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 Burns E M et al. BMJ 2010;341 ©2010 by British Medical Journal Publishing Group

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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