Fully Ambulatory Laparoscopic Sleeve Gastrectomy

Fully Ambulatory Laparoscopic Sleeve Gastrectomy: 328 Consecutive Patients in a Single Tertiary Bariatric Center Fabio Garofalo, Ronald Denis, Omar Abouzahr, Pierre Garneau, Radu Pescarus & Henri Atlas Obesity Surgery The Journal of Metabolic Surgery and Allied Care ISSN 0960-8923 OBES SURG DOI 10.1007/s11695-015-1984-0

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Author's personal copy OBES SURG DOI 10.1007/s11695-015-1984-0

ORIGINAL CONTRIBUTIONS

Fully Ambulatory Laparoscopic Sleeve Gastrectomy: 328 Consecutive Patients in a Single Tertiary Bariatric Center Fabio Garofalo 1 & Ronald Denis 1 & Omar Abouzahr 1 & Pierre Garneau 1 & Radu Pescarus 1 & Henri Atlas 1

# Springer Science+Business Media New York 2015

Abstract Background Laparoscopic sleeve gastrectomy (LSG) is becoming one of the most popular bariatric procedures because of its short operative time, good resolution of comorbidities, excellent weight loss, and low complications rate. However, the safety of LSG as a day-surgery procedure has not yet been widely documented. Methods A retrospective analysis of a prospectively collected bariatric database, in a single institution, between August 2012 and February 2015, yielded 980 patients who underwent LSG; 328 patients (33.5 %) responded to established criteria and were operated on a 1-day surgery basis (length of stay< 12 h). Results There were 258 (78 %) primary LSG and 70 revisional LSG (22 %) performed on 284 females and 44 males, with a mean age (±SD) of 38±9 years. Mean (±SD) preoperative body mass index (BMI) was 45 ± 6 kg/m2.

Operative time was 68±17 min (mean±SD). There were no deaths. A total of 322 patients (98.2 %) were discharged home the day of surgery. There were 6 (1.8 %) unplanned overnight hospitalization, and 28 patients (8.5 %) were readmitted between days 1 and 30. Most patients (25/34, 73 %) were hospitalized for minor problems, such as pain, nausea, and/or vomiting. There were two cases of (0.6 %) gastric staple line leaks, three (0.9 %) of intra-abdominal hematomas, two (0.6 %) of pneumonia, one (0.3 %) of acute pancreatitis, and one (0.3 %) of urinary tract infection. All patients recovered well. Conclusions LSG can be performed as an outpatient procedure in selected patients, with acceptable results in terms of retention, readmission, and complication rates.

* Henri Atlas [email protected]

Introduction

Fabio Garofalo [email protected] Ronald Denis [email protected] Omar Abouzahr [email protected] Pierre Garneau [email protected] Radu Pescarus [email protected] 1

Département de Chirurgie, Division de Chirurgie Bariatrique, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, 5400 boul. Gouin ouest Montréal, Québec H4J 1C5, Canada

Keywords Ambulatory surgery . Obesity . Laparoscopic sleeve gastrectomy

The prevalence of morbid obesity is steadily increasing and represents a serious worldwide public health problem [1], with a financial impact on health care costs that keeps rising. Current medical literature supports the role of bariatric surgery in lowering the costs associated with common, often mortal, comorbidities such as diabetes mellitus, hypertension, dyslipidemia, and heart disease [2, 3]. The laparoscopic sleeve gastrectomy (LSG) is one of the bariatric procedures that is gaining in popularity because of a low operative time, satisfactory resolution of comorbidities, and excellent weight loss outcomes [4]. Avenues to simplify procedures and lower costs for this surgery, without decreasing the level of medical care, are sought after for medical and financial reasons, and one of

Author's personal copy OBES SURG

these is a shorter postoperative stay. Our institution is a tertiary bariatric center with an average of 600 bariatric procedures yearly and where an LSG was first performed in 2007. Between that time and August 2015, a total of 2061 patients sustained LSG, and in August 2012, a fully ambulatory LSG program, with clearly defined selection criteria, was developed. The goal of this study is to demonstrate the feasibility of the LSG as ambulatory surgery with a length of stay (LOS) 50 kg/m2, age more than 45 years, hypertension, male gender, and pulmonary embolism. Patients are divided in three classes according to the OS-MRS score: class A, low risk with no or only one risk factor; class B, average risk with two or three risk factors; and class C, high risk with four or five risk factors. This classification, used for gastric bypass surgery, can reasonably be adapted to sleeve gastrectomy. Patient’s ASA score (American Society of Anesthesiologists classification of physical status) must be I, II, or III if cleared by the internist. Obstructive sleep apnea (OSA) screening was required for all patients. If, upon screening, patients were found to have either moderate or severe OSA, treatment with continuous positive airway pressure (CPAP) therapy was required before surgery as well as approval by a pneumologist. Insulin-dependent diabetes, poorly controlled high blood pressure, and a class C score (OS-MRS) were exclusion criteria for ambulatory surgery (Fig. 1).

