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

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.

Safety and cost of performing laparoscopic sleeve gastrectomy with same day discharge at a large academic hospital

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is the most common surgical treatment for morbid obesity. While certain specialized ambulatory surgery centers offer LSG on an outpatient basis, patients undergoing LSG at most academic centers are admitted to hospital for initial postoperative convalescence and monitoring. Our institution has begun to offer LSG with same-day discharge (SDD) in select patients. We aimed to compare the perioperative outcomes and costs for patients undergoing LSG with inpatient admission versus SDD.

METHODS

All patients enrolled in the SDD program from December 2020 through July 2022 were identified from a prospectively maintained database. Patients enrolled in this pathway were analyzed on an intention-to-treat basis even if ultimately admitted postoperatively. Propensity scoring was used to match these patients 1:1 to those with planned inpatient recovery based on age, BMI, and ASA classification.

RESULTS

Seventy-five patients were enrolled in the LSG with SDD program during the study period. Among these, 62 patients (82.7%) had successful immediate postoperative discharge. Reasons for cancelation of planned SDD included anxiety (n = 5), pain (n = 3), nausea (n = 2), and one patient each with hypotension, urinary retention, and bleeding. After matching, there were no differences in age, BMI, or ASA classification in a comparison group of patients with planned inpatient recovery. There were no differences in perioperative complications. There were no readmissions or requirements for outpatient intravenous fluids among patients with SDD, compared to n = 3 (4.0%) and n = 2 (2.7%) in the inpatient cohort, respectively. The total perioperative cost for patients undergoing LSG with planned SDD was 6.8% less than those with inpatient recovery.

CONCLUSION

With appropriate protocols, LSG with same-day discharge can safely be performed at large academic surgery centers without increased morbidity or need for additional services in the perioperative period. SDD may be associated with decreased costs and allows for more efficient hospital bed allocation.

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.

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.

Efficacy and safety of enhanced recovery after surgery protocol on minimally invasive bariatric surgery: a meta-analysis

BACKGROUND

Enhanced recovery after surgery (ERAS), a multidisciplinary and multimodal perioperative care protocol, has been widely used in several surgical fields. However, the effect of this care protocol on patients receiving minimally invasive bariatric surgery remains unclear. This meta-analysis compared the clinical outcomes of the ERAS protocol and standard care (SC) in patients who underwent minimally invasive bariatric surgery.

MATERIAL AND METHODS

PubMed, Web of Science, Cochrane Library, and Embase databases were systematically searched to identify literature reporting the effects of the ERAS protocol on clinical outcomes in patients undergoing minimally invasive bariatric surgery. All the articles published until 01 October 2022, were searched, followed by data extraction of the included literature and independent quality assessment. Then, pooled mean difference (MD) and odds ratio with a 95% CI were calculated by either a random-effects or fixed-effects model.

RESULTS

Overall, 21 studies involving 10 764 patients were included in the final analysis. With the ERAS protocol, the length of hospitalization (MD: -1.02, 95% CI: -1.41 to -0.64, P <0.00001), hospitalization costs (MD: -678.50, 95% CI: -1196.39 to -160.60, P =0.01), and the incidence of 30-day readmission (odds ratio =0.78, 95% CI: 0.63-0.97, P =0.02) were significantly reduced. The incidences of overall complications, major complications (Clavien-Dindo grade ≥3), postoperative nausea and vomiting, intra-abdominal bleeding, anastomotic leak, incisional infection, reoperation, and mortality did not differ significantly between the ERAS and SC groups.

CONCLUSIONS

The current meta-analysis indicated that the ERAS protocol could be safely and feasibly implemented in the perioperative management of patients receiving minimally invasive bariatric surgery. Compared with SC, this protocol leads to significantly shorter hospitalization lengths, lower 30-day readmission rate, and hospitalization costs. However, no differences were observed in postoperative complications and mortality.

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.

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.

