patients with who underwent Roux-en-Y Gastric Bypass (RYGB) with successful SDD. The study evaluated the effectiveness of the safety net that included simple remote monitoring with a pulsoximeter and thermometer, a phone consultation on postoperative day (POD) 1, and a physical consultation on POD 2-4. Furthermore, an analysis was performed on various factors including pain scores, painkiller usage, and incidences of nausea and vomiting on POD 1.

RESULTS

In this study, 373 consecutive patients were included, of whom 19 (5.1%) were readmitted until POD 4. Among these, 12 patients (3.2%) reached out to the hospital themselves, while 7 (1.9%) were readmitted after phone or physical consultations. Ten of the readmitted patients had tachycardia. On POD 1, the mean numeric rating scale was 4 ± 2, and 96.6% of the patients used acetaminophen, 35.5% used naproxen, and 9.7% used oxynorm. Of the patients, 13.9% experienced nausea and 6.7% reported vomiting.

CONCLUSION

A postoperative care protocol for SDD after RYGB, comprising simple remote monitoring along with a phone consultation on POD 1 and a physical checkup on POD 2-4, was effective in monitoring patient recovery and detecting all early complications.

Feasibility of Same-Day Discharge After Laparoscopic Roux-en-Y Gastric Bypass in Patients with Well-Regulated Obstructive Sleep Apnea

INTRODUCTION

Same-day discharge after bariatric surgery is increasingly being performed. In current practice, patients with only minor comorbidities are considered eligible for same-day discharge after laparoscopic Roux-en-Y gastric bypass (RYGB). Obstructive sleep apnea (OSA) is a common comorbidity in patients with morbid obesity, with a prevalence of around 70-80% among patients undergoing bariatric surgery. Continuous positive airway pressure (CPAP) is the current gold standard treatment for OSA. We aimed to investigate whether same-day discharge after RYGB is feasible for patients with compliant use of CPAP.

METHODS

In this single-center prospective feasibility study, patients were selected who were scheduled for RYGB and were adequately treated for OSA. Compliance on the use of CPAP had to be proved (> 4 h per night for 14 consecutive nights). There were strict criteria on approval upon same-day discharge. The primary outcome was the rate of successful same-day discharge. Secondary outcomes included short-term complications, emergency department presentations, readmissions, and mortality.

RESULTS

Forty-nine patients underwent RYGB with intended same-day discharge, of whom 45 (92%) were successfully discharged. Three patients had an overnight stay because of divergent vital signs and one patient due to a delayed start of the surgery. Two patients (4%) were readmitted in the first 48 h postoperatively, both due to intraluminal bleeding which was managed conservatively (Clavien-Dindo 2). There were no severe complications in the first 48 h after surgery.

CONCLUSION

Same-day discharge after RYGB can be considered feasible for selected patients with well-regulated OSA.

Same-Day Discharge After Laparoscopic Roux-en-Y Gastric Bypass: a Cohort of 500 Consecutive Patients

INTRODUCTION

There is an increasing demand on hospital capacity worldwide due to the COVID-19 pandemic and local staff shortages. Novel care pathways have to be developed in order to keep bariatric and metabolic surgery maintainable. Same-day discharge (SDD) after laparoscopic Roux-en-Y gastric bypass (RYGB) is proved to be feasible and could potentially solve this challenge. The aim of this study was to investigate whether SDD after RYGB is safe for a selected group of patients.

METHODS

In this single-center cohort study, low-risk patients were selected for primary RYGB with intended same-day discharge with remote monitoring. All patients were operated according to ERAS protocol. There were strict criteria on approval upon same-day discharge. It was demanded that patients should contact the hospital in case of any signs of complications. Primary outcome was the rate of successful same-day discharge without readmission within 48 h. Secondary outcomes included short-term complications, emergency department visits, readmissions, and mortality.

RESULTS

Five hundred patients underwent RYGB with intended SDD, of whom 465 (93.0%) were successfully discharged. Twenty-one patients (4.5%) were readmitted in the first 48 h postoperatively. None of these patients had a severe bleeding. This results in a success rate of 88.8% of SDD without readmission within 48 h.

