Transcript Safety of Ambulatory Bariatric Surgery

Safety of Ambulatory
Bariatric Surgery
Senapati PS, Menon A, Al-Rashedy M, Thawdar
P, Akhtar K, Ammori BJ
Department of Obesity and Metabolic Surgery
Salford Royal Hospital, UK
Demand for Laparoscopic Bariatric Surgery
is increasing
©2010 by British Medical Journal Publishing Group
Burns E M et al. BMJ 2010;341
But this comes at a cost….
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Mean cost of laparoscopic bariatric surgery is
$17000 a patient according to an economic analysis
of 3561 patients
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Cremieux PY, Buchwald H et al. American Journal
Management Care. 2008 Sep;14(9):589-96.
Economic costs may be addressed with
ambulatory stay following surgery
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Meta-analysis of trials comparing ambulatory
stay versus inpatient following laparoscopic
cholecystectomy demonstrated reduced
costs with higher patient satisfaction and
comparable 30-day readmission rates.
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Ahmed et al. Surg Endosc 2008 Sep;22(9):1928-34.
Ambulatory stay following laparoscopic
gastric banding shown to reduce costs by
600 euros per patient
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Wasowicz-Kemps et al. Surg Endosc 2006; 20:1233-7.
Evidence for Ambulatory Bariatric
Surgery
Laparoscopic Gastric Band Insertion
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Systematic review of 1 RCT and five cohort studies
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99.9% of 2549 patients were discharged within 23 hours
0.55% 30-day readmission
Thomas H et al. Obes Surg 2011 Jun;21(6):805-10.
RYGB
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Median stay in large study of 4631 patients is 2 days. However
Medicare guidelines recommend ambulatory stay
Lancaster RT et al. Surg Endosc 22:2554-2563
Milliman Care guidelines Ambulatory Care 14th edition, Seattle
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Systematic review of 4 cohort studies
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84% of 2201 patients discharged within 23 hours
1.82% 30-day readmission
Thomas H et al. J Laparoendosc Adv Surg Tech A. 2011
Oct;21(8):677-81.
Objectives
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To examine discharge within 23 hours of
laparoscopic bariatric surgery in terms of:
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Feasibility
Safety
Methods
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Retrospective single-centre review of patients
undergoing laparoscopic bariatric surgery
between October 2008 and January 2012.
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Decision to discharge made by senior member
of clinical team, and after review by specialist
nurses, dietician, and diabetic team (when
indicated)
Patient Selection
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Inclusions (Planned Inpatient Stay cases)
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Roux-en-Y Gastric Bypass (RYGB)
Sleeve Gastrectomy (LSG)
Adjustable Gastric Banding (LAGB)
Revisional bariatric surgery
Exclusions (short planned day cases)
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Insertion of Intra-gastric Balloon
LAGB port revisions/removals
Outcomes and Analysis
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Outcome measures
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Demographic data including pre-operative Body Mass Index (BMI)
Successful discharge within 23 hours of surgery
Readmission to hospital within 30 days of surgery
All-cause mortality following surgery
Analysis
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Comparisons made between success of 23 hour discharge between
different operative groups with One-Way ANOVA test.
Comparisons also made between patients <23 hour stay and
patients>23 hour stay with 2 tailed t-test and Chi-squared where
appropriate
 Demographics (Age, Gender, BMI)
 Operating time
 30-day readmission
Results
Operation
type
Number of
patients
Median
Age
Median
Body mass index
(BMI)
(kg/m²)
Median
Length of stay
(hours)
Median
30 Day
Readmission
(%)
All cases
585
46
52.8
30
2.6
(18-67)
(37.8-80.9)
(13-552)
46
52.8
32
(20-67)
(44.2-80.9)
(17-552)
48
52.3
23
(18-63)
(37.8-72.0)
(19-72)
45
46.2
29
(26-64)
(31.2-63.6)
(13-264)
43
58.4
26
(26-61)
(22.5-71.0)
(16-552)
RYGB
LSG
LAGB
Revisional
471
53
27
34
3.0
1.9
0
0
Successful Discharge within 23
hours of surgery
% Cases discharged <23 hours hours
60
51.8
50
44.1
*
40
•LSG patients less likely to
be discharged <23h
compared to LAGB p<0.05)
34
30
29.1
**
24.4
20
10
0
All cases
RYGB
LSG
Operation
•RYGB patients significantly
less likely to be discharged
<23h compared to all other
groups (p<0.01)
LAGB
Revsional
Success vs. Failure of 23 hour stay
Postoperative Stay
<23 hour
Postoperative Stay
>23 hour
P value
Median Age
43 years
46 years
<0.001
% Females
80%
76.10%
0.23
BMI
50 kg/m²
50.8 kg/m²
0.61
% Diabetics
18%
36%
<0.001
Operating Time
85 minutes
95 minutes
0.18
30 day
Readmission
2.90%
2.40%
0.72
Mortality
0%
0.2% (1 mortality)
Complications
1.8%
3.4%
0.29
Discussion
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Ambulatory stay following laparoscopic bariatric surgery is feasible
after laparoscopic bariatric surgery, without compromising safety
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Age and Diabetic status may be significant factors to consider when
selecting patients for ambulatory stay.
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The low rates of successful 23-hour discharge with RYGB and LSG
may be explained by:
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The patients in this study were not initially planned for ambulatory stay
Patient co-morbidities and intra-operative factors which may or may not
be modifiable
Higher proportion of diabetic patients
Resource limitations preventing prompt discharge
Further work needed to identify preoperative factors predicting
successful ambulatory stay to allow better patient selection
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