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 BIDA May 2012

Demand for Laparoscopic Bariatric Surgery is increasing Burns E M et al. BMJ 2010;341 ©2010 by British Medical Journal Publishing Group

Co-morbidity Resolution Gastric BandingGastric BypassBPD or DS EWL47%62%70% Resolution of DM48%84%99% Resolution of Hyperlipidaemia 59%68%83% Resolution of HT43%68%83% Resolution of Sleep Apnoea 95%80%92% Buchwald et al. JAMA.2004:292:

Bariatric Surgery versus intensive medical therapy in obese patients with diabetes 150 patients between ages of patients between ages of BMI range of BMI range of Average HBA1c 9.2% Average HBA1c 9.2% Duration of diabetes >8years Duration of diabetes >8years Randomised to intensive medical tt versus GBYP or Sleeve gastrectomy Randomised to intensive medical tt versus GBYP or Sleeve gastrectomy Primary end point was HBA1c of 6% at 12months Primary end point was HBA1c of 6% at 12months Proportion of pts achieved primary end point was 12% in medial arm and 42% and 37% in the GBYP and Sleeve gastrectomy respectively Proportion of pts achieved primary end point was 12% in medial arm and 42% and 37% in the GBYP and Sleeve gastrectomy respectively Bariatric surgery achieved glycaemic control in significanty more pts than medical therapy alone Bariatric surgery achieved glycaemic control in significanty more pts than medical therapy alone Schauer P R et al. N Eng J Med April 2012

Types of obesity Surgery Restrictive Restrictive Vertical banded gastroplasty Vertical banded gastroplasty Adjustable Gastric Banding Adjustable Gastric Banding Sleeve Gastrectomy Sleeve Gastrectomy Malabsorptive Malabsorptive Jejunoileal bypass Jejunoileal bypass Biliopancratic Diversion Biliopancratic Diversion Duodenal Switch Duodenal Switch Combined Combined Gastric Bypass Gastric Bypass Newer Novel models Newer Novel models Sleeved jejunoileal bypass Sleeved jejunoileal bypass Ileal interposition Ileal interposition Endobarrier Endobarrier Miscellaneous Miscellaneous

ADJUSTABLE GASTRIC BANDING

Gastric Bypass

Sleeve Gastrectomy

BILIOPANCREATIC DIVERSION (BPD) Malabsorptive Malabsorptive larger stomach pouch larger stomach pouch higher amount of weight loss higher amount of weight loss greater malabsorption of nutrients greater malabsorption of nutrients excess weight loss of 74 % at 1 year, 78 % at 2 years, 81 % at 3 years, 84 % at 4 years, and 91 % at 5 years*. excess weight loss of 74 % at 1 year, 78 % at 2 years, 81 % at 3 years, 84 % at 4 years, and 91 % at 5 years*. resolves type 2 diabetes in almost 77% of patients** resolves type 2 diabetes in almost 77% of patients** *Duodenal Switch: An Effective Therapy for Morbid Obesity – Intermediate Results” Baltasar A, Bou R. Obesity Surgery 2001 Feb; 11(1): ** Buchwald H, Avidor Y, Braunwald E, et al. Bariatric Surgery—A Systematic Review of the Literature and Meta-analysis. Journal of the American Medical Association 2004 Oct 13;292(14).

BILIOPANCREATIC DIVERSION (BPD) WITH DUODENAL SWITCH Malabsorptive Malabsorptive larger stomach pouch larger stomach pouch higher amount of weight loss higher amount of weight loss greater malabsorption of nutrients greater malabsorption of nutrients excess weight loss of 74 % at 1 year, 78 % at 2 years, 81 % at 3 years, 84 % at 4 years, and 91 % at 5 years*. excess weight loss of 74 % at 1 year, 78 % at 2 years, 81 % at 3 years, 84 % at 4 years, and 91 % at 5 years*. resolves type 2 diabetes in almost 77% of patients** resolves type 2 diabetes in almost 77% of patients** *Duodenal Switch: An Effective Therapy for Morbid Obesity – Intermediate Results” Baltasar A, Bou R. Obesity Surgery 2001 Feb; 11(1): ** Buchwald H, Avidor Y, Braunwald E, et al. Bariatric Surgery—A Systematic Review of the Literature and Meta-analysis. Journal of the American Medical Association 2004 Oct 13;292(14).

Five-Year Healthcare Utilization Five-Year Healthcare Utilization Christou NV, Sampalis JS, Liberman M, et al. Surgery Decreases Long-Term Mortality, Morbidity, and Health Care Use in Morbidly Obese Patients. Annals of Surgery 2004;240(3): > Economic payoff of obesity surgery within 3.5 years as a result of reductions in direct healthcare costs. > After 5 years, the total hospitalization costs for control group was 29 % higher than for those who had surgery. Obesity surgery is cost effective. BARIATRIC MEAN (SD) CONTROLS MEAN (SD) P- VALUE Hospitalizations 2.75 (3.44)3.17 (3.22)0.001 Hospital Days (38.97)36.59 (25.41)0.001 Physician Visits 9.62 (15.8)17.00 (21.74)0.001

But this comes at a cost…. Mean cost of laparoscopic bariatric surgery is $17000 a patient according to an economic analysis of 3561 patients Mean cost of laparoscopic bariatric surgery is $17000 a patient according to an economic analysis of 3561 patients Cremieux PY, Buchwald H et al. American Journal Management Care Sep;14(9): Cremieux PY, Buchwald H et al. American Journal Management Care Sep;14(9):

