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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.

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Safety of Ambulatory Bariatric Surgery

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  1. 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

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

  3. But this comes at a cost…. • 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. 2008 Sep;14(9):589-96.

  4. 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. • 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 • Wasowicz-Kemps et al. Surg Endosc 2006; 20:1233-7.

  5. Evidence for Ambulatory Bariatric Surgery • Laparoscopic Gastric Band Insertion • Systematic review of 1 RCT and five cohort studies • 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 • 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 • Systematic review of 4 cohort studies • 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.

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

  7. Methods • Retrospective single-centre review of patients undergoing laparoscopic bariatric surgery between October 2008 and January 2012. • Decision to discharge made by senior member of clinical team, and after review by specialist nurses, dietician, and diabetic team (when indicated)

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

  9. Outcomes and Analysis • Outcome measures • 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 • 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

  10. Results

  11. 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) * **

  12. Success vs. Failure of 23 hour stay

  13. Discussion • 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. • 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 • 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

  14. Thank you for listening

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