Enhanced Recovery After Surgery Facilitates Next Day Discharge for Laparoscopic Roux-en-Y Gastric Bypass: Experience from a Provincial Referral Program

doi:10.21203/rs.3.rs-3142942/v1

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Enhanced Recovery After Surgery Facilitates Next Day Discharge for Laparoscopic Roux-en-Y Gastric Bypass: Experience from a Provincial Referral Program

https://doi.org/10.21203/rs.3.rs-3142942/v1

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Introduction:

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a common bariatric procedure, but patients often experience extended inpatient stays. Enhanced recovery after surgery (ERAS) protocols aim to expedite recovery and discharge. In the province of Manitoba, Canada, the Centre for Metabolic and Bariatric Surgery (CMBS) is dedicated to providing bariatric care to the population. To enable earlier discharge, an overnight short-stay unit with ERAS protocols was introduced, along with transfer protocols for patients requiring prolonged care.

Methods

We retrospectively reviewed prospectively collected data on LRYGBs performed from November 2017 to December 2020. Surgical indications included BMI ≥ 35 with comorbidities or BMI 40–55 without comorbidities, approved by a multidisciplinary bariatric team. Postoperative evaluations were conducted 16–21 hours post-surgery. Patients were educated about potential complications and required to reside within one hour of a tertiary center for seven days. This study reports descriptive outcomes: length of stay (LOS), 30-day emergency room (ER) presentations, 7-day readmissions, and 30-day readmissions.

Results

Among the 439 LRYGB patients, the postoperative day 1 discharge rate was 94.8%, and day 2 discharge rate was 1.8%. A small proportion (2.7%, n = 12) required transfer due to anticipated prolonged LOS, primarily for delayed intraabdominal hemorrhage (66.7%) requiring reoperation and precautionary measures for technically challenging procedures (16.7%). Two brief ICU admissions occurred, with no mortalities. ER presentation rate within 30 days was 10.3% (n = 45), 7-day readmission rate was 2.7% (n = 12), and 30-day readmission rate was 4.1% (n = 18). Gastrointestinal intolerance was the most common reason for readmission.

Conclusion

Implementing an ERAS protocol for LRYGB enabled safe next-day discharge for 94.8% of patients. ER presentation and readmission rates aligned with existing literature, supporting the feasibility of next-day discharge for appropriately selected bariatric patients. These findings contribute to the evidence base for optimizing postoperative care and enhancing patient outcomes in bariatric surgery.

General Surgery

Laparoscopic Roux-en-Y gastric bypass

enhanced recovery after surgery

postoperative length of stay

emergency room presentations

readmissions

bariatric surgery

Obesity is a complex disease that impacts the health, wellbeing, and life expectancy of populations worldwide (1). A World Health Organization report from 2021 indicates that obesity rates have tripled since 1975 (2). Bariatric surgery remains the most effective and enduring intervention for treating obesity (3). While rates of different procedures vary between countries, the laparoscopic Roux-en-Y gastric bypass (LRYGB) remains one of the most commonly performed bariatric procedures.

There is significant regional variation in the median postoperative length of stay for LRYGB. A 2018 report from the International Federation Surgery Obesity indicates the median length of stay was 3 days in Asia and Eastern Europe, 2 days in Western Europe, and 1 day in North America between 2014 and 2018. The report also confirms that 99% of bariatric procedures are now performed laparoscopically. In addition to minimally invasive techniques, surgical programs continue to implement advances in perioperative care to facilitate safe early discharge in the form of enhanced recovery after surgery (ERAS).

ERAS is an evolution of the multimodal fast-track management introduced by Kehlet et al. for colorectal surgery (4–5). This model of evidence-based management integrates preoperative, intraoperative, and postoperative care plans to regulate body physiology and improve recovery. ERAS has been proven to reduce length of stay, morbidity, mortality, and healthcare resource utilization (6–7). Similar protocols have since been adopted by most major surgical specialties (8).

The first formal ERAS guideline for bariatric surgery was published in 2016 based on limited high-quality evidence specific to bariatric surgery, and many of its recommendations are inferred from colorectal data (9). Newer systematic reviews with a greater proportion of randomized controlled trials support the safety and decreased length of stay (LOS) of ERAS protocols in bariatric surgery (10–11). Multiple national consensus guidelines, which standardize implementation of ERAS nationally, support the recommendations originally made by Thorell et al. (9, 12–13).

The traditional LOS after LRYGB in North America has decreased over time with refinement in laparoscopic technique and the introduction of ERAS protocols. Recent large-scale analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program registry suggest that 98.1% of LRYGB patients had a LOS over 1 day, with an average of 2 days (14, 15). Prior to the 2016 guidelines, there were a few early adopters of fast-track approaches that suggested the safety of next-day discharge for LRYGB (16–17).

