High acuity sleeve gastrectomy patients in a free-standing ambulatory surgical center

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.

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.

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.

Portomesenteric Vein Thrombosis in Patients Undergoing Sleeve Gastrectomy: an Updated Systematic Review and Meta-Analysis of 101,914 Patients

INTRODUCTION

Portomesenteric vein thrombosis (PMVT) is a rare but potentially fatal complication of sleeve gastrectomy (SG). The rising prevalence of SG has led to a surge in the occurrence of PMVT, while the associated risk factors have not been fully elucidated. This study aims to determine the incidence and risk factors of PMVT in patients undergoing SG.

METHODS

A comprehensive literature search was performed in PubMed and EMBASE databases. Proportion and regression meta-analyses were conducted.

RESULTS

In a total of 76 studies including 101,914 patients undergoing SG, we identified 357 patients with PMVT. Mean follow-up was 14.4 (SD: 16.3) months. The incidence of PMVT was found to be 0.50% (95%CI: 0.40-0.61%). The majority of the population presented with abdominal pain (91.8%) at an average of 22.4 days postoperatively and PMVT was mainly diagnosed with computed tomography (CT) (96.0%). Hematologic abnormalities predisposing to thrombophilia were identified in 34.9% of the population. Advanced age (p=0.02) and low center volume (p <0.0001) were significantly associated with PMVT, while gender, BMI, hematologic abnormality, prior history of deep vein thrombosis or pulmonary embolism, type of prophylactic anticoagulation, and duration of prophylactic anticoagulation were not associated with the incidence of PMVT in meta-regression analyses. Treatment included therapeutic anticoagulation in 93.4% and the mortality rate was 4/357 (1.1%).

CONCLUSION

PMVT is a rare complication of sleeve gastrectomy with an incidence rate <1% that is associated with low center volume and advanced age but is not affected by the duration or type of thromboprophylaxis administered postoperatively.

Remote patient monitoring to facilitate same-day discharge after laparoscopic sleeve gastrectomy: a pilot evaluation

BACKGROUND

Limited hospital inpatient capacity, exacerbated by SARS-CoV-2 (COVID-19) and associated staffing shortages, has driven interest in converting surgeries historically done as inpatient procedures to same-day surgeries (SDS). Remote patient monitoring (RPM) has the potential to increase safety and confidence in SDS but has had mixed success in a bariatric population.

OBJECTIVES

Assess the feasibility of and adherence to a protocol offering patients same-day laparoscopic sleeve gastrectomy (SG) supported by RPM with an updated wearable device. Secondary outcomes were readmissions, costs, adherence, and clinical alarm rates.

SETTING

Academic, military tertiary referral center (United States).

METHODS

A single-center, retrospective case control study of patients undergoing SG, comparing SDS with RPM to patients admitted to the hospital for SG during this time. Patients for SDS were selected by set inclusion/exclusion criteria and patient/surgeon preference, and perioperative management was standardized.

RESULTS

Twenty patients were enrolled in the SDS group, then compared with 53 inpatients. Inpatients were older (46 versus 39, P = .006), but with no significant differences in sex, preoperative body mass index, or co-morbidities. RPM wearable and blood pressure adherence was found to be 97% and 80%, respectively. Readmission rates were similar (10% versus 7.5%, P > .05). RPM alarm rates were .5 (0-1.3) per patient for each 24-hour home monitoring period. SDS patients also demonstrated the potential for cost savings over inpatient SG, depending on the number of patients monitored per day as well as the healthcare setting.

CONCLUSIONS

SG as SDS with RPM was a feasible approach. It should be evaluated in other surgical procedures and higher-risk patient populations.

Portal venous system thrombosis after bariatric surgery: A systematic review and meta-analysis

BACKGROUND

Portal venous system thrombosis can develop after bariatric surgery. A systematic review and meta-analysis was conducted to evaluate the incidence of portal venous system thrombosis after bariatric surgery and clarify the role of anticoagulation for the prevention of portal venous system thrombosis after bariatric surgery.

