OBES SURG DOI 10.1007/s11695-014-1408-6

ORIGINAL CONTRIBUTIONS

Simplified Fast-Track Laparoscopic Roux-en-Y Gastric Bypass Thomas W. Pike & Alan D. White & Niki J. Snook & Stephen G. Dean & J. Peter A. Lodge

# Springer Science+Business Media New York 2014

Abstract Background The surgical management of complex or morbid obesity is increasing exponentially. Laparoscopic procedures are being increasingly utilized due to their similar efficacy but shorter hospital stay and faster convalescence when compared with open surgery. Despite this, many patients remain in hospital for a number of days after laparoscopic obesity surgery due to concerns about potential sequelae. We present the results of our simplified fast-track service, designed to enable discharge of all patients on postoperative day one following laparoscopic Roux-en-Y gastric bypass (LRYGB). Methods All patients operated on by a single surgeon during a 3-year period underwent fast-track management and were included. Our simplified fast-track service has three components; it is applicable to all patients, patients are counselled regarding fast-track discharge and the only routine postoperative investigations are full blood count and serum C-reactive protein (CRP). CRP was investigated as a prognosticator for complications following LRYGB. Results One hundred twelve patients underwent a LRYGB during the study period (35 male, median age 44 [18–73], median BMI 49.4 [36.5–75.0]). Ninety-eight patients (87.5 %) were discharged the day after LRYGB. Five patients developed postoperative complications (three major, two minor). One patient required readmission following discharge on T. W. Pike (*) : A. D. White : J. P. A. Lodge Department of HPB and Transplant Surgery, St James’s University Hospital, Leeds LS9 7TF, UK e-mail: [email protected] N. J. Snook : S. G. Dean : J. P. A. Lodge Department of Bariatric Surgery, Spire Leeds Hospital, Leeds, UK N. J. Snook : S. G. Dean Department of Anaesthesia, St James’s University Hospital, Leeds, UK

postoperative day 1. A CRP greater than 100 mg/L on postoperative day 1 was found to predict major complications with 100 % sensitivity and 95 % specificity with a diagnostic accuracy of 0.98. Conclusion Our simplified fast-track LRYGB service allows the vast majority of patients to be safely and successfully discharged on postoperative day 1. Keywords Laparoscopic . Gastric bypass . Fast track . CRP . Early discharge

Introduction The surgical management of patients with complicated or morbid obesity has increased exponentially since the beginning of the millennium [1]. There is no definite consensus on the optimum surgical procedure [2], but laparoscopic Rouxen-Y gastric bypass (LRYGB) has become an established surgical management for such patients [3–5]. Previously, open Roux-en-Y gastric bypass had been considered the ‘gold standard’ management for morbid obesity [6]. LRYGB has become increasingly popular due to similar efficacy but shorter hospital stay and faster convalescence when compared with open surgery [7–10]. Despite this, many patients still stay in hospital for several days following LRYGB due to concerns about potential sequelae. Furthermore, many surgeons routinely undertake radiological studies to try to promptly delineate those patients who have developed early complications [11–13], despite the limited diagnostic value of these investigations and their added cost [14–18]. Fast-track services for LRYGB are beginning to be developed, and show promising early results [3, 19, 20]. However, as with the learning curve described in performing LRYGB [6, 21], they report an institutional learning curve in the development of a fast-track

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system. They also emphasize the importance of careful patient selection for fast-track management [3, 19]. We present the results from our fast-track LRYGB service, developed to allow discharge on postoperative day 1, from inception of the surgical service, for all patients.