We present results from a fast-track LRYGB program designed to support safe discharge at less than 24 hours after surgery. To our knowledge, these data are the first Canadian cohort in compliance with the ERAS guidelines to present greater than 2 years of experience in planned next-day discharge. This study seeks to report the outcome measures of LOS, short-term complications, readmission, and reoperations in this patient cohort.

Institutional ethics approval was obtained for this study from the University of Manitoba, Health Research Ethics Board (approval number: H2017:036 [HREB # 20466]).

Population

The Centre for Metabolic and Bariatric Surgery (CMBS) provides all provincially funded bariatric surgical care for the province of Manitoba. A short-stay unit was opened at the community site in November 2017 to facilitate overnight and short-stay surgery. Protocols include early morning rounding before 7:00 am to facilitate early discharge.

This study involved a retrospective review of prospective data from the Centre for Metabolic and Bariatric Surgery database between November 2017 and March 2020 and a targeted chart review for details regarding specific complications. The sample includes all patients from November 2017–December 2020 that meet inclusion criteria.

Patients undergoing bariatric surgery through CMBS must meet criteria consistent with the commonly accepted National Institutes of Health indications for bariatric surgery: BMI ≥ 35 with obesity related comorbidities or ≥ 40, failure of diet and exercise to manage weight, and compliance with follow-up plans, diet, exercise, and behavior modification (18). The CMBS program currently accepts patients with BMI of 35 to 55 and age ranging from 18 to 65 years. Participants must abstain from smoking or other inhaled nicotine products for at least 1 year prior to surgery. This study includes primary LRYGB and revisional procedures. Patients undergoing laparoscopic sleeve gastrectomy (8% of patients during the study period) were excluded from analysis.

Preoperative

Patients who meet criteria were enrolled in a multidisciplinary program over approximately 4–6 months that includes assessments by a dietitian, nurse, clinical psychologist, kinesiologist, and four bariatric surgeons. All candidates undergo standard program education tailored to suit the individual patient’s needs. Preoperative preparation includes diet teaching and expectations about early postoperative recovery with the goal of discharge the morning after surgery if criteria are met. Strategies are reviewed to discuss early postoperative hydration, management of constipation, and expectations for postoperative pain.

Patients consume a low-calorie preoperative diet (950kcal/day) for two weeks if their BMI is 35–49 or 3 weeks if their BMI is 50 or greater. Patients are fasted per anesthesia society guidelines, and no carbohydrate loading is recommended. Prior to the restrictive diet, patients are instructed to review diabetic medications with their endocrinologist or family physician for potential modification to avoid hypoglycemia.

Medical history and medications are also reviewed by a preadmission clinic for patient optimization. Anti-hypertensive medications such as ACE inhibitors and ARBs are held for one week preoperatively.

Perioperative

Antimicrobial prophylaxis with weight-dosed cefazolin is administered preoperatively to prevent surgical site infections. Vancomycin or clindamycin is used as an alternative if a true penicillin allergy is determined. Thromboprophylaxis involves subcutaneous preoperative unfractionated heparin followed by postoperative low molecular weight heparin. Pneumatic compression stockings are applied before induction and removed prior to transfer at the completion of surgery. If applicable, excess hair is removed preoperatively with clippers. Skin is prepped with a chlorohexidine solution.

Anesthesiologists were previously educated on managing bariatric patients through local rounds. Anesthetic considerations of liberal antiemetics and short-acting agents are generally undertaken. A restrained approach to intravenous (IV) fluids is followed intraoperatively. Local anesthetic is either administered at port sites or with additional transversus abdominus plane (TAP) blocks at the discretion of the surgeon.

The LRYGB standardized technique is performed by four surgeons at a Provincial Bariatric Surgery Program. A jejunojejunostomy is formed with a single firing of a linear stapler, and the resultant common enterotomy is closed by suture. The gastrojejunostomy is made in an ante-colic, retro-gastric fashion and formed by a linear stapler followed by sutured common enterotomy closure. Mesenteric defects are closed with a non-absorbable suture. The standard practice of the program is to perform an air leak test with a large bore lavage tube within the gastric pouch. Peritoneal drains or Foley catheters are not routinely used.

Postoperative

Order sets have been developed with standardized postoperative IV fluids, antiemetics, analgesia, and diet. Patients’ home medications are initially managed at the discretion of the surgeon. A multimodal analgesia approach is taken with oral acetaminophen and IV non-steroidal anti-inflammatory drugs (NSAIDs). Oral and IV narcotic medications are available as breakthroughs, but patients are encouraged to use them sparingly. Patient-controlled analgesia is not routinely ordered. NSAIDs are not prescribed after discharge.

Patients are provided a clear fluid diet once recovered and fully awake on postoperative day 0. Volume of intake is carefully monitored in a patient logbook. Patients may advance to a full fluid diet on postoperative day 1 or after discharge.