A randomized controlled trial of an enhanced recovery after surgery protocol in patients undergoing laparoscopic sleeve gastrectomy

BACKGROUND

The purpose of this study was to evaluate the effect of an enhanced recovery after surgery (ERAS) protocol on opioid and anti-emetic use, length of stay and safety after laparoscopic sleeve gastrectomy (LSG).

METHODS

Patients who underwent LSG between March 2018 and January 2019 at our accredited, high-volume bariatric surgery center were randomized to either standard of care (SOC) or ERAS. ERAS included a pre- and post-surgical medication regimen designed to reduce postoperative nausea, vomiting and pain. Outcomes included post-operative symptom scores, opioid use, anti-emetic use, time to achieve readiness for discharge (RFD) and inpatient and 30-day adverse events, readmissions and emergency department visits.

RESULTS

The final analysis included 130 patients, (SOC 65; ERAS 65). Groups did not differ on demographics or comorbidities. Relative to SOC, fewer ERAS patients utilized opioids in the hospital ward (72.3% vs. 95.4%; p < .001), peak pain scores were significantly lower, and median time to achieve RFD was shorter (28.0 h vs. 44.4 h; p = 0.001). More ERAS patients were discharged on post-operative day 1 (38.5% vs. 15.4%; p < .05). The overall use of rescue anti-emetic medications was not different between groups. Rates of postoperative 30-day events, readmissions, and emergency department visits did not differ between groups.

CONCLUSION

Relative to SOC, ERAS was associated with earlier discharge, lower pain scores, less frequent use of opioids and use in lower amounts after LSG with no differences in 30 day safety outcomes.

Same-Day Discharge After Minimally Invasive Colectomy

This article describes elements of a same-day discharge program for minimally invasive colectomy as an evolution of enhanced recovery pathways for colorectal surgery.

Postbariatric EArly discharge Controlled by Healthdot (PEACH) trial: study protocol for a preference-based randomized trial

Introduction

Performing bariatric surgery in a daycare setting has a potential reduction in hospital costs and increase in patients’ satisfaction. Although the feasibility and safety of such care pathway has already been proven, its implementation is hampered by concerns about timely detection of short-term complications. This study is designed to evaluate a combined outcome measurement in outpatient bariatric surgery supplemented by a novel wireless remote monitoring system versus current standard of care.

Methods and analysis

A total of 200 patients with multidisciplinary team approval for primary bariatric surgery will be assigned based on their preference to one of two postoperative trajectories: (1) standard of in-hospital care with discharge on the first postoperative day or (2) same day discharge with ongoing telemonitoring up to 7 days after surgery. The device (Healthdot R Philips) transfers heart rate, respiration rate, activity, and body posture of the patient continuously by LoRaWan network to our hospital’s dashboard (Philips Guardian). The primary outcome is a composite outcome measure within 30 days postoperative based on mortality, mild and severe complications, readmission, and prolonged length-of-stay. Secondary outcomes include patients’ satisfaction and data handling dimensions.

Trial registration

ClinicalTrials.govNCT04754893, Registered on 12 February 2021.

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

Same-day discharge for laparoscopic Heller myotomy

BACKGROUND

Laparoscopic Heller myotomy is an effective treatment for achalasia. There are little data on the safety and feasibility of same-day discharge after laparoscopic Heller myotomy.

OBJECTIVE

This study aimed to describe the experience with same-day discharge after laparoscopic Heller myotomy at one hospital.

METHODS

A retrospective cohort study including all patients who underwent laparoscopic Heller myotomy between 2007 and 2016 at University Health Network (UHN), Toronto, Canada. There was no consent required as the study was retrospective study. This study was approved by the UHN IRB. Planned same-day discharge patients were compared to planned inpatient with respect to post-op complications, length of stay, and number of emergency visits.