Preoperative assessment included full blood count, renal function and electrolytes, thyroid function, hepatic enzymes, albumin and proteins, HDL, coagulation status (INR and PTT), glycemia and glycated hemoglobin, iron level, and vitamins (folic acid, vitamin D, and B12). All patients included for day surgery had normal hemoglobin and no hepatic or renal deficiency, and any vitamin deficiency was corrected before surgery. Patients had to follow a low-calorie diet for 2 weeks prior to the intervention, ensuring an intake of 900 kcal and 90 g of protein per day, to reduce liver size and facilitate exposure of the stomach and cardia. All patients participated in a preoperative nutritional course. Interventions were performed at the beginning of the operational program, and no more than two cases could be performed daily, as patients had to be released before 7:00 p.m. The anesthetic team must be experienced with an anesthetic protocol adapted to ambulatory surgery favoring the use of short-term action anesthetics and the administration of corticosteroids (dexamethasone 4 to 8 mg at induction) which has already been shown to be beneficial in reducing nausea and postoperative stress [8–10]; dexamethasone is used systematically in our institution. Postoperative nausea and vomiting control also require the systematic injection of 4 mg of ondansetron, before, at the start, and at the end of the surgery [11, 12]. Postoperative analgesic was reinforced by the injection of 20 ml of bupivacaine at 0.5 % under the left diaphragmatic cupola [13, 14] and by a 15-ml bupivacaine infiltration of the port scars [15, 16]. All patients received a total of 1 l of Ringer Lactate at the beginning of surgery followed by another liter administered gradually during the surgical procedure and finished in the recovery room. A 5-trocart standardized technique was adopted. Gastric transection began 4 to 5 cm from the pylorus by successive applications of an endo-linear cutter stapler, using a gastric calibration bougie size 36 or 40 French (Fr). Overriding suturing with absorbable material on the staple line was applied by two out of four surgeons. The staple line was thoroughly inspected, and metal clips or oversewing was added in the case of residual bleeding, by all surgeons. All skin incisions were infiltrated with a total of 15 ml of bupivacaine 0.5 %. Patients were released home in accordance with the modified Post-Anesthesia Care Units (PACU) discharge protocol [17]. This included eupneic, mobile, and well-oriented patients, with normal blood pressure and oxygen saturation, clear urine, and clean bandage, with pain and nausea controlled through oral medication. Neither postoperative imaging nor blood tests were planned. The exit oral prescription included thromboprophylaxis with low molecular weight heparin (LMWH) for 21 days, analgesic, antiemetics, laxatives, and proton pump inhibitor for 6 weeks postoperatively (Fig. 2). Particular attention was paid to refeeding guidelines with strict liquid intake fractioned

Author's personal copy OBES SURG Fig. 1 Selection criteria

Inclusion Criteria

Exclusion Criteria

Paents characterisc

Paents characterisc

Age < 55 y.o. with BMI < 50 kg/m2 Age < 45 y.o. with BMI ≥ 50 and < 55 Kg/m2 ASA score I or II ASA score III if cleared by internist Mild OSA* Moderate or severe OSA* if treated with CPAP OS-MRS‡ grade A or B Proof or residence 40 Km radius from hospital

Age ≥ 55 y.o. BMI ≥ 55 Kg/m2 ASA score ≥ IV OS-MRS‡ grade C Insulin-dependent diabetes Poorly controlled hypertension

Hospital characterisc Experienced surgeon Bed available if hospitalizaon overnight Operaon scheduled in the morning

* Obstrucve sleep apnea, ‡ Obesity Surgery Mortality Risk Score

for the first 4 days and a small dose progressive diet recommended after surgery. All patients were provided with a

bariatric surgery food guide, available on our website. A bariatric surgery nurse ensured telephone contact 24 h

