Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization). Surg Obes Relat Dis. 2015;11:335-342. [PMID: 25614354 DOI: 10.1016/j.soard.2014.08.017]

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.

A Prospective Multicenter Standard of Care Study of Outpatient Laparoscopic Sleeve Gastrectomy

A global shift is occurring as hospital procedures move to ambulatory surgical settings. Surgeons have performed outpatient sleeve gastrectomy (SG) in bariatric surgery since 2010. However, prospective trials are needed to ensure its safety before widespread adoption.

PURPOSE

The study aimed to present a comprehensive report on the prospective data collection of 30-day outcomes of outpatient primary laparoscopic SG (LSG). This trial seeks to assess whether outpatient LSG is non-inferior to hospital-based surgery in selected patients who meet the outpatient surgery criteria set by the American Society for Metabolic and Bariatric Surgery.

MATERIALS AND METHODS

This study is funded by the Society of American Gastrointestinal and Endoscopic Surgeons and has been approved by the Advarra Institutional Review Board (Pro00055990). Cognizant of the necessity for a prospective approach, data collection commenced after patients underwent primary LSG procedures, spanning from August 2021 to September 2022, at six medical centers across the USA. Data centralization was facilitated through ArborMetrix. Each center has its own enhanced recovery protocols, and no attempt was made to standardize the protocols.

RESULTS

The analysis included 365 patients with a mean preoperative BMI of 43.7 ± 5.7 kg/m2. Rates for 30-day complications, reoperations, readmissions, emergency department visits, and urgent care visits were low: 1.6%, .5%, .2%, .2%, and 0%, respectively. Two patients (0.5%) experienced grade IIIb complications. There were no mortalities or leaks reported.

CONCLUSION

The prospective cohort study suggests that same-day discharge following LSG seems safe in highly selected patients at experienced US centers.

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.

Laparoscopic sleeve gastrectomy as a hybrid day care procedure: a case series of the first 53 patients at a tertiary care center

Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric procedure. Outpatient LSG is gaining popularity, but the literature is conflicting regarding its safety. Innovative approaches are needed to improve access to bariatric surgery. In this pilot study, we proposed an alternative approach to assess the safety and efficacy of LSG in selected cases as hybrid day care surgery. Data were collected retrospectively from 53 patients who underwent LSG between June 2017 and September 2020 using a hybrid day care approach. Outcomes of the study included patient demographics, clinical characteristics, and outcome variables, including conversion to inpatient care, emergency room visits after discharge, and patient satisfaction. Fifty-three patients (68% females) were included in the study. Mean age was 35.32 years, and mean preoperative body mass index was 42.93. The most common comorbidity was type 2 diabetes mellitus (30.2%), followed by hypertension (15.09%), hypothyroidism (13.2%), and dyslipidemia (9.4%). One (1.89%) patient visited the emergency room because of abdominal pain and was managed and discharged with analgesia. Readmission within 24 h of discharge was not required. One (1.89%) patient developed a staple line gastric leak two weeks after the surgery and was successfully managed with a gastric stent. The series had no mortality, with high patient and family satisfaction. Our approach to performing LSG in hybrid day care surgery is safe and feasible. Adopting this protocol will improve the utilization of resources, while maintaining high levels of patient satisfaction with safety outcomes comparable to the current practice.

Cost-savings of short stay sleeve gastrectomy and walk-in hydration clinic versus conventional inpatient care

OBJECTIVE

We aim to evaluate the cost-saving of the short stay ward (SSW) versus conventional inpatient care following sleeve gastrectomy (LSG). We also compared the readmission rates pre- and post-inception of the intravenous hydration clinic and analyzed the cost-savings.

METHODS

Patients who underwent LSG between December 2021 to March 2022 with SSW care were compared with standard inpatient care. Total costs were analyzed using univariate analysis. With a separate cohort of patients, 30-day readmission rates in the 12-months preceding and following implementation of the IV hydration clinic and associated cost-savings were evaluated.

RESULTS

After matching on the propensity score to within ± 0.1, 20-subjects pairs were retained. The total cost per SSW-subject was significantly lower at $13,647.81 compared to $15,565.27 for conventional inpatient care (p = 0.0302). Lower average ward charges ($667.76 vs $1371.34, p < 0.0001), lower average daily treatment fee per case ($235.68 vs $836.54, p < 0.0001), and lower average laboratory investigation fee ($612.31 vs $797.21, p < 0.0001) accounted for the difference in costs between the groups. Thirty-day readmission rate reduced from 8.9 to 1.8% after implementation of the hydration clinic (p < 0.01) with decreased 30-day readmission cost (S$96,955.57 vs. S$5910.27, p < 0.01).

CONCLUSION

SSW for LSG is cost-effective and should be preferred to inpatient management. Walk-in hydration clinics significantly reduced readmission rates and result in tremendous cost-savings.

Making lemonade with lemons: a multicenter effort to improve outpatient sleeve gastrectomy amid the COVID-19 pandemic

BACKGROUND

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.

OBJECTIVES

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.

SETTING

A retrospective analysis of sleeve gastrectomy patients was conducted from February 2020 to August 2021.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

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

Impact of the COVID-19 pandemic on bariatric surgery in North America – A retrospective analysis of 834,647 patients

Background

COVID-19 has transformed surgical care, yet little is known regarding implications for bariatric surgery.

Objective

We sought to characterize the effect of COVID-19 on bariatric surgery delivery and outcomes.

Setting

The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) collects data from 885 centers in North America.

