Bariatric Surgery as an Ambulatory Procedure

Transcription

1 CENTRO DE EXCELENCIA PARA EL ESTUDIO Y TRATAMIENTO DE LA OBESIDAD Bariatric Surgery as an Ambulatory Procedure Miguel-A. Carbajo Caballero Director del Centro de Excelencia de Cirugía de la Obesidad y las Enfermedades Metabólicas. Hospital Campo Grande, Valladolid, España

2 APCA

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7 Morbid and supermorbid obesity A serious or very severe desease that may be accompanied of co-morbidities threatening the health and life, as well as involve a high surgical and anesthetic risk

8 Beginning Outpatient laparoscopic gastric banding: initial experience De Waele B, Lauwers M, Van Nieuwenhove Y, Delvaux G Obes Surg Sep;14(8): Inclusion criteria BMI >35 Kg/m2 with co-morbid conditions Living within a reasonable distance from the hospital Adult company at home Results 9 women and 1 man The mean time lapse between the end of the operation and discharge from hospital was 9.6 hours No readmissions and complications at 1 month

9 Gastric Banding in outpatient surgery Outpatient Weight Loss Surgery: Initiating a Gastric Bypass and Gastric Banding Ambulatory Weight Loss Surgery Center Kent C. Sasse, MD, MPH, John H. Ganser, MD, Mark D. Kozar, MD, JSLS Jan Mar; 13(1): Laparoscopic gastric banding is safe in outpatient surgical center Cobourn C, Mumford D, Chapman MA, Wells L. Obes surg 2010 Apr;20(4): Can bariatric surgery be done as an outpatient procedure? Mc Carty TM Adv Surg. 2006;40: Laparoscopic adjustable gastric banding in an ambulatory surgery center Watkins BM, Ahroni JH, Michaelson R et al. Surg Obes Relat Dis. 2008;4:S Adjustable Gastric Banding in an Ambulatory Surgery Center Watkins BM, Montgomery KF, Ahrori JH, et al. Obes Surg. 2005;15: Outpatient Laparoscopic Adjustable Gastric Banding in Super Obese Patients Montgomery KF, Watkins BM, Ahroni JH et. Al. Obes Surg Jun;17(6):711-6

10 Cost Laparoscopic gastric banding for morbid obesity: outpatient procedure versus overnight stay Wasowicz-Kemps D K, Bliemer B, Boom F A, De Zwaan N M, Van Ramshorst B The day after surgery the patient had to return to the outpatient department and be seen by the nurse practitioner; the patient was given a contrast swallow to document the position of the band. A comparator group of patients were given the same treatment but they stayed in hospital for one night after surgery. The mean hospital stay was 1.48 days (range: 1 to 7) in the OP group and 2.32 days (range: 2 to 4) in the OS group, (p=0.004). Patients in the OP group had a significantly worse level of postoperative pain, (p=0.009). At 6 weeks, mean patient satisfaction (maximum possible score 10) was 8.1 (range: 4 to 10) in the OP group and 8.8 (range: 7.5 to 10) in the OS group, (p=0.06). Surg Endosc Aug;20(8):

11 Outpatient Surgery in Super-Obese Patients? Outpatient laparoscopic Adjustable Gastric Banding in Super-obese Patients Montgomery KF, Watkins BM, Ahroni JH, Michaelson R, Abrams RE, Erlitz MD, Scurlock JE. RESULTS: 320 super-obese patients underwent an outpatient LAGB. There were no deaths, significant cardiopulmonary complications, significant intraoperative bleeding, conversion to open laparotomy, or hospital admissions. 3 patients (0.1%) developed gastric edema causing transient obstruction, and 1 developed a delayed colon perforation from electrocautery incurred during adhesiolysis. Obes Surg Jun;17(6):711-6