The patient is reviewed by the surgeon or designate (bariatric surgical fellow) 16–21hrs postoperatively. Rounds occur prior to the start of the operative day to facilitate patient flow and operative throughput. Bloodwork is reviewed to aid in determining blood loss, electrolyte abnormalities, or acute kidney injury. Discharge criteria include adequate analgesia with oral medication, tolerance of fluid diet, independent ambulation, and the presence of clinically stable vitals. Those who do not meet the above criteria will remain admitted for further management or transferred to a dedicated tertiary care hospital if a longer stay is anticipated. All patients are provided with a prescription for a proton pump inhibitor (PPI) for 6 months.

All discharged patients are instructed to remain within 1 hour of the dedicated bariatric tertiary center for 7 days in case of immediate postoperative complications. A nurse navigator contacts the patient within one week and at one month after discharge to confirm expected recovery and answer questions. A clinical appointment is arranged with the surgeon at 4–6 weeks postoperatively.

Outcomes and Analysis

The primary outcomes of LOS and early 30-day postoperative complications were determined. Early complications were subcategorized into delayed discharged (greater than one day), reoperation, ER presentation, and readmission.

All patients were managed similarly with the implementation of the fast-track program and short-stay unit. As such, there was no comparison group. Any patients with anticipated LOS greater than one day due to significant baseline comorbidities (minority of patients) had their surgery performed at a tertiary hospital. Eight percent (n = 38) of patients undergoing surgery at the tertiary site during the study period were excluded from this study. Transfers to the tertiary hospital for complications or an unanticipated prolonged stay were considered delayed discharges.

Patient information on LOS and complications was prospectively entered into the CMBS database used for this study. A secondary review was undertaken of all bariatric admissions to the tertiary site during the study period to capture ER presentations or hospital admissions that were not reported in the CMBS database. A qualified surgeon reviewed each operative report, primary delayed discharge, and readmission chart to determine complications up to 30 days after surgery.

Study Cohort & 30-Day Mortality

A total of 439 patients underwent LRYGB and participated in the fast-track protocol during the study period. There were no recorded mortalities during the study period.

Length of Stay Outcomes & Readmission

There were 416 (94.8%) patients within the cohort who underwent next-day discharge from the time of their operation. Eight (1.8%) patients were discharged on post-operative day 2. Twelve (2.7%) patients required transfer to a dedicated tertiary center for a prolonged admission (Table 1)

A total of 18 (4.1%) readmissions occurred within 30 days. Of these readmissions, the majority were captured with an early presentation, with 12 (66.7%) presenting within 0–7 days, 15 (83.3%) within 0–10 days, and 6 (33.3%) presenting from 7–30 days post operatively. Two (0.5%) patients required admission to the intensive care unit following exploratory laparoscopy due to intra-abdominal bleeding.

Early Reoperations and Interventions

The overall reoperation rate was 11 (2.2%). Five (1.1%) patients required reoperation at postoperative day 0 to 1 and subsequent transfer to a dedicated tertiary care facility. All cases were related to postoperative intraabdominal bleeding. An additional 6 (1.4%) patients required a reoperation beyond 24 hours postoperatively. Five (83.3%) of these patients presented within 7 days due to various complications (abdominal collection, anastomotic leak, umbilical hernia). One (16.6%) of these patients presented with a gastrojejunal anastomotic leak after post-operative day 7. One (0.2%) patient in the study cohort required therapeutic endoscopic intervention for a gastrojejunal anastomotic stricture.

Emergency Department Presentations

Forty-five (10.3%) patients presented to a hospital during the postoperative period, and 60% (27/45) of these presentations were managed by the emergency physician or surgical consultant and discharged home without admission (Table 1). The other 40% (18/45) of patients required admission to a hospital. The primary diagnoses of these minor complaints were constipation and other pain not associated with the surgical sites. Readmissions were most associated with gastrointestinal (GI) intolerance, pain, or surgical site infection (SSI; Fig. 1).

Patient Transfers

Twelve (2.7%) patients required transfer from the short-stay unit to a dedicated tertiary care hospital for prolonged admission. Of these transfers, 1 (8.3%) was transferred on postoperative day 0, 9 (75.0%) were transferred on postoperative day 1, and 2 (16.7%) were transferred on postoperative day 2. The median LOS of transferred patients was 3 (IQR2.5) days.

The reasons for patient transfer were either monitoring after early reoperation or for precautionary monitoring after the index bariatric operation. Five (41.7%) patients underwent reoperation at the primary hospital site prior to transfer. All of these reoperations were performed due to intra-abdominal hemorrhage. Three (25%) patients were transferred for monitoring of stable intraabdominal bleeding, and 2 (16.7%) patients were transferred for precautionary monitoring after technically challenging index operations.

