Discussion:
The median length of stay for either a SG or a RNY surgery was 2 days. Length of stay in patients undergoing a laparoscopic sleeve gastrectomy was unaffected by the day of the week the operation occurred or the BMI, ASA grade and diabetic status of the patient. However, in patients who underwent a Roux-en-Y gastric bypass, being operated on a Friday or having a BMI > 60 resulted in an increased length of stay of 1 and 2 days respectively.
Readmission following a laparoscopic sleeve gastrectomy and Roux-en-y gastric by-pass occurred in 13 (6%) of patients within 30 days and 15 (7%) of patients within 60 days. The commonest reasons for readmission were pain and vomiting. These rates are consistent with the literature.(7)
The association between extremes of BMI (either very high or very low) and post-operative complication rates has previously been described in the literature.(8, 9) In our study, we found that patient with a BMI >60 had an increased post-operative length of stay independent of other factors measured. These patients are likely to have excessive subcutaneous fat around wound sites, which is known to contribute to impaired wound healing due to increased oxidative stress(10). A higher BMI may be associated with a technically difficult surgery or a surgery which involves a longer operating time and therefore more complications relating to anaesthesia. Data on the reason for increased length of stay was not recorded during this study.
Decreased functional status has been associated with an increased length of stay in patients undergoing bariatric procedures.(11) Our study, using ASA grades as a marker of functional status found no such association. A limitation in our study certainly is the potential for a type I error, due to there being very few number of patients in ASA grades I and II due to the natural cohort of the selected patient population. There does exist more accurate measures of functional status- disability indexes, ability to performed a pre-determined task such as climb a specific number of stairs.(12) These could have proven more beneficial in this study.
Bariatric surgery has been shown to be beneficial in patients with metabolic syndrome, particularly in in their glycaemic control.(13) In fact, RYGB has been shown to attenuate the clinical effects of DM to a larger extent than just medical management.(14) This is in large part due to the amount of weight lost. Post-op optimization of their diabetic control can naturally add to their length of stay. Our study did not find this to be true however. Our study was limited in this regard as only a diagnosis of diabetes was established, whereas data on glycaemic control pre-and post op would have been of huge benefit.
In our study, we found that patients who underwent a Roux-en-Y gastric bypass on a Friday ended up staying a day longer than those operated on another day. There are a multitude of factors to explain this: Weekend discharges at this institution were led by the specialist registrars (SpR) of varying experience levels and exposure to bariatric surgery. On retrospect, it was discovered that many were unfamiliar with the specific discharge criteria for bariatric patients. This leads to a reluctance to discharge patients over the weekend. Therefore, patients operated on a Friday inevitably end up staying an extra day to be reviewed by a bariatric consultant during the weekday rather than being discharged over the weekend.
The complex nature of bariatric patients requires a multi-disciplinary team approach to achieve holistic care. This is not limited to bariatric surgeons, anaesthetists, specialist nurses, psychologists, psychiatrists, endocrinologists, radiologists, metabolic physicians, pharmacists, physiotherapy and occupational therapy teams.(15) All of these services are not readily available over the weekend and could account for the delay in discharge.
Patient confidence was also a key contributor to going home on a weekday compared to the weekend. Being a central London teaching hospital means that logistical reasons involving transportation home over the weekend could decrease patient’s confidence in successfully going home. Follow-up at home is also only arranged during the weekdays, and thus patients are much more reluctant to go home over the weekend knowing that they could potentially be left without support at home until the Monday.
What was interesting was that our study found that patients undergoing a sleeve gastrectomy all had a similar length of hospital stay irrespective of their BMI or what day of the week they were operated on. The 30-day complication rates are greater with the bypass surgery when compared to the sleeve gastrectomy, with primary complications including infections and haemorrhage.(16) This creates a natural tendency to be overly cautious with these group of patients over the weekend when ward cover is limited and could account for our findings.
Our study examines a single surgeon’s operating lists over a 3-year period. A potential selectability bias could exist in picking more complicated patients for a list where there is more staffing to cover for any complications. This could skew the significance of our operating day outcomes.
Identifying some of the issues raised in our study raises the possibility for multiple future avenues: A stricter protocol can be created to easily facilitate weekend discharges in particular. To help identify why some weekend bariatric discharges are delayed, a survey can be created and distributed to junior registrars with the aim of increasing their confidence in managing these patients post-op and in identifying when they are appropriate and safe for discharge. Examining glycaemic control can help better identify diabetes plays a role in the length of stay of these patients. 6 monthly follow-up rates is naturally where this study could be headed to determine whether length of stay had any significant outcome on long-term outcomes.