Same-day discharge (SDD) after Roux-en-Y gastric bypass (RYGB) seems to be safe and has comparable outcomes to inpatients discharged on postoperative days on-two, according to researchers from the University of Illinois at Chicago, IL. They caution that as the number of SDD cases are increasing there is a need to standardised patient selection criteria and perioperative management protocols. The findings were featured in the paper, ‘Is Same-Day Discharge After Roux-en-Y Gastric Bypass Safe? A Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Database Analysis’, published in Obesity Surgery.
The authors noted that the adoption minimally invasive techniques and the introduction of Enhanced Recovery After Surgery (ERAS) protocols have reduced the length of hospitalisation without increasing the postoperative morbidity or readmission rates. However, although SDD might help to reduce costs and healthcare staff workload, it is not known whether it provides any direct benefit to patients. Furthermore, the ideal patient population and perioperative management for ambulatory bariatric surgery are not standardised.
To investigate the outcomes from SDD surgery, they analysed data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for patients who underwent elective RYGB between 2015 and 2020. The sample was divided into two groups according to the length of hospital stay (LOS): same-day discharge RYGB (SDD-RYGB) (LOS 0 days) and inpatient RYGB (In-RYGB) (LOS 1–2 days). The primary outcomes of interest were 30-day overall morbidity, serious morbidity readmission, reoperation, intervention, and mortality rates. Secondary outcome measures included operative time, outpatient dehydration treatment, and emergency department visits.
A total of 276,447 RYGBs were performed in MBSAQIP centres: 3,275 (1.2%) same-day discharge, 107,143 (38.7%) POD 1 discharge, 124,414 (45%) POD 2 discharge, and 41,615 (15.1%) POD ≥ 3 discharge. The proportion of patients undergoing same-day (2015: 0.9% vs. 2020: 2.2%, p<0.001) and POD 1 discharge after RYGB (2015: 25.9% vs. 2020: 52.4%, p<0.001) increased significantly during the study period. However, the frequency of POD2 (2015: 53.4% vs. 2020: 34.4%, p<0.001) and POD ≥ 3 discharge RYGB (2015: 19.8% vs. 11%, p<0.001) decreased (Figure 1). After inclusion and exclusion criteria were applied, a total of 167,188 RYGB patients were assessed, including 2,156 SDD-RYGB and 165,032 In-RYGB.
Mean age, proportion of females, ASA classification and preoperative BMI were similar between the groups. The presence of gastroesophageal reflux disease and obstructive sleep apnoea (OSA) was more frequent in the In-RYGB group.
Outcomes
The outcomes showed that in the SDD-RYGB cohort, operative time was significantly shorter (SDD-RYGB: 106.8 vs. In-RYGB: 114.4 min, p<0.001) and the presence of a bariatric specialist more frequent (SDD-RYGB: 83.1% vs. In-RYGB: 80.7%, p=0.002). However, intraoperative drain placement (SDD-RYGB: 17.4% vs. In-RYGB: 22.5%, p<0.001) and performance of a provocative test to check the anastomosis (SDD-RYGB: 91.6% vs. In-RYGB: 93.1%, p=0.01) were more frequent in the inpatient group.
On univariate analysis, 30-day overall morbidity (SDD-RYGB: 11.3% vs. In-RYGB: 10.2%, p=0.08), serious morbidity (SDD-RYGB: 3.1% vs. In-RYGB: 3%, p=0.70), reoperation (SDD-RYGB: 1.4% vs. In-RYGB: 1.2%, p=0.54), intervention (SDD-RYGB: 1.1% vs. In-RYGB: 1.6%, p=0.12), readmission (SDD-RYGB: 4.8% vs. In-RYGB: 4.8%, p=0.97) and mortality rates (SDD-RYGB: 0.04% vs. In-RYGB: 0.09%, p=0.45) were comparable between inpatient and same-day discharge patients.
Outpatient dehydration treatment (SDD-RYGB: 5.3% vs. In-RYGB: 4%, p=0.008), blood transfusion (SDD-RYGB: 0.4% vs. In-RYGB: 0.2%, p=0.02), progressive renal insufficiency (SDD-RYGB: 0.2% vs. In-RYGB: 0.04%, p=0.01) and cerebrovascular accident (SDD-RYGB: 0.09% vs. In-RYGB: 0.008%, p=0.01) rates were higher after SDD-RYGB. Multivariate logistic regression analysis also showed a lower risk of 30-day intervention (p=0.04) in same-day discharge patients.
“Since the frequency of this practice is increasing, standardised patient selection criteria and perioperative management protocols are needed,” the authors concluded. “Potential delay in the diagnosis and management of postoperative complications after same-day discharge RYGB warrants further investigation and preventive measures.”
Further information
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