Methods

The MBSAQIP database was evaluated with 2 cohorts described: the COVID-19 and the pre–COVID-19, with patients receiving surgery in 2020 and 2015–2019, respectively. Yearly operative trends were characterized, and bivariate analysis compared demographics and postoperative outcomes. Multivariable modeling evaluated 30-day readmission, reintervention, and reoperation rates and factors associated with undergoing Roux-en-Y gastric bypass.

Results

We evaluated 834,647 patients, with 155,830 undergoing bariatric surgery during the 2020 pandemic year. A 12.1% reduction in total cases (177,208 in 2019 versus 155,830 in 2020; P < .001) and 13.8% reduction in cases per center occurred (204.2 cases per center in 2019 versus 176.1 cases per center in 2020; P < .001). Patients receiving bariatric surgery during the pandemic were younger and had fewer co-morbidities. Use of sleeve gastrectomy increased (74.5% versus 72.5%; P < .001), and surgery during COVID-19 was associated with reduced Roux-en-Y gastric bypass procedure selection (odds ratio = .83; 95% CI: .82–.84; P < .001). Length of stay decreased significantly (1.4 ± 1.4 days versus 1.6 ± 1.4 days; P < .001), yet postoperative outcomes were similar. After adjusting for co-morbidities, patients during COVID-19 had decreased 30-day odds of readmission and reintervention and a small increase in odds of reoperation.

Conclusion

The COVID-19 pandemic dramatically changed bariatric surgery delivery. Further studies evaluating the long-term effects of these changes are warranted.

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

Short-term Outcomes of Day-Case Stoma Closure: A Prospective, Observational Study

BACKGROUND

Elective stoma closure is a common, standardized procedure in digestive surgery.

OBJECTIVE

This study aimed to evaluate the feasibility of day-case surgery for elective stoma closure.

DESIGN

This is a prospective, single-center, nonrandomized study of consecutive patients undergoing day-case elective stoma closure.

SETTING

This study was performed at a French tertiary hospital between January 2016 and June 2018.

PATIENTS

Elective stoma closure was performed by local incision with an ASA score of I, II, or stabilized III.

OUTCOME MEASURES

The primary end point was the day-case surgery success rate in the overall population (all patients having undergone elective stoma closure) and in the per protocol population (patients not fulfilling any of the preoperative or perioperative exclusion criteria). The secondary end points (in the per protocol population) were the overall morbidity rate (according to the Clavien-Dindo classification), the major morbidity rate (Clavien score ≥3), and day-case surgery quality criteria (unplanned consultation, unplanned hospitalization, and unplanned reoperation).

RESULTS

Between January 2016 and June 2018, 236 patients (the overall population; mean ± SD age: 54 ± 17; 120 men (51%)) underwent elective stoma closure. Fifty of these patients (21%) met all the inclusion criteria and constituted the per protocol population. The day-case surgery success rate was 17% (40 of 236 patients) in the overall population and 80% (40 of 50 patients) in the per protocol population. In the per protocol population, the overall morbidity rate was 30% and the major morbidity rate was 6%. Of the 40 patients with successful day-case surgery, the unplanned consultation rate and the unplanned hospitalization rate were both 32.5%. There were no unplanned reoperations.

LIMITATIONS

This was a single-center study.

CONCLUSION

In selected patients, day-case surgery for elective stoma closure is feasible and has acceptable complication and readmission rates. Day-case elective stoma closure can therefore be legitimately offered to selected patients. See Video Abstract at http://links.lww.com/DCR/B583.

RESULTADOS A CORTO PLAZO DEL CIERRE DE ESTOMA AMBULATORIO UN ESTUDIO OBSERVACIONAL Y PROSPECTIVO

ANTECEDENTES:El cierre electivo de un estoma es un procedimiento común y estandarizado en cirugía digestiva.OBJETIVO:Evaluar la viabilidad de la cirugía ambulatoria para el cierre electivo de estomas.DISEÑO:Un estudio prospectivo, unicéntrico, no aleatorizado de pacientes consecutivos sometidos a cierre de estoma electivo ambulatorio.ESCENARIO:Un hospital terciario francés entre enero de 2016 y junio de 2018.PACIENTES:Cierre electivo de estoma realizado por incisión local con una puntuación de la American Society of Anesthesiologists de I, II o III estabilizado.PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal fue la tasa de éxito de la cirugía ambulatoria en la población general (todos los pacientes habiendo sido sometidos a cierre de estoma electivo) y en la población por protocolo (pacientes que no cumplían con ninguno de los criterios de exclusión preoperatorios o perioperatorios). Los resultados secundarios (en la población por protocolo) fueron la tasa de morbilidad general (según la clasificación de Clavien-Dindo), la tasa de morbilidad mayor (puntuación de Clavien ≥ 3) y los criterios de calidad de la cirugía ambulatoria (consulta no planificada, hospitalización no planificada y reoperación no planificada).RESULTADOS:Entre enero de 2016 y junio de 2018, 236 pacientes (la población general; edad media ± desviación estándar: 54 ± 17; 120 hombres (51%)) se sometieron al cierre electivo del estoma. Cincuenta de estos pacientes (21%) cumplieron todos los criterios de inclusión y constituyeron la población por protocolo. La tasa de éxito de la cirugía ambulatoria fue del 17% (40 de 236 pacientes) en la población general y del 80% (40 de 50 pacientes) en la población por protocolo. En la población por protocolo, la tasa de morbilidad general fue del 30% y la tasa de morbilidad mayor fue del 6%. De los 40 pacientes con cirugía ambulatoria exitosa, la tasa de consultas no planificadas y la tasa de hospitalización no planificada fueron ambas del 32.5%. No hubo reoperaciones no planificadas.LIMITACIONES:Este fue un estudio de un solo centro.CONCLUSIÓN:En pacientes seleccionados, la cirugía ambulatoria para el cierre electivo de estoma es factible y tiene tasas aceptables de complicaciones y reingreso. Por lo tanto, se puede ofrecer legítimamente el cierre electivo ambulatorio de estoma a pacientes seleccionados. Consulte Video Resumen en http://links.lww.com/DCR/B583.