Since the inception of ERAS, surgical specialties, including bariatric surgery, have adopted this evidence-based practice (8). Randomized controlled trials of ERAS support a statistically significant reduction in LOS; however, a recent review of 47,906 patients in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) found that LRYGB patients stay an average of 2 days postoperatively (15). The findings of this study illustrate that our ERAS bariatric surgery protocol, in line with recently published national guidelines, can be safely implemented with a 94.8% next-day discharge rate for patients undergoing LRYGB (12). One difference in protocol is that the consensus guidelines recommend the use of metronidazole for antimicrobial prophylaxis; however, there is no evidence to support a significant benefit (19). Discharge by postoperative day 1 was first shown to be safe in LSG, and studies now consider same-day discharge (20). The adoption of a similar next-day discharge program has been slower for the more complex LRYGB despite the lack of a statistical difference in readmission or reoperation rates (21–22).

Early iterations of LRYGB ERAS protocols in the literature highlight the importance of preoperative patient education and familiarity with the program, as 11% of patients required an additional day of admission for social reasons (17). In comparison, our study saw 1.8% of patients discharged on postoperative day 2 and 2.7% transferred for prolonged admission. A recent randomized controlled trial comparing conventional versus ERAS pathways found a surprisingly similar functional hospital stay (20.5 h vs 17.4 h, p-value < 0.001) due to the bias caused by a well-established fast-track program years prior (22).

The authors perform bariatric procedures at a provincial bariatric program. We described a replicable patient pathway. The primary endpoint of decreased length of stay highlights the effectiveness of fast-track programs with both complication and readmission rates tied to its clinical success. Patients are educated to present to the tertiary care center associated with the bariatric program. Unique to our program is the requirement for postoperative patients to remain within 1 hour of the specialized center for a total of 7 days. For that reason, it is unlikely that we have missed any significant 7-day readmissions to other sites.

Of the 10.3% of patients who presented to a care center within 30 days, only 4.1% required re-admission. The majority of these presentations were managed by an emergency physician or consulting surgeon without admission. This is comparable to previously reported rates within the literature. The 30-day readmission rates of a 47,906 patient MBSAQIP database were reported to be 6.49% and 5.42% for female and male, respectively (15). In our cohort, readmissions were most associated with gastrointestinal (GI) intolerance, pain, or surgical site infection (SSI; Fig. 1). When including intrabdominal hemorrhage as the most common reason for delayed discharge, this was consistent with common causes of readmission after the LRYGB published in the literature (23).

Limitations

The majority of readmissions in our study were captured within the first 7 days postoperatively (66.7%; n = 12) during the recommended time of proximity to the specialized tertiary care site. This result does hold potential sample bias due to the limitation of data capture outside of the participating hospitals. The reassurance of proximity to care could also aid in the high rate of next-day discharge, and seeking out care early may be a result of the 7-day requirement; however, objective measurement of this was not included.

Our study presents evidence that an established ERAS protocol for LRYGB allows 94.8% of patients to be safely discharged home the next day. The ER presentation and 7-day and 30-day readmission rates were comparable to existing literature suggesting that next-day discharge is feasible for appropriately selected gastric bypass patients.

Disclosures

Drs. Krista Hardy, Caleb Leung, Jonathan Seto, Simon Tewes, Wenjing He, Ashley Vergis have no conflicts of interest to disclose.

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Table 1. Length of Stay Outcomes & Readmission

Variables
Number of Patients	N=439
Next Day Discharge (n, %)	416 (94.8%)
Day 2 Discharge (n, %)	8 (1.8%)
Transfer (n, %)	12 (2.7%)
Readmissions within 30 days (n, %)	19 (4.1%)
0-7 days 0-10 days 7-30 days	12 (66.7%) 15 (83.3%) 6 (33.3%)
Reoperations and Interventions	11 (2.2%)
Postoperative day one Anastomotic leak After postoperative day one Therapeutic endoscopy	5 (1.1%) 1 (16.6%) 6 (1.4%) 1 (16.6%)
Emergency Department Presentations	45 (10.3%)
Without admission Readmission	27 (60%) 18 (40%)
Transfers	12 (2.7%)
Postoperative day one Postoperative day two	1 (8.3%) 2 (16.7%)

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Enhanced Recovery After Surgery Facilitates Next Day Discharge for Laparoscopic Roux-en-Y Gastric Bypass: Experience from a Provincial Referral Program

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Version 1

Abstract

Introduction:

Methods

Results

Conclusion

Figures

BACKGROUND

METHODS

Population

Preoperative

Perioperative

Postoperative

Outcomes and Analysis

Results

Study Cohort & 30-Day Mortality

Length of Stay Outcomes & Readmission

Early Reoperations and Interventions

Emergency Department Presentations

Patient Transfers

Discussion

Limitations

Conclusion

Declarations

Disclosures

References

Table

Status:

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