RESULTS

A total of 209 patients were identified. Same-day discharge was planned in 67 (33.5%) cases compared to 133 (66.5%) cases that were planned for inpatient. The study population was 49% male. On average, inpatients had 2.3 pre-operative comorbidities and same-day discharge patients had 1.6 pre-operative comorbidities. The average length of stay for the inpatient group was 3.5 days. Among the same-day surgery group, 15 had an unplanned admission following surgery (22%). Of those who were admitted, the average length of stay was 1.27 days. Only 1 same-day discharge was readmitted after hospital discharge, while 4 in inpatient group were readmitted. The post-operative complication rate was (15%) 20 of inpatient compared to four (6.0%) of same-day discharge. Number of emergency visits for inpatient group were 7 (5.3%) compared to 3 (4.5%) for same-day discharge group. There was one mortality case in inpatient group due to post-op complication.

CONCLUSION

Same-day surgery is feasible for laparoscopic Heller myotomy, with a similar complication and readmission rate as inpatient surgery.

Quality of recovery assessment of day case and multiday stay patients undergoing elective laparoscopic cholecystectomy

Objectives

Many laparoscopic cholecystectomy operations are performed with at least overnight admission. Current research shows that laparoscopic cholecystectomy is safe and feasible to do as a day case. Patient centred outcomes are less well understood.

Material and Methods

Elective laparoscopic cholecystectomy patients at a single metropolitan hospital in Melbourne, Australia were surveyed 24 hours after surgery using the 15-question Quality of Recovery (QoR-15) survey. A comparison was made between day case surgeries and multi-day surgeries.

Results

One hundred and eight patients were recruited consisting of 34 day case and 74 multi-day patients. Patient groups did not differ in terms of age, sex or postoperative morbidity. The multi-day group had a higher proportion of comorbid patients (p-value = 0.03). There was no significant dif- ference in overall QoR-15 score between the two groups, although there was an observed trend towards a higher score in the day case group (132.0 vs 127.9, p= 0.147). QoR-15 individual question results showed that day cases rated significantly better for sleep quality and for less feelings of anxiety or worry. The differences narrowed when comparing patient groups as they were booked (intention-to-treat). There were no identified sub-groups that had a significantly higher score if admitted multi-day.

Conclusion

Quality of recovery following day case laparoscopic cholecystectomy is just as good, if not better, than multi-day cases. Laparoscopic cholecystectomy as a day case is both safe and economically superior to multi-day management. This gives further weight to current recommendations suggesting that the majority of laparoscopic cholecystectomy operations could be performed as day cases.

Characterizing Timing of Postoperative Complications Following Elective Roux-en-Y gastric Bypass and Sleeve Gastrectomy

Purpose

With the growing prevalence of bariatric procedures performed worldwide, it is important to understand the timing of postoperative complications following bariatric surgery and the differences which may exist between procedures.

Methods

This retrospective study was conducted using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2017 to 2018. All patients with primary elective Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) procedures were included. The primary outcome was to characterize the timing of postoperative complications for RYGB and SG.

Results

A total of 316,314 patients were identified with 237,066 (74.9%) in the SG cohort and 79,248 (25.1%) in the RYGB cohort. Early complications included myocardial infarction (4.7 ± 6.4 days), cardiac arrest (6.4 ± 8.5 days), pneumonia (6.9 ± 6.9 days), progressive renal insufficiency (8.1 ± 8.1 days), and acute renal failure (8.2 ± 7.6 days). Late complications included Clostridioides difficile infection (11.3 ± 7.8 days), organ space infections (11.7 ± 7.9 days), deep incisional infections (12.4 ± 6.6 days), superficial incisional infections (13.2 ± 6.9 days), and urinary tract infections (14.0 ± 8.4 days). SG patients were more likely to be diagnosed later than RYGB patients with regard to superficial incisional infections (14.0 ± 7.4 days vs 12.5 ± 6.3 days; p = 0.002), organ space infections (12.6 ± 7.8 days vs 10.8 ± 7.9 days; p = 0.001), acute renal failure (9.3 ± 8.1 days vs 6.8 ± 6.8 days; p = 0.03), and pulmonary embolism (13.7 ± 7.5 days vs 11.3 ± 8.0 days; p = 0.003). No significant difference in timing was observed for any other complication by procedures.