Efficacy of patient selection criteria for obesity surgery in a non-high-dependency unit/intensive care unit facility

BACKGROUNDS

Publicly funded obesity surgery remains underfunded in Australia. One barrier to expansion is the perception that perioperative care requires critical care facilities. This study evaluates the effectiveness of patient selection criteria in avoiding unplanned patient transfer and adverse outcomes in obesity surgery performed at a facility without a high-dependency unit/intensive care unit (HDU/ICU).

METHODS

Retrospective analysis was performed on patients undergoing obesity surgery between January 2017 and March 2020 in a centre with specific screening criteria. Criteria included: body mass index <48 for males and <52 for females with up to three stable comorbidities from a selected list. Revision sleeve or bypass procedures were contraindicated. Primary outcome was patient transfer to our main campus. Secondary outcomes included return to theatre (RTT), readmission and death. Outcomes were compared to laparoscopic cholecystectomies (LC) performed at the same centre.

RESULTS

A total of 387 obesity surgery procedures were performed; 372 patients (96%) were discharged without complication. Fifteen (3.9%) were transferred to the main campus, eight were admitted to ICU and two required re-operation. Twelve (3.1%) were readmitted within 30 days of discharge, five required re-operation. Transfer, 30-day readmission and 30-day emergency department presentation rates were similar in comparison to LC. RTT during index admission (0.5% vs. 3.0%; p = 0.006) and during 30-day post-operative period (1.8% vs. 4.4%; p = 0.025) was lower in the obesity surgery group.

CONCLUSION

Carefully selected screening criteria allow obesity surgery to be performed at a well-supported non-HDU/ICU facility with few complications and acceptable rates of unplanned patient transfer.

The Causes of Gastroesophageal Reflux after Laparoscopic Sleeve Gastrectomy: Quantitative Assessment of the Structure and Function of the Esophagogastric Junction by Magnetic Resonance Imaging and High-Resolution Manometry

BACKGROUND

The incidence of de novo gastroesophageal reflux disease (GERD) after LSG is substantial. However, an objective correlation with the structural gastric and EGJ changes has not been demonstrated yet. We aimed to prospectively evaluate the effects of laparoscopic sleeve gastrectomy (LSG) on the structure and function of the esophagogastric junction (EGJ) and stomach.

METHODS

Investigations were performed before and after > 50% reduction in excess body weight (6-12 months after LSG). Subjects with GERD at baseline were excluded. Magnetic Resonance Imaging (MRI), high-resolution manometry (HRM), and ambulatory pH-impedance measurements were used to assess the structure and function of the EGJ and stomach before and after LSG.

RESULTS

From 35 patients screened, 23 (66%) completed the study (age 36 ± 10 years, BMI 42 ± 5 kg/m²). Mean excess weight loss was 59 ± 18% after 7.1 ± 1.7-month follow-up. Esophageal acid exposure (2.4 (1.5-3.2) to 5.1 (2.8-7.3); p = 0.040 (normal < 4.0%)) and reflux events increased after surgery (57 ± 24 to 84 ± 38; p = 0.006 (normal < 80/day)). Esophageal motility was not altered by surgery; however, intrabdominal EGJ length and pressure were reduced (both p < 0.001); whereas the esophagogastric insertion angle (35° ± 11° to 51° ± 16°; p = 0.0004 (normal < 60°)) and esophageal opening diameter (16.9 ± 2.8 mm to 18.0 ± 3.7 mm; p = 0.029) were increased. The increase in reflux events correlated with changes in EGJ insertion angle (p = 0.010). Patients with > 80% reduction in gastric capacity (TGV) had the highest prevalence of symptomatic GERD.

CONCLUSION

LSG has multiple effects on the EGJ and stomach that facilitate reflux. In particular, EGJ disruption as indicated by increased (more obtuse) esophagogastric insertion angle and small gastric capacity were associated with the risk of GERD after LSG. clinicaltrials.gov: NCT01980420.

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

BACKGROUND

Shortening of hospital stay to 1 night has not affected the short-term safety of patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB). Whether the RYGB is feasible in an ambulatory setting (same-day discharge) without overnight hospital stay remains to be answered. We aimed to evaluate the feasibility of same-day discharge after laparoscopic Roux-en-Y gastric bypass (RYGB) using additional live video consultation and remote monitoring. Same-day discharge (SDD) was defined as surgery without postoperative overnight hospital stay.

METHODS

This was a single-center prospective feasibility study in a selected group of patients undergoing a RYGB. Fifty patients undergoing a primary RYGB were selected and potentially treated following the SDD protocol. After SDD discharge patients were remotely monitored after surgery for 48 h using a medical device measuring vital signs three times a day. Video consultations were performed by a doctor twice a day for 2 postoperative days. Primary outcome was the success rate (%) of SDD. Secondary outcomes were emergency room presentations, readmissions, early complications (<30 days), and patient satisfaction.

