HOUSTON – An ambulatory approach to laparoscopic sleeve gastrectomy is a safe and viable option to improve patient satisfaction and soften the economic blow of these procedures on patients, based on a large series at one surgery center in Cincinnati.
“With proper patient selection, utilization of enhanced recovery pathways with an overall low readmission rate and the complication profile point to the feasibility of laparoscopic sleeve gastrectomy [LSG] as a safe outpatient procedure,” said Sepehr Lalezari, MD, now a surgical fellow at Johns Hopkins University, Baltimore.
Dr. Sepehr Lalezari
About 105,000 LSG operations were performed in the United States in 2015, representing 54% of all bariatric operations, according to the American Society for Metabolic and Bariatric Surgery.
Patient selection and strict adherence to protocols are keys to success for ambulatory LSG, Dr. Lalezari said. Suitable patients were found to be ambulatory, between ages 18 and 65 years; had a body mass index (BMI) less than 55 kg/m2 for males and less than 60 kg/m2 for females; weighed less than 500 lb; had an American Society of Anesthesiologists’ classification score less than 4; and had no significant cardiopulmonary impairment, had no history of renal failure or organ transplant, and were not on a transplant wait list.
In this series, 71% of patients (579) were female, and the average BMI was 43. The total complication rate was 2.3% (19); 17 of these patients required hospital admission.
Postoperative complications included gastric leaks (seven, 0.9%); intra-abdominal abscess requiring percutaneous drainage (four, 0.5%); dehydration, nausea, and/or vomiting (four, 0.5%); and one of each of the following: acute cholecystitis, postoperative bleeding, surgical site infection (SSI), and portal vein thrombosis/pulmonary embolism.
The two complications managed on an outpatient basis were the SSI and one intra-abdominal abscess, Dr. Lalezari said.
“The only readmissions in our series that could have been possibly prevented with an overnight stay in the hospital were the four cases of nausea, vomiting, and/or dehydration,” he said. “These only accounted for 0.5% of the total cases performed.”
The readmission rates for ambulatory LSG in this series compared favorably with large trials that did not distinguish between ambulatory and inpatient LSG procedures, Dr. Lalezari noted. A 2016 analysis of 35,655 patients in the American College of Surgeons National Surgical Quality Improvement Program database reported a readmission rate of 3.7% for LSG (Surg Endosc. 2016 Jun;30[6]:2342-50).
A larger study of 130,000 patients who had bariatric surgery reported an LSG readmission rate of 2.8% (Ann Surg. 2016 Nov 15. doi: 10.1097/SLA.0000000000002079). The most common cause for readmissions these trials reported were nausea, vomiting, and/or dehydration.
Bariatric surgeons have embraced enhanced recovery pathways and fast-track surgery, with good results, Dr. Lalezari said, citing work by Zhamak Khorgami, MD, and colleagues at the Cleveland Clinic (Surg Obes Relat Dis. 2017 Feb;13[2]:273-80).
“Looking at fast-track surgery, they found that patients discharged on postoperative day 1 vs. day 2 or 3 did not change outcomes”; those discharged later than postoperative day 1 trended toward a higher readmission rate of 2.8% vs. 3.6%, Dr. Lalezari said.
The enhanced recovery/fast track protocol Dr. Lalezari and his coauthors used involves placing intravenous lines and infusing 1 L crystalloid before starting the procedure, and administration of famotidine and metoclopramide prior to anesthesia. The protocol utilizes sequential compression devices and avoids Foley catheters and intra-abdominal drains. Patients receive dexamethasone and ondansetron during the operation. The protocol emphasizes early ambulation and resumption of oral intake.
The operation uses a 36-French bougie starting about 5 cm from the pylorus, and all staple lines are reinforced with buttress material. At the end of the surgery, all incisions are infiltrated with 30 cc of 0.5% bupivacaine with epinephrine.
Patients are ambulating about 90 minutes after surgery and are monitored for 3-4 hours. They receive a total volume of 3-4 L crystalloids. When they’re tolerating clear liquids, voiding spontaneously, and walking independently, and their pain is well controlled (pain score less than 5/10) and vital signs are within normal limits, they’re discharged.
Postoperative follow-up involves a call at 48 hours and in-clinic follow-up at weeks 1 and 4. Additional follow-up is scheduled at 3-month intervals for 1 year, then at 6 months for up to 2 years, and then yearly afterward.
“With proper patient selection and utilization of enhanced recovery pathways, the low overall readmission rate (2.1%) and complication profile (2.3%) in our series point to the feasibility of laparoscopic sleeve gastrectomy as a safe outpatient procedure,” Dr. Lalezari said.
He reported having no relevant financial disclosures.