Conclusion

We demonstrate that significant differences in timing exist between complications and that these differences also vary by surgical procedure.

Graphical abstract

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.

Laparoscopic sleeve gastrectomy alters 1H-NMR-measured lipoprotein and glycoprotein profile in patients with severe obesity and nonalcoholic fatty liver disease

Patients with morbid obesity frequently present non-alcoholic fatty liver (NAFL) and non-alcoholic steatohepatitis (NASH) associated with pro-atherogenic alterations. Laparoscopic sleeve gastrectomy (LSG) is an effective treatment for weight reduction, and for the remission of hepatic alterations. Using ¹H-nuclear magnetic resonance (¹H-NMR), we investigated the effects of LSG on lipoprotein and glycoprotein profile in patients with morbid obesity and liver disease. We included 154 patients with morbid obesity (49 non-NASH, 54 uncertain NASH, 51 definite NASH). A blood sample was obtained before surgery and, in patients with definite NASH, one year after surgery. Patients with NASH had increased concentrations of medium and small VLDL particles, VLDL and IDL cholesterol concentrations, IDL, LDL, and HDL triglyceride concentrations, and elevated glycoprotein levels. These changes were more marked in patients with type 2 diabetes mellitus. LSG produced significant decreases in the concentration of VLDL particles, VLDL cholesterol and triglycerides, an increase in the concentration LDL particles and LDL cholesterol concentrations, and a decrease in protein glycation. We conclude that patients with obesity and NASH had significant alterations in circulating levels of lipoproteins and glycoproteins that were associated with the severity of the disease. Most of these changes were reversed post-LSG.

Laparoscopic hiatal hernia repair as same day surgery: Feasibility, short-term outcomes and costs

INTRODUCTION

Laparoscopic hiatal hernia repair is commonly performed with 1 night hospitalization. The aim was to assess repairs as same-day-surgery (SDS).

METHODS

Costs/short-term outcomes of SDS were compared to hospital-stay < 24-h: observation (OBS) and hospital-stay ≥ 24-h: inpatient (INP). Outcomes were assessed by postoperative 30-day ER visits/readmissions.

RESULTS

There were 262 procedures, excluding 50 reoperative repairs, 212 procedures were included: There were 66 SDS, 65 OBS and 81 INP. SDS vs. OBS: OBS were older, had higher ASA, less type I and more type III and IV hernias. Costs were significantly less in the SDS group with no difference in post-operative ER visits/post-discharge readmissions. SDS vs. INP: INP were older, had higher ASA, less type I and more type III and IV hernias. Costs were significantly less in the SDS group with no difference in post-operative ER visits/post-discharge readmissions.

CONCLUSION

Laparoscopic hiatal hernia repair can be performed as SDS in majority of elective repairs with good short-term outcomes and reduced cost.

Does ERAS impact outcomes of laparoscopic sleeve gastrectomy in adolescents?

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols have been successfully implemented in several surgical fields; however, the application of ERAS in the pediatric population is still limited.

OBJECTIVES

The aim was to determine if implementation of an ERAS protocol can improve outcomes of laparoscopic sleeve gastrectomy (LSG) in adolescents.

SETTING

University Hospital, United States.

METHODS

A retrospective analysis of 112 adolescent patients who underwent LSG from February 2011 to July 2019 was conducted. An ERAS protocol was instituted in June 2016. Conventional care patients (n = 51) were compared with ERAS patients (n = 61). Comparisons were made using Χ² tests or Fisher's exact for categoric data and Wilcoxon-rank sum tests for continuous data. Multiple linear regression was used to adjust length of stay for patient characteristics.

RESULTS

The 2 cohorts were similar in age, sex, race, number of co-morbidities, and preoperative body mass index. The volume of intraoperative fluid, intraoperative and postoperative opioids were significantly reduced in the ERAS group (P < .0001). The number of ERAS elements received per patient increased from a median of 9 to 15 (P < .0001). ERAS group had more discharges on postoperative day 1 (48% versus 6 %, respectively). Length of stay was significantly lower in the ERAS group (2.34 versus 2.04 median d, respectively). Difference was still significant after adjusting for age, sex, race/ethnicity, payor status, American Society of Anesthesiologists score, preoperative body mass index, and the duration of surgery (P < .0001). There were no differences in postoperative complications and 30-day readmissions.