RESULTS

A total of 50 patients were selected for the SDD treatment protocol between June 2020 and November 2020. An SDD success rate of 88 % (44/50 patients) was achieved. Five patients (10%) presented at the emergency room, 2 of whom (4%) were readmitted because of a complication within 30 days after surgery. Overall, patients who followed the SDD protocol reported high satisfaction scores.

CONCLUSION

A RYGB with SDD can be considered feasible using remote monitoring for a selected group of patients.

Can We Identify Patients Appropriate for Same-Day Discharge After Laparoscopic Fundoplication?

Background: Patients, surgeons, and payers are interested in reducing hospital length of stay. Outpatient laparoscopic fundoplication (LF) can be done safely and cost effectively. There is low acceptance of this practice due to fear of readmission and patient dissatisfaction. Our aim was to identify factors predicting failure of same-day discharge after LF. Methods and Procedures: We simulated an outpatient setting for patients who underwent LF from 2017 to 2018 and collected the data prospectively. A perioperative pain and nausea protocol was utilized. Postoperatively, patients were given a liquid diet and oral medications, observed overnight, and then discharged after standard criteria were met. Failure was defined by the need for physician intervention after 3 hours or failure to discharge. Univariate and multivariable logistic regression analyses were performed assessing factors associated with failure. Two-sample t-test and chi-squared tests were used for significance. Results: Ninety-eight patients were included. Twenty patients failed, primarily due to the need for intravenous medications. Seven were discharged on postoperative day 1 but required physician intervention after 3 hours. Thirteen patients stayed >23 hours. Two patients were readmitted within 1 week of discharge. There was one acute recurrence, requiring reoperation, and one conversion to laparotomy. We found no statistically significant patient risk factor, comorbidity, or perioperative variable that could reliably predict failure of same-day discharge. Conclusion: This study suggests that same-day discharge after LF is safe and feasible. However, 20% of patients will unpredictably fail to meet discharge criteria.

[SOFFCO-MM guidelines for the resumption of bariatric and metabolic surgery during and after the Covid-19 pandemic]

Face à l’émergence de la pandémie à COVID 19, l’activité de chirurgie bariatrique/métabolique a été arrêtée. Le confinement et l’arrêt de cette chirurgie ont eu un impact sous-estimé sur la population obèse avec prise de poids, et aggravation des comorbidités. Un certain nombre de candidats à cette chirurgie sont exposés à un risque important de mortalité liée à la pandémie. En effet, l’obésité et le diabète sont deux facteurs de risque majeurs de forme grave d’infection à COVID-19. Le seul traitement efficace actuel de l’obésité est la chirurgie métabolique avec un bénéfice rapide et durable. Il paraît donc nécessaire de reprendre une activité de chirurgie métabolique. Le but de ce travail est de hiérarchiser la reprise chirurgicale afin qu’elle soit progressive et cohérente. Les organigrammes proposés aideront les centres à déterminer les patients prioritaires selon la balance bénéfice-risque. Le diabète a une place centrale dans l’arbre décisionnel. Les modalités de reprise seront variables d’un centre à l’autre selon les ressources humaines, matérielles et médicamenteuses, et seront à adapter à l’évolution épidémique. Un consentement éclairé spécifique sera nécessaire. Un dépistage chez les patients obèses est à envisager dont les modalités de dépistage sont élaborées sur la base des connaissances disponibles. En cas de suspicion de COVID, la chirurgie doit être différée. Il faut insister sur les mesures et gestes barrières afin de protéger le patient et le personnel soignant. Un confinement est fortement suggéré pour le patient durant le premier mois postopératoire. Le suivi des patients sera effectué de préférence par téléconsultation.

Comparison of safety and utilization outcomes in inpatient versus outpatient laparoscopic sleeve gastrectomy: a retrospective, cohort study

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is the most common type of bariatric surgery performed in the United States and may be performed on an outpatient basis. Limited literature exists comparing outcomes of outpatient and inpatient LSG, and study results are conflicting.

OBJECTIVES

To compare safety and utilization outcomes of outpatient versus inpatient LSG.

SETTINGS

Retrospective, multihospital database study (Optum Pan-Therapeutics Database).

METHODS

Patients 18 years of age and older who underwent LSG between October 1, 2015, and December 31, 2018, were identified from the Optum Pan-Therapeutics Database and classified as having undergone outpatient or inpatient surgery. Nearest neighbor propensity score matching and generalized estimating equations accounting for procedural physician-level clustering were used to compare the following outcomes between outpatient and inpatient LSG: all-cause 30-day patient morbidity, hospital readmission, readmission length of stay, bariatric reoperation. and mortality.

RESULTS

We identified 22,945 patients (outpatient: 1542; inpatient: 21,403) meeting the study inclusion criteria. After propensity score matching, the inpatient and outpatient groups contained 1542 and 13,903 patients, respectively. Bariatric reoperation (n = 13) and mortality (n = 5) were rare events occurring in <.1% of all cases. Compared with the inpatient group, the outpatient group had a statistically significant lower readmission length of stay (4.63 versus 3.23 days; P = .0057). Otherwise, there was no significant association between procedure setting and 30-day overall morbidity (4.8% versus 5.3%; P = .5775) or hospital readmission (2.6% versus 2.1%; P = .1841).

CONCLUSIONS

Safety and utilization outcomes were similar between outpatient and inpatient LSG, and outpatient LSG was associated with shorter hospital readmission length of stay.