Methods All patients who underwent LRYGB, conducted by a single surgeon, were included in the study, beginning with the first patient undergoing bariatric surgery following completion of training (May 2010–October 2013). Patients were selected for surgery based on NICE Obesity Guidelines [22]. Patients were preoperatively assessed by a multi-disciplinary team comprising of surgeons, anaesthetists, an endocrinologist, dieticians and a psychologist. No preoperative selection criteria were applied to identify those patients who might be suitable for fast-track discharge. All patients were considered to be potentially suitable for fast-track discharge. All patients underwent repeated counselling that, barring complications, they would be discharged the day after LRYGB. This management practice was emphasized at every patient contact with the surgeon, both preoperatively and postoperatively, to optimally manage patients’ expectations of their inpatient hospital stay. We have found from previous experience with other types of surgery that patients are much more likely to be discharged 1 day after surgery if they are expecting to be discharged 1 day after surgery, Table 1. All patients underwent LRYGB using a standardized technique. Multi-modal analgesia was used where appropriate and patient-controlled analgesia by pump avoided to enable easier postoperative mobilization. Following induction of anaesthesia, a 28FG oro-gastric tube was placed. IV access was obtained in all patients but arterial lines were used only in selected patients with cardiac problems. Urinary catheters were not used to encourage patients to mobilize at an early stage postoperatively to pass urine. Four 12-mm laparoscopic ports were placed in the upper abdomen and a Nathanson retractor inserted through a 3-mm incision for liver retraction. A 15–30-ml gastric pouch was created with a 45-mm ECHELON FLEX™ ENDOPATH® Stapler (Ethicon Endo-Surgery (Europe) GmbH, Norderstedt, Germany) and the apex excised. After division of the omentum, the duodenojejunal flexure was identified and a 60-cm biliopancreatic limb brought up to the pouch to create an ante-colic gastroenterostomy, using the endosurgical stapler for the posterior wall and two layers of absorbable sutures

Table 1 Consultation model Initial consultation

Patient given information about the procedure Counseling given regarding discharge on POD 1 Morning of procedure Counseling given regarding discharge on POD 1 Procedure Laparoscopic Roux-en-Y Gastric Bypass Post-procedure Counseling given regarding discharge on POD 1 Postoperative day one Review of physiological parameters, clinical examination and review of blood tests Counseling given regarding discharge on POD 1 Patient discharged

for the anterior wall. In similar fashion, a 120-cm alimentary limb was anastomosed to the biliopancreatic limb and the small bowel was then divided with the endosurgical stapler to complete the Roux-en-Y, with closure of the mesenteric spaces by sutures. At the completion of surgery, a methylene blue insufflation test was performed in all patients. Following LRYGB, all patients were carefully observed overnight on the high dependency unit and then general ward before discharge. Invasive monitoring was avoided and the nursing staff supported early mobilization and oral fluid intake; oral fluids were encouraged as soon as patients were awake. In order to try to expeditiously identify those patients who may have developed an early complication as a result of LRYGB, we routinely performed a full blood count (to check for anaemia) and serum C-reactive protein (CRP) on postoperative day 1. These were the only routine postoperative investigations. All patients were regularly reviewed by the operating surgeon; immediately postoperatively, on the following morning and at the planned time of discharge. On each occasion, simple counselling was given regarding expectations in terms of symptoms and progress, with an emphasis on early discharge in the absence of complications. Prior to discharge, all patients were given simple instructions detailing how to contact the surgical team if any concerns arose following discharge. A set criterion readmission policy was not used; each case was managed as the clinical scenario dictated. Our simplified fast-track LRYGB service has no other significant components than those three points described above: 1. It is applicable to all bariatric patients. 2. Patients are counselled pre- and postoperatively that, barring any complications, they will be discharged the day after surgery. 3. Routine postoperative investigations consist of a full blood count and serum CRP only.

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Data was recorded on a prospectively maintained database. Preoperative factors including sex, age, preoperative BMI, previous surgeries, and medical co-morbidities were collected as well as operative details and postoperative follow-up. Complications were recorded and codified according to the Clavien-Dindo classification [23]. Statistical analysis was performed using Prism version 6.0c (GraphPad Software, La Jolla, California, USA). The Mann–Whitney U test was used to compare continuous data; a p value of <0.05 was considered statistically significant. The diagnostic value of serum CRP was determined by analysing the area under the curve of the receiver operating characteristic.

Results One hundred twelve consecutive patients underwent a LRYGB during the study period (35 male: 77 female, median age 44 [range 18–73], median BMI 49.4 [range 36.5–75.0]). Postoperative complications occurred in five patients (4.5 %). Major complications were observed in three patients, all graded as Clavien-Dindo IIIb. One patient developed a gastric leak, one suffered a small bowel perforation and one patient required a laparoscopy for abdominal pain and raised inflammatory markers, which found nothing of significance. All of these complications were identified and definitive management performed on postoperative day 1. Two patients developed minor complications, both Clavien-Dindo II; one patient developed a chest infection requiring oral antibiotics and one required a blood transfusion. Again, both of these complications were identified on postoperative day one and appropriate management instigated. There were no postoperative deaths. There was no significant difference between those patients who developed complications and those that did not in terms of sex, age, preoperative BMI, previous surgeries or medical co-morbidities. Ninety-eight patients (87.5 %) were discharged 1 day after LRYGB. The average inpatient stay was 1 day [range 1–6], Fig. 1. Eight of the 14 patients with a greater than 1-day inpatient stay remained in the hospital for social reasons and were deemed to be surgically fit for discharge on postoperative day 1. One patient developed an anaesthetic complication and was subsequently discharged on postoperative day 2. One patient discharged on day 1 was subsequently readmitted on postoperative day 7 for an internal herniation at the enteroenterostomy site, requiring a repeat laparoscopy and closure of the mesenteric defect. There were no other readmissions. Serum CRP was recorded on all patients on postoperative day 1. CRP was found to directly correlate with major complications (p=0.001), Fig. 2.

