AT OBESITY WEEK 2017
NATIONAL HARBOR, MD. (FRONTLINE MEDICAL NEWS) – Laparoscopic sleeve gastrectomy has been associated with low mortality, but the mortality is even lower when it includes overnight observation, according to a national database evaluation.
Among patients discharged on the same day, 30-day mortality was 0.1%, but it fell to 0.2% among patients discharged the following day, according to Colette Inaba, MD, a surgery resident at the University of California, Irvine.
In absolute risk, this translated into an increased odds ratio for mortality of 5.7 (P = .032) for same-day discharge. After adjustment for numerous potential confounders including operating time and number of postoperative swallow studies, the OR for mortality fell to 4.7, but the statistical strength for the greater risk increased (P less than .01).
“Surgeons who are considering same-day discharge in sleeve gastrectomy patients should have a low threshold to admit these patients for overnight observation given our findings,” Dr. Inaba reported at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.
Same-day discharge has been associated with an increased mortality risk in previously published descriptive institutional reviews, but this is the first study to evaluate this question through analysis of a national database, according to Dr. Inaba. It was based on 37,301 laparoscopic sleeve gastrectomy cases performed in 2015 and submitted to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. All participants in this database are accredited bariatric centers.
There were baseline differences between same-day and next-day discharges, but many of these differences conferred the next-day group with higher risk. In particular, the next-day group had significantly higher rates of hypertension, diabetes mellitus, hypercholesterolemia, chronic obstructive pulmonary disease, and sleep apnea. On average, the procedure time was 13 minutes longer in the next-day versus the same-day discharge groups.
In addition to mortality, 30-day morbidity and need for revisions were compared between the two groups, but there were no significant differences between groups in the rates of these outcomes.
Overall, the baseline demographics of the patients in same-day and next-day groups were comparable, according to Dr. Inaba. She described the population as predominantly female and white with an average body mass index of 45 kg/m2. In this analysis, only primary procedures (excluding redos and revisions) were included.
Relative to the next-day discharge cases, a significantly higher percentage of same-day discharge procedures were performed with a surgical tech or another provider rather than a designated first-assist surgeon, according to Dr. Inaba. For next-day cases, a higher percentage was performed with the participation of fellows or surgical residents. There were fewer swallow studies performed before discharge in the same-day discharge group.
Very similar results were generated by a study evaluating same-day discharge after laparoscopic Roux-en-Y gastric bypass, according to John M. Morton, MD, chief of bariatric and minimally invasive surgery, Stanford (Calif.) University. Dr. Morton, first author of the study and moderator of the session in which Dr. Inaba presented the LSG data, reported that same-day discharge in that study was also associated with a trend for an increased risk of serious complications ( Ann Surg. 2014;259:286-92 ).
“Same-day discharge is often reimbursed at a lower rate, so there is less pay and patients are at greater risk of harm,” Dr. Morton said.
The reasons that same-day discharge is associated with higher mortality cannot be derived from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, but, Dr. Inaba said, “Our thought is it is a function of failure to rescue patients from respiratory complications.” She acknowledged that this is a speculative assessment not supported by data, but she suggested that history of sleep apnea might be a particular indication to consider next-day discharge.
Dr. Inaba reports no financial relationships relevant to this topic.