SOFFCO-MM guidelines for the resumption of bariatric and metabolic surgery during and after the Covid-19 pandemic

Bariatric/metabolic surgery was paused during the Covid-19 pandemic. The impact of social confinement and the interruption of this surgery on the population with obesity has been underestimated, with weight gain and worsened comorbidities. Some candidates for this surgery are exposed to a high risk of mortality linked to the pandemic. Obesity and diabetes are two major risk factors for severe forms of Covid-19. The only currently effective treatment for obesity is metabolic surgery, which confers prompt, lasting benefits. It is thus necessary to resume such surgery. To ensure that this resumption is both gradual and well-founded, we have devised a priority ranking plan. The flow charts we propose will help centres to identify priority patients according to a benefit/risk assessment. Diabetes holds a central place in the decision tree. Resumption patterns will vary from one centre to another according to human, physical and medical resources, and will need adjustment as the epidemic unfolds. Specific informed consent will be required. Screening of patients with obesity should be considered, based on available knowledge. If Covid-19 is suspected, surgery must be postponed. Emphasis must be placed on infection control measures to protect patients and healthcare professionals. Confinement is strongly advocated for patients for the first month post-operatively. Patient follow-up should preferably be by teleconsultation.

Ambulatory bariatric surgery: does it really lead to higher rates of adverse events?

BACKGROUND

Correlating patient outcomes with length of stay (LoS) is an important consideration in metabolic and bariatric surgery. At present, conflicting data exists regarding patient safety for ambulatory (AMB) metabolic and bariatric surgery.

OBJECTIVE

Outcomes for AMB-metabolic and bariatric surgery patients (LoS <1 d) undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) were compared with matched patients with LoS ≥1 day (non-AMB) using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry.

SETTING

MBSAQIP national database.

METHODS

The MBSAQIP registry was queried for patients undergoing SG or RYGB (2015-2017) and patients grouped as AMB/non-AMB. Exclusion criteria included LoS >4 days, age <18 or >75 years, revision surgery, gastric banding, body mass index <35 kg/m², and day of surgery mortality. Variables were combined into major/minor complications and 30-day mortality. Analysis was performed using univariate and multivariate logistic regression and propensity matching.

RESULTS

After exclusions were applied 408,895 patients remained (9973 AMB). Overall, 111,279 patients underwent RYGB (1032 AMB) and 297,616 underwent SG (8941 AMB), with similar demographic characteristics and co-morbidities between groups. For AMB patients, there was no increase in 30-day mortality, reoperation, or readmission, and fewer drains were placed versus matched non-AMB patients. In AMB-SG patients more surgical site infections were reported versus non-AMB-SG, although AMB-SG patients had fewer intensive care unit admissions. For AMB-RYGB, no differences in complications were detected versus non-AMB-RYGB.

CONCLUSION

Based on our analysis of the MBSAQIP database, patients undergoing laparoscopic RYGB or SG procedures can be safely discharged on the day of their procedure without increased incidence of mortality, reoperation, or readmission.

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.

Efficacy of Postoperative Upper Gastrointestinal Series (UGI) and Computed Tomography (CT) Scan in Bariatric Surgery: a Meta-analysis on 7516 Patients

BACKGROUND

To demonstrate the lack of utility and efficacy of routine early postoperative upper gastrointestinal study (UGI) in obese patients undergoing bariatric surgery and to show the higher efficacy of CT scan in cases of clinical suspicion of a leakage, a meta-analysis was performed.

MATERIALS AND METHODS

A literature search including articles published in last 18 years was performed. For both UGI and CT scan, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. A first analysis considered overall patients, and a second analysis considered only symptomatic patients.

RESULTS

Starting from 1233 eligible citations, 18 articles, including 7516 patients, were left. The pooled sensitivity was 54% for UGI (95% CI 34-74) with a high heterogeneity (I² = 99.8%, p < .001), whereas CT scan showed a pooled sensitivity of 91% (95% CI 89-93) significantly higher than sensitivity of UGI series (p < 0.01), with a high heterogeneity (I² = 98.9%, p < .001). In symptomatic patients the pooled sensitivity of UGI series was significantly lower than sensitivity of CT scan [49% (95% CI 31-68) vs 94% (95% CI 92-96), p < 0.01]. PPV showed a significant difference between UGI series and CT scan (54 vs 100%, p < 0.01). Specificity for UGI series was 98.6%, and specificity for CT scan was 99.7% (p = ns); the mean NPV was 96 and 98% for UGI series and CT scan (p = ns).

CONCLUSIONS

According to our results, a CT scan triggered by clinical suspicion must be considered the first-line procedure to detect a postoperative leak following primary sleeve gastrectomy or Roux-en-Y gastric bypass.

Role of abdominal drainage in bariatric surgery: Report of six cases

BACKGROUND

Abdominal drainage allows for timely detection of hemorrhage, but it cannot prevent hemorrhage. Whether routine abdominal drainage is needed during bariatric procedures remains controversial. Few reports describe the role of abdominal drainage in the diagnosis and treatment of abdominal hemorrhage in bariatric surgery.

CASE SUMMARY

Six cases of hemorrhage after bariatric surgery were described, including three cases with and three without abdominal drainage during the first surgery. The hemorrhage in five of the six cases was controlled by conservative treatment. Abdominal hemorrhage was found through the drainage tube on the day of the operation in the three patients with abdominal drainage during the first surgery. Emergency treatment was initiated, and their conditions gradually stabilized within 48 h. No patients required a reoperation. Abdominal hemorrhage was found later in the patients without abdominal drainage. Although the hemorrhage was controlled by conservative treatment in two cases (1 and 2), reoperation and percutaneous drainage were performed for abdominal infection and pelvic hemorrhage. An obsolete encapsulated effusion that may require treatment in the future was left in the abdominal cavity of a patient (Case 1).