Fig. 1 Postoperative length of stay (days). The black section on postoperative day 2 represents patients deemed surgically fit for discharge on postoperative day 1

Examining the area under the curve of the receiver operating characteristic (ROC) revealed that a CRP greater than 100 mg/L on postoperative day 1 can predict major complications with 100 % sensitivity and 95 % specificity with a diagnostic accuracy of 0.98 (95 % confidence interval, 0.944– 1; p=0.001): Fig. 3. Patients were followed up for a maximum of 36 months (median 12 months). Average percentage excess weight loss (%EWL) at 12, 24 and 36 months was 65.5 % (SD 20.3), 58.4 % (SD 18.1) and 58.2 % (SD 13.0), respectively; Fig. 4.

Conclusion Despite major advances in the surgical management of morbid or complicated obesity in recent years, inpatient hospital stay remains prolonged for the majority of patients. This is likely to be because of concern regarding the potential complications of LRYGB which, though rare, are potentially catastrophic. As the early identification of major complications can prevent mortality [24, 25], there have historically been great efforts made to try and identify those patients who have suffered complications following LRYGB. This has required patients to remain in hospital while postoperative investigations or prolonged clinical observation is undertaken. Our simplified fast-track LRYGB management system shows that excellent postoperative weight loss can be achieved and patients safely discharged on postoperative day 1, without an increase in complications or subsequent readmissions. Our simplified management protocol has three core principles: Firstly, all patients can potentially be managed using a fasttrack system. In our study, preoperative factors did not predict

OBES SURG Fig. 2 Serum CRP on postoperative day 1 of patients who experienced major complications cf. those with no major complications

those patients who developed early complications or required a longer than 1 day inpatient hospital stay. There is support for this finding in the literature [17, 26], but also conflicting evidence [19]. We are confident in our ability to detect early complications of LRYGB (detailed below) and those patients without an early complication may be discharged home safely. The development of late complications will not be reduced by a longer postoperative stay. Secondly, we emphasize the importance of pre- and postoperative management of patients’ expectations. Scant attention is paid to this aspect of surgical care in the literature, but we maintain it is vital to the success of a fast-track programme. Much has been made recently of the advantages of enhanced recovery protocols, particularly in colorectal surgery [27–30], but we

Fig. 3 Receiver operating characteristic (ROC) curve of CRP 1 day after LRYGB

wonder whether the impact of effective patient education may be responsible for a large amount of it. Thirdly, major complications can be reliably identified by serum CRP on postoperative day 1. CRP has previously been shown to be useful in the early identification of complications following LRYGB [31, 32], but most previous studies looked at serum CRP levels on postoperative day 2 or beyond. All of the patients who developed major complications in our study had a serum CRP greater than 100 mg/L on day 1. The absence of a raised CRP on postoperative day 1, used in conjunction with physiological parameters and a thorough clinical examination, can be used to support the discharge of the vast majority of patients undergoing LRYGB on day 1. In summary, the use of our simplified LRYGB management system allows for the safe discharge of the vast majority of patients on postoperative day 1.

Fig. 4 Percentage excess weight loss (%EWL) following LRYGB

OBES SURG Acknowledgments The authors would like the acknowledge the invaluable help and assistance that has been provided by Ann Horsfall, Lyndsay Keeley, Maureen Sugden, Carol Thornton, Maria Fowler, Wendy Bartle, Anna Tchaikosky and Suzanne Wynne-Jones at Spire Leeds Hospital during the development of the surgery programme and care protocols. The senior author would particularly like to thank Mikael Stokel, Goran Lundergaardh and Claus Riber for providing bariatric surgical training at Hamlet Hospital in Copenhagen, Denmark. Conflicts of Interest All authors declare no conflicts of interest.

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