METHODS

PubMed, EMBASE, and Cochrane Library databases were searched. The incidence of portal venous system thrombosis after bariatric surgery was pooled by a random-effect model. Subgroup analyses were performed to explore the incidence of portal venous system thrombosis according to the average duration of prophylactic anticoagulation (extended versus short-term). Meta-regression and sensitivity analyses were performed to explore the source of heterogeneity.

RESULTS

Among 2,714 papers initially screened, 68 studies were included. Among 100,964 patients undergoing bariatric surgery, 300 developed portal venous system thrombosis. The pooled overall incidence of portal venous system thrombosis after bariatric surgery was 0.419% (95% confidence interval: 0.341%-0.505%). The pooled incidence of portal venous system thrombosis after bariatric surgery was numerically lower in patients who received extended prophylactic anticoagulation protocol after bariatric surgery than those who received short-term prophylactic anticoagulation protocol (0.184% vs 0.459%). Meta-regression analyses demonstrated that sample size (P = .006), type of surgery (P < .001), and average duration of prophylactic anticoagulation (P = .024) might be sources of heterogeneity, but not region, publication year, history of bariatric surgery, follow-up duration, or use of prophylactic anticoagulation. Sensitivity analyses could not identify any source of heterogeneity. The estimated mortality of portal venous system thrombosis after bariatric surgery was 1.33%.

CONCLUSION

Portal venous system thrombosis after bariatric surgery is rare, but potentially lethal. Extended prophylactic anticoagulation protocol may be considered in patients at a high risk of developing portal venous system thrombosis after bariatric surgery.

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.

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.

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.

Perioperative Risks Are Similar for Normal versus Selected High-Body Mass Index Patients Undergoing Outpatient Hand and Elbow Surgery

BACKGROUND

Many ambulatory surgery centers use body mass index as a screening tool to make admissions decisions because of complication risks associated with high-body mass index patients. The objective of this investigation was to evaluate perioperative complications in a cohort of high-body mass index patients undergoing hand and elbow surgery at an ambulatory surgery center. The authors' hypothesis was that anesthesia-related complications for this cohort would be similar to those of a normal-body mass index group.

METHODS

The authors retrospectively reviewed data from all hand and elbow procedures performed on patients with a high body mass index (>40 kg/m). One hundred eighty-nine high-body mass index patients and 189 normal-body mass index patients were included in the analysis.

RESULTS

The average weight-based dosage of propofol was similar in both groups but was lower in the high-body mass index group for midazolam and fentanyl. Two high-body mass index patients had oxygen desaturations in the postanesthesia care unit. No patients developed complications related to anesthesia. In the high-body mass index group, one patient developed hypotension in the postanesthesia care unit, was admitted to the emergency room for monitoring, but was discharged the following morning.

CONCLUSIONS

Outpatient hand surgical care of high-body mass index patients can be performed safely. Body mass index alone should not be considered as an absolute contraindication for surgery. Careful patient selection, evaluation of comorbidities, and close involvement of the anesthesia and medical teams are critical.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Risk management in outpatient surgery

Outpatient surgery has become a national policy priority set by health care authorities (targets for more than 70% of outpatient procedures by 2022), making ambulatory hospitalization the new standard of care. This practice introduces new risks along the patient's course. Even though these risks are low and although the literature and data from insurance databases is reassuring, the risks in outpatient surgery remain poorly understood. Risks can be organizational in view of the many stages of the patient journey that must be formalized-medical, anesthetic or surgical-in view of planned discharge the same evening as the procedure, and medico-legal because of the importance of the discharge authorization and the information provided to the patient. A risk management approach (a priori or a posteriori) has become a mandatory part of a policy of continuous quality improvement and safety of care. The coordination of all the team members (surgeon, anesthesiologist, nursing and administrative staff and the patient's accompanying person) as well as the patient's active participation are essential to minimize risks and prevent complications.