CONCLUSION

The possibility of controlling abdominal hemorrhage after bariatric/metabolic surgery by conservative treatment is high. When hemorrhage occurs, abdominal drainage can reduce the probability of reoperation by reducing the formation of blood clots behind the stomach.

Laparoscopic sleeve gastrectomy follow-up: use of connected devices in the postoperative period

BACKGROUND

During the last decade, laparoscopic sleeve gastrectomy (LSG) has become the most performed bariatric procedure worldwide.

OBJECTIVES

To evaluate the feasibility of the use of connected devices in monitoring patients operated on by LSG and discharged 24 hours after surgery under the enhanced recovery after surgery protocol.

SETTING

Private hospital, France.

METHODS

This is a prospective pilot study designed to assess the risk and benefit of using connected devices in the postoperative follow-up of patients operated on by LSG. Patients operated on with LSG were discharged 24 hours after surgery, and vital signs such as blood pressure, heart rate, peripheral capillary oxygen saturation, and temperature were monitored via connected devices with data sent to an internet platform to make them immediately viewable by the surgeon.

RESULTS

The study population consisted of 82 women and 18 men. The mean body mass index was 43.4 kg/m², and the mean age was 39.6 years. Two patients were reoperated on for bleeding and, consequently, were excluded from the study. At postoperative day 8, 1 patient presented with tachycardia, fever, and mild abdominal discomfort. After the alert was received from the internet platform, the patient was immediately contacted, admitted to the ward, and promptly reoperated on. At 1 year after the surgery, the mean percentage of excess weight loss and total weight loss were 68.1 ± 18.1% and 36 ± 9.8 kg, respectively. For the patients not available for follow-up at the 1-year control, weight loss data were extrapolated from the internet platform. Globally, 92% of patients felt safe when they returned home, and 92% of patients would recommend this way of managing the postoperative period.

CONCLUSIONS

In conclusion, this study shows that the early postoperative follow-up to an intervention such as LSG can be done at the patient's home under the monitoring of connected devices without a risk of increase in the rate of complications and rehospitalization. The role of the connected devices in the long-term postoperative follow-up seems promising.

Management of Uncomplicated Acute Appendicitis as Day Case Surgery: Can Outcomes of a Prospective Study Be Reproduced in Real Life?

BACKGROUND

The feasibility of day case surgery (DCS) appendectomy for uncomplicated acute appendicitis (UCAA) was evaluated by the prospective AppendAmbu (Feasibility of Outpatient Appendectomy for Acute Appendicitis) study (ClinicalTrials.gov ID NCT01839435). The aim of this study was to evaluate the real-life feasibility of DCS for UCAA.

STUDY DESIGN

This single-center, retrospective, non-interventional study was conducted after the AppendAmbu study and included UCAA only. The primary end point was DCS success rate (ie length of stay <12 hours) in the intention-to-treat population (all patients with UCAA) and in the per-protocol population (population with UCAA and no preoperative and intraoperative exclusion criteria). The secondary end points were to determine the DCS quality criteria to evaluate and compare the morbidity and mortality of DCS and conventional hospitalization for UCAA (Clavien, Comprehensive Complication Index) and to externally validate the St Antoine criteria for the selection of patients for DCS.

RESULTS

From January 2016 to September 2017, two hundred and ninety-six patients underwent operations for acute appendicitis. The proportion of patients with successful DCS management was 27% in the intention-to-treat population and 95% in the per-protocol population. The unplanned consultation rate was 15%, the unplanned hospitalization rate was 4%, and the unplanned reoperation rate was 0%. The postoperative morbidity of patients managed by DCS was not different from that of patients managed in conventional hospitalization. The DCS success rate was 0%, with a St Antoine score of 0, and 80% of patients had a St Antoine score of 5 (p < 0.0001).

CONCLUSIONS

Day case surgery constitutes progress in surgery as a result of enhanced recovery programs. It avoids unnecessary prolonged hospitalization.

Laparoscopic sleeve gastrectomy as day-case surgery: a review of the literature

Day-case surgery (DCS) in digestive surgery is a hot topic, and new indications for DCS in the field of gastrointestinal surgery have recently been described. Laparoscopic sleeve gastrectomy (LSG) has become a popular bariatric procedure in recent years. LSG is a reproducible, standardized procedure with a short operating time and possibly simple perioperative management. It therefore meets the criteria to be performed as a DCS procedure. Recently published series of LSG as DCS have demonstrated its feasibility. In this review on LSG performed as DCS, we focused on the management of risks associated with DCS and the results of such type of management. A literature search was conducted in the PubMed and Embase databases. Six studies were selected, comprising a total of 6227 patients. Most published series were retrospective single-center studies. Inclusion criteria were similar between most studies (primary sleeve gastrectomy for most series, patients with a body mass index ≥40 kg/m² or a body mass index ≥35 kg/m² in the presence of co-morbidities), while exclusion criteria were based on literature data for some studies (using series on risk factors for morbidity and mortality after Roux-en-Y gastric bypass) and personal experience for other series. The mortality rate of LSG as DCS ranges 0%-.08%, while the overall complication rate ranges 0%-10%. The unplanned overnight admission rate after LSG ranges .8%-8%. The unscheduled hospitalization rates range 2.1%-8.5%. LSG performed as DCS is feasible with good results, but cannot be proposed for all patients. Good selection is necessary in others to avoid increased risk of morbidity and mortality.