CONCLUSIONS

Same-day discharge after RYGB is safe, provided that patients are carefully selected and strict discharge criteria are used. It is an effective care pathway to reduce the burden on hospital capacity.

Outcomes of same-day discharge sleeve gastrectomy and Roux-en-Y gastric bypass: a systematic review and meta-analysis

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.

Telemonitoring for perioperative care of outpatient bariatric surgery: Preference-based randomized clinical trial

IMPORTANCE

Implementation of bariatric surgery on an outpatient basis is hampered by concerns about timely detection of postoperative complications. Telemonitoring could enhance detection and support transition to an outpatient recovery pathway.

OBJECTIVE

This study aimed to evaluate non-inferiority and feasibility of an outpatient recovery pathway after bariatric surgery, supported by remote monitoring compared to standard care.

DESIGN

Preference-based non-inferiority randomized trial.

SETTING

Center for obesity and metabolic surgery, Catharina hospital Eindhoven, the Netherlands.

PARTICIPANTS

Adult patients scheduled for primary gastric bypass or sleeve gastrectomy.

INTERVENTIONS

Same-day discharge with one week ongoing Remote Monitoring (RM) of vital parameters or Standard Care (SC) with discharge on postoperative day one.

MAIN OUTCOMES

Primary outcome was a thirty-day composite Textbook Outcome score encompassing mortality, mild and severe complications, readmission and prolonged length-of-stay. Non-inferiority of same-day discharge and remote monitoring was accepted below the selected margin of 7% upper limit of confidence interval. Secondary outcomes included admission duration, post-discharge opioid use and patients' satisfaction.

RESULTS

Textbook Outcome was achieved in 94% (n = 102) in RM versus 98% (n = 100) in SC (RR 2.9; 95% CI, 0.60-14.23, p = 0.22). The non-inferiority margin was exceeded which is a statistically inconclusive result. Both Textbook Outcome measures were above Dutch average (5% RM and 9% SC). Same-day discharge reduced hospitalization days by 61% (p<0.001) and by 58% with re-admission days included (p<0.001). Post-discharge opioid use and satisfaction scores were equal (p = 0.82 and p = 0.86).

CONCLUSION

In conclusion, outpatient bariatric surgery supported with telemonitoring is clinically comparable to standard overnight bariatrics in terms of textbook-outcome. Both approaches reached primary endpoint results above Dutch average. However, statistically the outpatient surgery protocol was neither inferior, nor non-inferior to the standard pathway. Additionally, offering same-day discharge reduces the total hospitalization days while maintaining patient satisfaction and safety.

Is Same-Day Discharge After Roux-en-Y Gastric Bypass Safe? A Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Database Analysis

Purpose

Same-day discharge (SDD) after bariatric surgery is gaining popularity. We aimed to analyze the safety of SDD after Roux-en-Y gastric bypass (RYGB) and compare its outcomes to inpatients discharged on postoperative days 1–2.

Materials and Methods

We performed a retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database for the period 2015–2020. Patients who underwent primary laparoscopic RYGB and were discharged the same day of the operation (SDD-RYGB) and inpatients discharged on postoperative days 1–2 (In-RYGB) were compared. Primary outcomes of interest were overall morbidity, serious morbidity, readmission, reoperation, intervention, and mortality rates.

Results

A total of 167,188 patients were included; 2156 (1.3%) SDD-RYGB and 165,032 (98.7%) In-RYGB. Mean age (SDD-RYGB: 44.5 vs. In-RYGB: 44.6 years), proportion of females (SDD-RYGB: 81.4% vs. In-RYGB: 80.6%), and mean body mass index (SDD-RYGB: 45.8 vs. In-RYGB: 45.9 kg/m²) were similar between groups. Overall morbidity (SDD-RYGB: 11.3% vs. In-RYGB: 10.2%; OR: 1.2, p = 0.08), serious morbidity (SDD-RYGB: 3.1% vs. In-RYGB: 3%; OR: 1.03, p = 0.81), reoperation (SDD-RYGB: 1.4% vs. In-RYGB: 1.2%; OR: 1.16, p = 0.42), readmission (SDD-RYGB: 4.8% vs. In-RYGB: 4.8%; OR: 1.01, p = 0.89), and mortality (SDD-RYGB: 0.04% vs. In-RYGB: 0.09%; OR: 0.53, p = 0.53) were comparable between groups. SDD-RYGB had lower risk of 30-day interventions (SDD-RYGB: 1.1% vs. In-RYGB: 1.6%; OR: 0.64, p = 0.04) compared to In-RYGB.

