IBCOx-9 Enhanced Recovery After Metabolic Surgery: Results of a De Novo Program for Same-day Cases in a Free-standing Ambulatory Surgical Center

Abstract

Abstract Background Metabolic Surgery (MS) is commonly performed in a hospital setting. Same-day case (SDC) MS has not been performed due to concern for patient safety and complications after discharge. Procedures performed in ambulatory surgical centers (ASC) provide several advantages over hospital-based surgery by improving patient experience, decreasing hospital acquired infections, decreasing cost, and increasing access to MS. We previously reported our experience with performing 2,534 patients who underwent sleeve gastrectomy (SG) in an ASC. The ability to replicate this program validates the safety of Enhanced Recovery After Metabolic Surgery (ERAMS) protocols. We have replicated the SDC program with a new team in a new facility using previously established ERAMS protocols. Objective To report safe and effective protocols for same-day metabolic surgery. Setting Free-standing ASC, Methods Data was collected retrospectively for all patients undergoing MS from June 2019 - December 2019, n = 18. Revisional procedures were not excluded from this study. Patients were excluded from the ASC criteria if they weighed >400 pounds, if anticipated surgery time was > 2 hours, if the patient had impaired mobility limiting early ambulation, if they had chronic obstructive pulmonary disease, severe sleep apnea or moderate cardiac risk. All surgeries were performed laparoscopically using a 38 French Bougie, staple line was initiated 4 cm from the pylorus. No buttress material was used. The upper 3 cm of the staple line was oversewn. Intraoperative blood pressure was raised 20 mm Hg to identify bleeding along the staple line. Drains were not routinely used. Patients were given 3-4 liters of intravenous fluid prior to discharge. Patients were discharged once ASC discharge criteria was met: ambulating, voiding, tolerating fluids, pain and nausea controlled and normal vital signs. Results Mean age was 41.3 years (21-70). Mean preoperative body mass index (BMI) was 43.2 (32-55). Mean operative time was 88.1 minutes (54-146). Average length of stay at the ASC was 386.7 minutes (165-547). There were no re-admissions, re-operations, or direct transfers from the ASC to the hospital. One patient was seen in the emergency department (ED) within 30 days (postoperative day 3) for anxiety and dysphagia. She was discharged from the ED after negative studies. Seventeen patients had SG. Four had concomitant hiatal hernia pairs. One had concomitant liver biopsy. Two patients were revisional: one patient had a previous gastric band; one patient had previous banded sleeve gastrectomy. Conclusion With an experienced metabolic surgeon, appropriate protocols, and a consistent operative team, MS can be performed safely as a SDC in a free-standing ASC on selective patients.