12 Outpatient Surgery in Super-Obese Patients? Outpatient laparoscopic Adjustable Gastric Banding in Super-obese Patients Montgomery KF, Watkins BM, Ahroni JH, Michaelson R, Abrams RE, Erlitz MD, Scurlock JE. Results: No complication arose or was more difficult to manage as a result of the procedure being done on an outpatient basis A barium esophagram is not performed routinely before discharge. Patients were typically discharged within 2 hours of completion of the operation,were contacted by phone the following day, and return to the office in 1 to 2 weeks for a routine check Obes Surg Jun;17(6):711-6

13 Outpatient Surgery? We defined outpatient as involving a total stay at the ambulatory surgery center (ASC) of less than 24 hours Sasse KC, Ganser JH, Kozar MD, et al. Outpatient Weight loss surgery: initiating a gastric bypass And gastric banding ambulatory weight loss surgery center. JSLS (2009)13:50 55

14 Outpatient Surgery? Results: Since 2002, we have performed 248 bariatric cases at the ASC, including 38 LRYGB and 210 LAGB procedures. In this Overall experience, 5 patients (2%) required readmissions within 30 days of surgery, and 98.6% of LAGB patients were discharged the same day; 62% were discharged after a 4-hour to 6-hour stay in the ASC. All LRYGB patients remained in the ASC overnight and were discharge within 24 hours of their procedure. Weight loss results have been excellent. Sasse KC, Ganser JH, Kozar MD, et al. Outpatient Weight loss surgery: initiating a gastric bypass And gastric banding ambulatory weight loss surgery center. JSLS (2009)13:50 55

15 Outpatient laparoscopic gastric bypass Optimizing Outcomes in Bariatric Surgery Outpatient Laparoscopic Gastric Bypass Todd M. McCarty, MD, * David T. Arnold, MD, * Jeffrey P. Lamont, MD, * Tammy L. Fisher, RN, * and Joseph A. Kuhn, MD Results: Two thousand consecutive patients undergoing outpatient lap RYGB were identified, and 84% (n = 1669) were discharged within 23 hours. Of these, 1.7% (n = 34) were readmitted within 30 days. The overall early and late complication rates were 1.9% (n = 38) and 4.3% (n = 86), respectively. The 30-day mortality rate was 0.1% (n = 2), and neither patient was discharged before death. Univariate analysis demonstrated surgeon experience (>50 cases), age (<56 years), body mass index (<60 kg/m 2 ), weight (400 lbs), comorbidities (<5), and intraoperative steroid bolus as predictive of successful outpatient discharge. Multivariate analysis revealed surgeon experience, comorbidities, body mass index, and steroid bolus as predictive variables. Ann Surg October; 242(4):

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17 CENTRO DE EXCELENCIA PARA EL ESTUDIO Y TRATAMIENTO DE LA OBESIDAD Laparoscopic Single- Loop Gastric Bypass assisted by Robotic Arm: Concepts and Results in a series of patients vs. 477 patients Roux- Y gastric bypass Miguel-A. Carbajo Caballero Director of the Center of Excellence of the Surgery of Obesity and Metabolic Diseases. Hospital Campo Grande, Valladolid, España

18 One Anastomosis Gastric Bypass by laparoscopy and robotic assistant Operative time and Hospital stay Primary Surgery 86 (45-180) Operating time (min.) Associated Procedures 112 (95-230) Previous Bariatric Procedures 180 ( ) Hospital Stay Uncomplicated patients Major Complications 2169 (98.5%) 1 day (15-23 h.) 31 (1.5%) 9 days (5-32 d.)

19 Conclusions 1. The concept of ambulatory surgery (true day surgery) as applied to the treatment of morbid obesity has little supporting evidence; based on very limited personal experiences and related exclusively to laparoscopic gastric banding. 2. Only one study (with controversial results) has been published in the world on super-morbid obese and ambulatory surgery with gastric band

20 Conclusions 3. There is more experience in extended ambulatory surgery ( less than 24 hours of hospital stay), for gastric banding and just a few series of gastric bypass requiring great experience and a very well trained team to make it possible 4. Our center of excellence in obesity surgery systematically performed the extended ambulatory surgery in one anastomosis gastric bypass 5. There are no similar experiences with other surgical techniques used for the treatmen of obesity

21 Thanks for your attention