CONCLUSIONS

An LSG ERAS protocol is associated with significant reduction in perioperative opioid use and length of stay with no increase in complications or readmission rates.

Association of Genetic Risk of Obesity with Postoperative Complications Using Mendelian Randomization

BACKGROUND

The extent to which obesity and genetics determine postoperative complications is incompletely understood.

METHODS

We performed a retrospective study using two population cohorts with electronic health record (EHR) data. The first included 736,726 adults with body mass index (BMI) recorded between 1990 and 2017 at Vanderbilt University Medical Center. The second cohort consisted of 65,174 individuals from 12 institutions contributing EHR and genome-wide genotyping data to the Electronic Medical Records and Genomics (eMERGE) Network. Pairwise logistic regression analyses were used to measure the association of BMI categories with postoperative complications derived from International Classification of Disease-9 codes, including postoperative infection, incisional hernia, and intestinal obstruction. A genetic risk score was constructed from 97 obesity-risk single-nucleotide polymorphisms for a Mendelian randomization study to determine the association of genetic risk of obesity on postoperative complications. Logistic regression analyses were adjusted for sex, age, site, and race/principal components.

RESULTS

Individuals with overweight or obese BMI (≥25 kg/m2) had increased risk of incisional hernia (odds ratio [OR] 1.7-5.5, p < 3.1 × 10-20), and people with obesity (BMI ≥ 30 kg/m2) had increased risk of postoperative infection (OR 1.2-2.3, p < 2.5 × 10-5). In the eMERGE cohort, genetically predicted BMI was associated with incisional hernia (OR 2.1 [95% CI 1.8-2.5], p = 1.4 × 10-6) and postoperative infection (OR 1.6 [95% CI 1.4-1.9], p = 3.1 × 10-6). Association findings were similar after limitation of the cohorts to those who underwent abdominal procedures.

CONCLUSIONS

Clinical and Mendelian randomization studies suggest that obesity, as measured by BMI, is associated with the development of postoperative incisional hernia and infection.

Laparoscopic sleeve gastrectomy reverses non-alcoholic fatty liver disease modulating oxidative stress and inflammation

BACKGROUND & AIMS

Hepatic alterations, such as in non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are frequently associated with obesity. To investigate the molecular mechanisms of these alterations and to identify molecules that could be used as potential therapeutic targets, we investigated the modulation of hepatic indices of oxidative stress and inflammation in obese patients undergoing laparoscopic sleeve gastrectomy (LSG).

METHODS

Patients (n = 436) attending our obesity clinic underwent LSG for weight loss. We obtained a diagnostic intraoperative liver biopsy, and a sub-cohort (n = 120) agreed to a 1-year follow-up that included donation of blood samples and additional liver biopsies. Selected key molecules in blood and liver tissue were used to investigate the hepatic alterations in obesity, and their response to LSG.

RESULTS

One year post-surgery, the prevalence of diabetes, dyslipidemia and hypertension decreased significantly. LSG improved liver histology features in all patients. Improvement was greater in severe cases of NAFLD including those with steatohepatitis, bridging fibrosis or cirrhosis. Significant pre-surgery differences in plasma, and liver markers of oxidative stress and inflammation (including chemokine C-C motif ligand 2, paraoxonase-1, galectin-3, and sonic hedgehog) were observed between patients with, and those without, NASH; post-surgery indicated consistent improvements in these parameters.

CONCLUSION

Our study shows that the histology and liver function of patients with morbid obesity are significantly improved after LSG via mechanisms that involve the reduction of oxidative stress and inflammatory processes. These data encourage the use of LSG as a therapeutic option to improve, or resolve, NAFLD.