Minor laparoscopic liver resection as day-case surgery (without overnight hospitalisation): a pilot study

BACKGROUND

Day-case surgery (DCS) has become increasingly popular over recent years, as has laparoscopic liver resection (LLR) for the treatment of benign or malignant liver tumours. The purpose of this prospective study was to demonstrate the feasibility of minor LLR as DCS.

METHODS

Prospective, intention-to-treat, non-randomised study of patients undergoing minor LLR between July 2015 and December 2017. Exclusion criteria were resection by laparotomy, major LLR, difficult locations for minor LLR, history of major abdominal surgery, hepatobiliary procedures without liver parenchyma resection, cirrhosis with Child > A and/or portal hypertension, significant medical history and exclusion criteria for DCS. The primary endpoint was the unplanned overnight admission rate. Secondary endpoints were the reason for exclusion, complication data, criteria for DCS evaluation, satisfaction and compliance with the protocol.

RESULTS

One hundred sixty-seven patients underwent liver resection during the study period. LLR was performed in 92 patients (55%), as DCS in 23 patients (25%). Reasons for minor LLR were liver metastasis (n = 9), hepatic adenoma (n = 5), hepatocellular carcinoma (n = 4), ciliated hepatic foregut cyst (n = 2) and other benign tumours (n = 3). All day-case minor LLR, except two patients, consisted of single wedge resection, while one patient underwent left lateral sectionectomy. There were four unplanned overnight admissions (17.4%), one unscheduled consultation (4.3%), two hospital readmissions (8.6%) and no major complications/mortality. Compliance with the protocol was 69.5%. Satisfaction rate was 91%.

CONCLUSION

In selected patients, day-case minor LLR is feasible with acceptable complication and readmission rates. Day-case minor LLR can therefore be legitimately proposed in selected patients.

An ERAS protocol for bariatric surgery: is it safe to discharge on post-operative day 1?

BACKGROUND

Laparoscopic sleeve gastrectomy is the most commonly performed bariatric surgery in the world. Enhanced recovery after surgery (ERAS) protocols have been shown to reduce complications and decrease length of stay for various types of surgeries. In this study, we propose an ERAS protocol for laparoscopic sleeve gastrectomy and compare the clinical outcomes with patients who received standard care.

METHODS

We performed a single-institution retrospective analysis in patients who underwent laparoscopic sleeve gastrectomy from February 2015 to December 2017. Patients were stratified into standard care and ERAS protocol groups. The ERAS protocol consisted of goal-directed patient education, specific pre- and post-op multi-modal medication regimen, early ambulation, and early oral intake. Patients were discharged on their first post-operative day if they met appropriate post-surgical milestones. The primary outcomes were length of stay, 7- and 30-day readmission rates, and complication rates. Secondary outcomes included anti-emetic and pain medication utilization, post-operative emesis episodes per day, post-operative pain scores, and mortality.

RESULTS

We included 214 consecutive patients who underwent sleeve gastrectomy, 130 were in the ERAS group and 84 were in the standard care group. Median hospital stay was significantly shorter in the ERAS group compared to the standard care group (1 vs. 2 days; p < 0.001). There were no differences in 7- or 30-day readmission rates (1.5 vs. 1.2%; p = 0.838, 2.3 vs. 2.4%; p = 0.966) or post-operative complications (6.2 vs. 3.6%; p = 0.410). The ERAS group also had decreased median intra-operative opioid consumption and self-reported pain scores on post-operative day 1 (27.5 MME vs. 27.4 MME; p = 0.044, 3.3 vs. 3.9; p = 0.046). Mortality rate was 0% overall.

CONCLUSION

A cost-effective ERAS protocol for laparoscopic sleeve gastrectomy results in shorter length of stay, without increase in peri-operative morbidity or readmission rates.

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.

Results of Laparoscopic Sleeve Gastrectomy in 541 Consecutive Patients with Low Baseline Body Mass Index (30-35 kg/m2)

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is currently the leading bariatric procedure and targets, among other obesity classes, patients with BMI 30-35 kg/m², which are reaching alarming proportions.

METHODS

Between February 2010 and August 2015, data on 541 consecutive patients with BMI 30-35 kg/m² undergoing LSG were prospectively collected and analyzed.

RESULTS

Mean age was 32 ± 8 years (13-65) and 419 (77.4 %) were women. Preoperative weight was 92.0 ± 8.8 kg (65-121) and BMI was 32.6 ± 1.5 kg/m² (30-35). Comorbidities were detected in 210 (39 %) patients. Operative time was 74 ± 12 min (40-110) and postoperative stay was 1.7 ± 0.22 days (1-3). There were no deaths, leaks, abscesses or strictures and the rate of hemorrhage was 1.2 %. At 1 year, 98 % were followed and BMI decreased to 24.7 ± 1.6, the percentage of total weight loss (% TWL) was 24.1 ± 4.7 while the percentage of excess BMI loss (%EBMIL) reached 106.1 ± 24.1. At 5 years, 76 % of followed patients achieved a ≥50 % EBMIL.

CONCLUSION

With appropriate surgical expertise, LSG in patients with BMI 30-35 kg/m² achieved excellent outcomes with a zero fistula rate.