Economic costs may be addressed with ambulatory stay following surgery 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. 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. Ahmed et al. Surg Endosc 2008 Sep;22(9): Ahmed et al. Surg Endosc 2008 Sep;22(9): Ambulatory stay following laparoscopic gastric banding shown to reduce costs by 600 euros per patient Ambulatory stay following laparoscopic gastric banding shown to reduce costs by 600 euros per patient Wasowicz-Kemps et al. Surg Endosc 2006; 20: Wasowicz-Kemps et al. Surg Endosc 2006; 20:

Evidence for Ambulatory Bariatric Surgery Laparoscopic Gastric Band Insertion Laparoscopic Gastric Band Insertion Systematic review of 1 RCT and five cohort studies Systematic review of 1 RCT and five cohort studies 99.9% of 2549 patients were discharged within 23 hours 99.9% of 2549 patients were discharged within 23 hours 0.55% 30-day readmission 0.55% 30-day readmission Thomas H et al. Obes Surg 2011 Jun;21(6): RYGB RYGB Median stay in large study of 4631 patients is 2 days. However Medicare guidelines recommend ambulatory stay Median stay in large study of 4631 patients is 2 days. However Medicare guidelines recommend ambulatory stay Lancaster RT et al. Surg Endosc 22: Milliman Care guidelines Ambulatory Care 14 th edition, Seattle Systematic review of 4 cohort studies Systematic review of 4 cohort studies 84% of 2201 patients discharged within 23 hours 84% of 2201 patients discharged within 23 hours 1.82% 30-day readmission 1.82% 30-day readmission Thomas H et al. J Laparoendosc Adv Surg Tech A Oct;21(8):

Objectives To examine discharge within 23 hours of laparoscopic bariatric surgery in terms of: To examine discharge within 23 hours of laparoscopic bariatric surgery in terms of: Feasibility Feasibility Safety Safety

Methods Retrospective single-centre review of patients undergoing laparoscopic bariatric surgery between October 2008 and January Retrospective single-centre review of patients undergoing laparoscopic bariatric surgery between October 2008 and January Decision to discharge made by senior member of clinical team, and after review by specialist nurses, dietician, and diabetic team (when indicated) Decision to discharge made by senior member of clinical team, and after review by specialist nurses, dietician, and diabetic team (when indicated)

Patient Selection Inclusions (Planned Inpatient Stay cases) Inclusions (Planned Inpatient Stay cases) Roux-en-Y Gastric Bypass (RYGB) Roux-en-Y Gastric Bypass (RYGB) Sleeve Gastrectomy (LSG) Sleeve Gastrectomy (LSG) Adjustable Gastric Banding (LAGB) Adjustable Gastric Banding (LAGB) Revisional bariatric surgery Revisional bariatric surgery Exclusions (short planned day cases) Exclusions (short planned day cases) Insertion of Intra-gastric Balloon Insertion of Intra-gastric Balloon LAGB port revisions/removals LAGB port revisions/removals

Outcomes and Analysis Outcome measures Outcome measures Demographic data including pre-operative Body Mass Index (BMI) Demographic data including pre-operative Body Mass Index (BMI) Successful discharge within 23 hours of surgery Successful discharge within 23 hours of surgery Readmission to hospital within 30 days of surgery Readmission to hospital within 30 days of surgery All-cause mortality following surgery All-cause mortality following surgery Analysis Analysis Comparisons made between success of 23 hour discharge between different operative groups with One-Way ANOVA test. 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 with 2 tailed t-test and Chi-squared where appropriate Comparisons also made between patients 23 hour stay with 2 tailed t-test and Chi-squared where appropriate Demographics (Age, Gender, BMI) Demographics (Age, Gender, BMI) Operating time Operating time 30-day readmission 30-day readmission

Results Operationtype Number of patientsMedianAgeMedian Body mass index (BMI)(kg/m²)Median Length of stay (hours)Median 30 Day Readmission(%) All cases (18-67)( )(13-552) RYGB (20-67)( )(17-552) LSG (18-63)( )(19-72) LAGB (26-64)( )(13-264) Revisional (26-61)( )(16-552)

Successful Discharge within 23 hours of surgery RYGB patients significantly less likely to be discharged <23h compared to all other groups (p<0.01) LSG patients less likely to be discharged <23h compared to LAGB p<0.05) ** *

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 day Readmission2.90%2.40%0.72 Mortality0% 0.2% (1 mortality) Complications1.8%3.4%0.29

Discussion Ambulatory stay following laparoscopic bariatric surgery is feasible after laparoscopic bariatric surgery, without compromising safety Ambulatory stay following laparoscopic bariatric surgery is feasible after laparoscopic bariatric surgery, without compromising safety Age and Diabetic status may be significant factors to consider when selecting patients for ambulatory stay. Age and Diabetic status may be significant factors to consider when selecting patients for ambulatory stay. The low rates of successful 23-hour discharge with RYGB and LSG may be explained by: The low rates of successful 23-hour discharge with RYGB and LSG may be explained by: The patients in this study were not initially planned for ambulatory stay 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 Patient co-morbidities and intra-operative factors which may or may not be modifiable Higher proportion of diabetic patients Higher proportion of diabetic patients Resource limitations preventing prompt discharge Resource limitations preventing prompt discharge Further work needed to identify preoperative factors predicting successful ambulatory stay to allow better patient selection Further work needed to identify preoperative factors predicting successful ambulatory stay to allow better patient selection

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