Safety and efficacy of outpatient sleeve gastrectomy: 2534 cases performed in a single free-standing ambulatory surgical center.

BACKGROUND: Sleeve gastrectomy (SG) is currently the most widely performed operation for treatment of morbid obesity. SG leads to significant weight loss and reduction in weight related comorbidities. Procedures performed in ambulatory surgical centers (ASC) can provide several advantages over hospital-based surgery. We present results of 2,534 consecutive patients who underwent SG in an ASC. OBJECTIVE: Assess the safety and efficacy of outpatient SG in a freestanding ASC. SETTING: Free-standing ASC, Eviva Bariatrics, Seattle WA. METHODS: Data was collected retrospectively for all patients undergoing SG from January 2008 - January 2018, n = 2,534. Revisional procedures were not excluded from this study. Patients were excluded from the ASC if they weighed >450 pounds, if anticipated surgery time was > 2 hours, if the patient had impaired mobility limiting early ambulation, or if there were medical problems requiring postoperative monitoring beyond 23 hours. RESULTS: Mean age was 45.9 years. Mean preoperative body mass index (BMI) was 41.9. Mean operative time was 70 minutes. 30-day complications included 3 mortalities (0.12%), 60 (2.53%) re-admissions, 35 (1.42%), re-operations, and 31 (1.22%) direct transfers from the ASC to a nearby hospital. There were 25 staple line leaks (0.99%). There were no open conversions. At 6 months average excess body weight loss (EWL) was 56.3% and total weight loss (TWL) was 20.9% (n = 1,758/2,303). At 1 year, EWL was 70.1% and TWL was 26.4% (n = 1,199/2,125). CONCLUSION: With experienced surgeons, appropriate protocols, and a consistent operative team, SG can be performed safely in a free-standing ASC.

Does the future of laparoscopic sleeve gastrectomy lie in the outpatient surgery center? A retrospective study of the safety of 3162 outpatient sleeve gastrectomies.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is a safe and effective procedure that can be performed as an outpatient procedure. OBJECTIVES: The aim of the study was to determine whether same-day discharge LSG is safe when performed in an outpatient surgery center. SETTING: Outpatient surgery centers. METHODS: The medical records of 3162 patients who underwent primary LSG procedure by 21 surgeons at 9 outpatient surgery centers from January 2010 through February 2018 were retrospectively reviewed. RESULTS: Three thousand one hundred sixty-two patients were managed with enhanced recovery after surgery protocol and were included in this analysis. The mean age and preoperative body mass index were 43.1 ± 10.8 years and 42.1 ± 7.1 kg/m2, respectively. Sleep apnea, type 2 diabetes, gastroesophageal reflux disease, hypertension, and hyperlipidemia were seen in 14.4%, 13.5%, 24.7%, 30.4%, and 17.6% patients, respectively. The mean total operative time was 56.4 ± 16.9 minutes (skin to skin). One intraoperative complication (.03%) occurred. The hospital transfer rate was .2%. The 30-day follow-up rate was 85%. The postoperative outcomes were analyzed based on the available data. The 30-day readmission, reoperation, reintervention, and emergency room visit rates were .6%, .6%, .2%, and .1%, respectively. The 30-day mortality rate was 0%. The total short-term complication rate was 2.5%. CONCLUSIONS: Same-day discharge seems to be safe when performed in an outpatient surgery center in selected patients. It would appear that outpatient surgery centers are a viable option for patients with minimal surgical risks.

High acuity sleeve gastrectomy patients in a free-standing ambulatory surgical center.