Enhanced Recovery after Bariatric Surgery: Systematic Review and Meta-Analysis

Enhanced recovery after surgery (ERAS) protocol is well established in many surgical disciplines and leads to a decrease in the length of hospital stay and morbidity. Multimodal protocols have also been introduced to bariatric surgery. This review aims to evaluate the current literature on ERAS in obesity surgery and to conduct a meta-analysis of primary and secondary outcomes. MEDLINE, Embase, Scopus and Cochrane Library were searched for eligible studies. Key journals were hand-searched. We analysed data up to May 2016. Eligible studies had to contain four described ERAS protocol elements. The primary outcome was the length of hospital stay; the secondary outcomes included overall morbidity, specific complications, mortality, readmissions and costs. Random effect meta-analyses were undertaken. The initial search yielded 1151 articles. Thorough evaluation resulted in 11 papers, which were analysed. The meta-analysis of the length of stay presented a significant reduction standard mean difference (Std. MD) = −2.39 (−3.89, −0.89), p = 0.002. The analysis of overall morbidity, specific complications and Clavien-Dindo classification showed no significant variations among the study groups. ERAS protocol in bariatric surgery leads to the reduction of the length of hospital stay while maintaining no or low influence on morbidity.

Changes in utilization and peri-operative outcomes of bariatric surgery in large U.S. hospital database, 2011-2014

Background

With the epidemic of morbid obesity, bariatric surgery has been accepted as one of the most effective treatments of obesity.

Objective

To investigate recent changes in the utilization of bariatric surgery, patients and hospital characteristics, and in-hospital complications in a nationwide hospital database in the United States.

Setting

This is a secondary data analysis of the Premier Perspective database.

Methods

ICD-9 codes were used to identify bariatric surgeries performed between 2011 and 2014. Descriptive statistics were computed and regression was used.

Results

A total of 74,774 bariatric procedures were identified from 436 hospitals between 2011 and 2014. During this time period, the proportion of gastric bypass (from 44.8% to 31.3%; P for trend < 0.0001) and gastric banding (from 22.8% to 5.2%; P for trend < 0.0001) decreased, while the proportion of sleeve gastrectomy (from 13.7% to 56.9%; P for trend < 0.0001) increased substantially. The proportion of bariatric surgery performed for outpatients decreased from 17.15% in 2011 to 8.11% in 2014 (P for trend < 0.0001). The majority of patients undergoing surgery were female (78.5%), white (65.6%), younger than 65 years (93.8%), and insured with managed care (53.6%). In-hospital mortality rate and length of hospital stay remained stable. The majority of surgeries were performed in high-volume (71.8%) and urban (91.6%) hospitals.

Conclusions

Results based on our study sample indicated that the popularity of various bariatric surgery procedures changed significantly from 2011 to 2014. While the rates of in-hospital complications were stable, disparities in the use of bariatric surgery regarding gender, race, and insurance still exist.

Influence of the Resected Gastric Volume on the Weight Loss After Laparoscopic Sleeve Gastrectomy

BACKGROUND

The relation between the resected gastric volume and the weight loss after laparoscopic sleeve gastrectomy appears conflicting in the literature. Both the residual and the resected volumes represent the total gastric volume, and if the weight loss is related to one of the two volumes, it should be related to the other. While some reports indicate that the weight loss is related to the resected gastric volume, others state that the weight loss is not related to the residual volume. The aim is to investigate the influence of the resected gastric volume on the weight loss after surgery.

METHODS

The study included 287 consecutive patients. Gastrectomy was performed encroaching over a 38-Fr calibrating tube all the way to the angle of His. Filling volume of the resected stomach, with tap water, was measured. Patients were analyzed into group 1 with BMI ≤50 kg/m(2) and group 2 >50 kg/m(2).

RESULTS

Females represented 74 % of cases. Mean age was 32.9 ± 9.5 years; preoperative BMI = 48.7 ± 7.9 kg/m(2). The mean resected gastric volume was 1525 ± 408 ml, and it was significantly lower in females compared to that in males (1443 ± 311 vs 1824 ± 502 ml, p < 0.001). Data were analyzed in two groups: group 1 with BMI ≤5050 kg/m(2) and group 2 >50 kg/m(2). Both groups were similar in preoperative BMI (p = 0.399) and excess weight percent (EW%) (p = 0.33). Group 2 had a resected gastric volume (1663 ± 424.7 ml) greater than that of group 1 (1440 ± 347 ml; p < 0.001). The percentage of excess weight loss (EWL%) was 57.9 ± 14.5 % at 6 months (62.7 ± 13.5 % vs 48.34 ± 11.29 %, p < 0.001), 77 ± 19 % at 12 months (84 ± 19.6 % vs 68 ± 14.2 %, p = 0.001), 76.6 ± 7.4 % at 18 months (79.7 ± 4.8 vs 74.7 ± 8.2 %, p = 0.5), and 75.8 ± 11.5 % at 24 months (81.7 ± 11.17 vs 70 ± 11 %, p = 0.8) (group 1 vs group 2, respectively). At 12 months, 86 % patients achieved more than 50 % EWL% (100 % of group 1 vs 60 % of group 2). Preoperative BMI correlated with resected gastric volume (r = 0.239, p = 0.004). In multiple regression, the initial BMI was a predictor of EWL% at 6 and 12 months (r partial = -0.65, p < 0.0001) while the resected gastric volume was not.

CONCLUSIONS

The resected gastric volume is related to the total gastric volume when the technique is standardized and the residual volume is calibrated using a consistent technique. It is not in itself a predictor of weight loss, but it is related to the initial BMI which predicts the weight loss.