Pre-operave phase

Intra-operave phase

Post-operave phase

Paents selecon

Anesthesia protocol

Recovery room

Inclusion criteria Exclusion criteria

Paents preparaon Low-calorie diet (2 weeks) Nutrional course Counseling

Inducon: Propofol (200/250 mg) Maintenance: Desﬂurane (1 MAC) Muscular relaxant: Rocoronium (50 mg) Reverse: Neosgmine (2.5 mg) Glycopirolate (0.5 mg) Narcocs: Morpine (15 mg) Fentanyl (250 mcg) Anemecs: Ondansetron (8 mg) Dexamethasone (8 mg)

Surgical protocol Anbioc prophylaxis (Cefazolin 2 g) Heparine 5000 UI sc before surgery Pneumac compression stockings Experienced surgeon Standardized laparoscopic technique Local anesthesia (Bupivacaine 0.5%)

Vital signs Pneumac compression stockings IPP: Pantoloc (40 mg) Antalgia: Hydromorphone (1-2 mg) Anemecs: Dimenhydrinate (50 mg) Ondansetron (4 mg)

Discharge protocol PACU* modiﬁed criteria: score >10/14 Prescripon: Enoxaparine (40 mg) Hydromorphone (2 mg) Dimenhydrinate (50 mg) Docusate sodium (200 mg) Pantoprazole (40 mg) Telephone contact 24 hours post-op.

*Post-Anesthesia Care Units Fig. 2 Institution’s ambulatory surgery protocol


postsurgery, repeated if needed at 48 h, and a follow-up visit was scheduled within 1 month postoperatively. Demographic characteristics of patients, intra/ postoperative complications, overnight hospitalization, readmission, and duration of operations were also analyzed. Statistical analysis was performed using the statistical package for social analysis (SPSS, version 15.0, Chicago, IL, USA). The results were presented with mean and standard deviation or number (%) as appropriate. Univariate analysis was performed by Pearson’s chi-square and Fisher’s exact test for categorical data and the Mann-Whitney test for continuous data. Multivariate analysis was performed using logistic regression analysis. The significance threshold was set at p≤ 0.05.

Results Ambulatory LSG was performed on a total of 328 patients (33.5 %) out of 980 LSGs, with 284 females and 44 males, with a mean age (±SD) of 38.4±8.5 years. Mean (±SD) BMI for these patients was 44.5±5.6 kg/m2. Patients with comorbidities were also enrolled for a full ambulatory LSG and are described in Table 1. A total of 322 patients (98.2 %) were discharged home the day of the surgery with an overall mean LOS after surgery of 8.1 h (range of 6–10 h). A total of 258 (78 %) primary LSGs and 70 revisional LSGs (22 %) were performed. From the revisional group, 58 patients had had laparoscopic adjustable gastric banding (LAGB) with band removal, and 10 patients a gastric plication. Two patients underwent LAGB removal and LSG in the same surgical procedure with no reported complications. Table 1

Patient characteristics

Characteristics

Patients (n=328)

Age (year) Body mass index (kg/m2) ASA score Women (%) Female/male ratio Comorbidities (%) Hypertension (%) Type II diabetes (%) Sleep apnea (%) Hyperlipidemia (%) Ambulatory surgery Length of stay (hours)

38.4 (±8.5)a 44.5 (±5.6)a 2.3 (±0.5)a 86.6 6/1 54.3 21.6 12.5 10.1 6.4

Overnight hospitalization (%) Readmission (%)

1.8 8.5

a

Mean±standard deviation

b

Mean and range

8.1 (6–10)b

A total of 121 patients (37 %) were discharged to a hotel or stayed with family, for the first 48 postoperative hours. There were six unplanned overnight hospitalizations and thus a retention rate of 1.8 %. Four patients stayed overnight because of postoperative nausea and vomiting, one for somnolence, and one for perioperative bleeding from short gastric vessels; a drain was left as a precaution. Of these six patients, one was released the next morning, four remained in hospital for 1 day, and the last one for 3 days. However, the patient that had revisional LSG, following previous surgery for LAGB removal and gastric plication, developed a major complication and was rehospitalized on day 21. This patient developed postoperative gastric leak, treated by endoscopic stenting and radiological drainage. A total of five endoscopic procedures were necessary to heal the leak. The patient was finally discharged home after 109 days of hospitalization. Twenty-eight other patients (8.5 %) were readmitted between days 1 and 30, only 1 from the revisional group and 27 from the primary LSG group. All readmitted patients had thoraco-abdominal computed tomography (CT) scans with oral contrast with a LOS of 2.3±4.9 days (mean±SD). Reasons for readmission are summarized in Table 2. When we compared comorbidities and readmission, we found 17 (61 %) patients with comorbidities who were readmitted compared to 11 (39 %) patients without comorbidities (p=0.474).

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