Conclusion

Same-day discharge after RYGB seems to be safe and has comparable outcomes to admitted patients. Standardized patient selection criteria and perioperative management protocols are needed to further increase the safety of this practice.

Graphical abstract

Ambulatory anesthesia and discharge: an update around guidelines and trends

PURPOSE OF REVIEW

Provide an oversight of recent changes in same-day discharge (SDD) of patient following surgery/anesthesia.

RECENT FINDINGS

Enhanced recovery after surgery pathways in combination with less invasive surgical techniques have dramatically changed perioperative care. Preparing and optimizing patients preoperatively, minimizing surgical trauma, using fast-acting anesthetics as well as multimodal opioid-sparing analgesia regime and liberal prophylaxis against postoperative nausea and vomiting are basic cornerstones. The scope being to maintain physiology and minimize the impact on homeostasis and subsequently hasten and improve recovery.

SUMMARY

The increasing adoption of enhanced protocols, including the entire perioperative care bundle, in combination with increased use of minimally invasive surgical techniques have shortened hospital stay. More intermediate procedures are today transferred to ambulatory pathways; SDD or overnight stay only. The traditional scores for assessing discharge eligibility are however still valid. Stable vital signs, awake and oriented, able to ambulate with acceptable pain, and postoperative nausea and vomiting are always needed. Drinking and voiding must be acknowledged but mandatory. Escort and someone at home the first night following surgery are strongly recommended. Explicit information around postoperative care and how to contact healthcare in case of need, as well as a follow-up call day after surgery, are likewise of importance. Mobile apps and remote monitoring are techniques increasingly used to improve postoperative follow-up.

Fighting the obesity pandemic during the COVID-19 pandemic

Background

The COVID-19 pandemic created delays in surgical care. The population with obesity has a high risk of death from COVID-19. Prior literature shows the most effective way to combat obesity is by weight loss surgery. At different times throughout the COVID-19 pandemic, elective inpatient surgeries have been halted due to bed availability. Recognizing that major complications following bariatric surgery are extremely low (bleeding 0–4%, anastomotic leaks 0.8%), we felt outpatient bariatric surgery would be safe for low-risk patients. Complications such as DVT, PE, infection, and anastomotic leaks typically present after 7 days postoperatively, well outside the usual length of stay. Bleeding events, severe postoperative nausea, and dehydration typically occur in the first few days postoperatively. We designed a pathway focused on detecting and preventing these early post-op complications to allow safe outpatient bariatric surgery.

Methods

We used a preoperative evaluation tool to risk stratify bariatric patients. During a 16-month period, 89 patients were identified as low risk for outpatient surgery. We designed a postoperative protocol that included IV hydration and PO intake goals to meet a safe discharge. We sent patients home with a pulse oximeter and had them self-monitor their pulse and oxygen saturation. We called all patients at 10 pm for a postoperative assessment and report of their vitals. Patients returned to clinic the following day and were seen by a provider, received IV hydration, and labs were drawn. RESULTS: 80 of 89 patients (89.8%) were successfully discharged on POD 0. 3 patients were readmitted within 30 days. We had zero deaths in our study cohort and no morbidity that would have been prevented with postoperative admission.

Conclusion

We demonstrate that by identifying low-risk patients for outpatient bariatric surgery and by implementing remote monitoring of vitals early outpatient follow-up, we were able to safely perform outpatient bariatric surgery.

Graphical abstract