BACKGROUND: Procedures performed in ambulatory surgical centers (ASC) can provide several advantages over hospital-based surgery. Understandably, concerns have been raised regarding "high acuity" cases in the ASC setting. Recently the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) presented protocols for ASCs to follow, requiring them to perform only "low acuity" cases to be compliant with accreditation. OBJECTIVE: Assess the safety and efficacy of outpatient sleeve gastrectomy (SG) on the "high acuity patient" in a free-standing ASC. SETTING: Free-standing ASC, Eviva Bariatrics, Seattle, Washington. METHODS: Data were collected retrospectively for all patients who underwent sleeve gastrectomy from January 1, 2013 to December 31, 2015, n = 1112. Of those patients, 120 were classified as "high acuity." RESULTS: Mean age was 51.7 years (24-73), mean body mass index was 42.4 (26.2-65.9). Mean operative time was 91 minutes. Five patients (4.2%) were readmitted within 30 days. Causes of re-admission were portal vein thrombosis (n = 2), intra-abdominal abscess (n = 1), infected hematoma (n = 1), and postoperative bleeding (n = 1). One patient (0.83%) was transferred from the ASC to a nearby hospital due to a postoperative bleed. One patient (0.83%) had a re-operation to evacuate a hematoma. One patient had a re-operation to wash out an infected hematoma. There were 0 confirmed staple line leaks. There were no open conversions and no deaths within 30 days or at 1 year. Follow-up was 83% (n = 100) at 6 months, and 65.0% at 1 year (n = 78). CONCLUSION: Criteria such as age, body mass index, or prior bariatric surgery did not reflect worse outcomes in a specialized ASC. With experienced surgeons, appropriate protocols, and a consistent operative team, SG can be performed safely in a free-standing ASC on select "high acuity" patients.

Long-term success and failure with SG is predictable by 3 months: a multivariate model using simple office markers.

INTRODUCTION: Despite being the most common surgery in the United States, little is known about predicting weight loss success and failure with sleeve gastrectomy (SG). Papers that have been published are inconclusive. We decided to use multivariate analysis from 2 practices to design a model to predict weight loss outcomes using data widely available to any surgical practice at 3 months to determine weight loss outcomes at 1 year. SETTING: Two private practices in the United States. METHODS: A retrospective review of 613 patients from 2 bariatric institutions were included in this study. Co-morbidities and other preoperative characteristics were gathered, and %EWL was calculated for 1, 3, and 12 months. Excess weight loss (%EWL)<55% at 1 year was defined as weight loss failure. Multiple variate analysis was used to find factors that affect %EWL at 12 months. RESULTS: Preoperative sleep apnea, preoperative diabetes, %EWL at 1 month, and %EWL at 3 months all affect %EWL at 1 year. The positive predictive value and negative predictive value of our model was 72% and 91%, respectively. Sensitivity and specificity were 71% and 91%, respectively. CONCLUSION: One-year results of the SG can be predicted by diabetes, sleep apnea, and weight loss velocity at 3 months postoperatively. This can help surgeons direct surgical or medical interventions for patients at 3 months rather than at 1 year or beyond.

Incidental gastric mesenchymal tumors identified during laparoscopic sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) is a well-tolerated and effective procedure for sustained weight loss and amelioration of weight-related co-morbidities. Rarely, unexpected pathology may be identified intraoperatively, which may alter the surgical plan. Gastrointestinal stromal tumors (GISTs) are among the more frequently encountered tumors and pose a particular concern because of their malignant potential. We review our findings of incidental tumors encountered during 1415 consecutive SGs. METHODS: Abnormal pathology records from all patients who underwent SG at our institution between 2009 and 2014 were reviewed. Patient demographic characteristics and clinical characteristics, tumor characteristics, including immunohistochemistry, operative course, and patient follow-up were reviewed. RESULTS: There were 17 incidental gastric mesenchymal tumors identified (1.2%) in 1415 SG procedures. This included 12 GISTs (.8%), 2 schwannomas (.1%), and 3 leiomyomas (.3%). In the majority of cases (1210/1415), the gastric specimens were not reviewed by a pathologist because there were no gross abnormalities appreciated by the surgeon. The GISTs were between .3 and 2.9 cm, and all were low grade with negative margins. Patients with GISTs tended to be older (mean age 55±9.3 y) than the rest of the patients. There was no evidence of recurrence on follow-up. CONCLUSION: Incidental gastric mesenchymal tumors are rarely encountered during SG. The vast majority were GISTs with an incidence of .8% in this population. Concomitant SG and tumor resection were feasible, without compromising the objectives of each. Complete tumor excision is necessary for tumors>2 cm.