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Quick and dirty?

'Drive-thru' gastric operations increase risk

Patients discharged on the day of their operation significantly increase their risk of serious complications
30-day mortality rate increased from 0.1% to 0.8% in study
two-day length of stay advocated as "reasonable"

According to a study presented at the American Society for Metabolic and Bariatric Surgery (ASMBS) 28th Annual Meeting, patients who receive a laparoscopic gastric bypass and are discharged either the day of or the day after their surgery significantly increase the risk for serious complications and death.
“This study shows what a difference a day makes. Bariatric surgery is safer than ever, but discharging patients too soon after surgery may be pushing the envelope too far, and may have serious consequences,” said Dr John Morton, Director of Bariatric Surgery at Stanford Hospitals and Clinics at Stanford University, CA, and is Chair of the ASMBS Access to Care Committee. ”A two-day length of stay appears reasonable for most people and results in a safety profile that rivals gallbladder or hip replacement surgery. To reduce it further may put patients at an increased chance of unnecessary risk. A patient should be discharged based on his or her individual risk profile. We counsel our patients to avoid drive-thru fast food, and also advise against drive-thru gastric bypass.”

Earlier discharge

The recently updated 14th edition of the Milliman Care Guidelines, published in 2010, recommended same-day discharge for patients having laparoscopic bariatric surgery. These guidelines are used by many hospitals and health plans to determine care and length of stay. At the time, the ASMBS argued that the recommendations were " not evidence-based and if implemented will decrease patient safety."
As a result, Morton and colleagues assessed laparoscopic gastric bypass outcomes by length of stay (LOS) for 51,788 patients who had the surgery between 2007 and 2010. Data were obtained from the Bariatric Outcomes Longitudinal Database (BOLD).
The median age of the patients having surgery was 45 years, and their median body mass index was 46.3 kg/m2. More than three quarters were women (78.6%), most had private insurance (86.2%), and 39.1% had more than five comorbid conditions.
The investigators found that patients who left the hospital on the day of surgery were 12 times more likely to have serious complications than those who stayed for two days (1.9% vs 0.16%). A two-day LOS is currently the national average in the US. Furthermore, the 30-day mortality rate was 13 times higher (odds ratio [OR], 13.02; p<0.0001) in those patients discharged on the day of surgery relative to those who spent two days in the hospital.
The overall 30-day mortality rate was 0.1% for patients who stayed in the hospital for two or more days compared with about 0.8% for those who were discharged on the same day of surgery.

“I was surprised by the magnitude”

“Even at a length of stay of one day, there was a doubled increased risk of 30-day mortality (OR, 2.02; p<0.05). I was not surprised that the outcomes would be worse, but I was surprised by the magnitude of the effect of early discharge. Length of stay appeared to be the leading risk factor ahead of age, gender, race, body mass index and obesity-related conditions,” said Norton. “Bariatric surgery is safer than ever, but discharging patients too soon after surgery may be pushing the envelope too far and may have serious consequences.”
"The real question is, can we predict who are the safest ones to send home, and how many misses will there be, and what will be the consequence? If, in healthcare, we knew the answers to those questions, we could focus resource utilization a little better,” said ASMBS past-president Bruce Wolfe, Scottsdale Bariatric Center, Arizona. “We understand the desire of those who pay the bills to minimize the cost, and we are anxious to do that as well, but we have to balance that with safety.”

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