Megan Brooks

June 15, 2011

June 15, 2011 (Orlando, Florida) — Sending patients who receive a laparoscopic gastric bypass home on either the day of or the day after their surgery significantly increases the risk for serious complications and death, according to a study presented here at the American Society for Metabolic and Bariatric Surgery (ASMBS) 28th Annual Meeting.

"This study shows what a difference a day makes," John Morton, MD, director of bariatric surgery at Stanford Hospitals and Clinics at Stanford University in California, noted in a statement from the conference.

"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," he added.

Push for Earlier Discharge Concerning

Some healthcare consulting groups around the country are advocating that length of stay (LOS) for laparoscopic gastric bypass should be 1 day, Dr. Morton explained in an interview with Medscape Medical News. The recently updated Milliman Guidelines go even further, recommending same-day discharge for patients having laparoscopic bariatric surgery.

"I am concerned about this," Dr. Morton said.

The new guidelines prompted Dr. Morton and colleagues to asses laparoscopic gastric bypass outcomes by LOS for 51,788 patients who had the surgery between 2007 and 2010. Data were obtained from the Bariatric Outcomes Longitudinal Database.

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 5 comorbid conditions.

Dr. Morton and colleagues 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 2 days (1.9% vs 0.16%). A 2-day LOS is currently the national average.

Furthermore, the 30-day mortality rate was 13 times higher (odds ratio [OR], 13.02; P < .0001) in those patients discharged on the day of surgery relative to those who spent 2 days in the hospital.

"Even at a length of stay of 1 day, there was a doubled increased risk of 30-day mortality (OR, 2.02; P < .05)," Dr. Morton noted.

The overall 30-day mortality rate was 0.1% for patients who stayed in the hospital for 2 or more days compared with about 0.8% for those who were discharged on the same day of surgery.

"I wasn't surprised that the outcomes would be worse, but I was surprised by the magnitude of the effect of early discharge," Dr. Morton said.

A Balancing Act

He noted that the last 7 years have seen a huge improvement in bariatric surgery outcomes, "with enormous reductions in complications."

"The mortality rate now averages about 0.2%, which rivals hip replacement and gallbladder surgery. I don't want all those gains that we've made in patient safety to be sacrificed from the point of getting patients out of the hospital well before they are ready," Dr. Morton said.

ASMBS President Bruce Wolfe, MD, from the Scottsdale Bariatric Center, Arizona, said: "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."

"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," Dr. Wolfe added.

Dr. Morton said a patient should be discharged based on his or her individual risk profile. A 2-day LOS "appears reasonable for most people," he added. "To reduce it further may put patients at increased chance of unnecessary risk."

American Society for Metabolic and Bariatric Surgery (ASMBS) 28th Annual Meeting: Abstract PL-110. Presented June 15, 2011.

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