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.