Ahmad I Elnahas, MD, FRCSC, David R Urbach, MD, MSc, FRCSC, Allan Okrainec, MDCM, MHPE, FACS, FRCSC, Fayez Quereshy, MD, MBA, FRCSC, Timothy D Jackson, MD, MPH, FRCSC. Division of General Surgery, Department of Surgery, University Health Network, University of Toronto.
There is controversy surrounding the safety and feasibility of next-day discharge following laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity. The objective of this study is to determine if “next-day discharge” following LRYGB is comparable to “standard discharge” (i.e. on postoperative day two) with respect to 30-day patient outcomes.
Methods and Procedures:
Data was obtained from the American College of Surgeons’ National Surgery Quality Improvement Program (ACS-NSQIP) participant use file to perform a retrospective cohort analysis. The study population consisted of patients discharged on either postoperative day (POD) 1 or 2 that underwent an elective LRYGB for morbid obesity between 2005 and 2011. Patients were excluded if they had prior surgery within 30 days, any relative contraindication to bariatric surgery, or any recorded complication/death during their principal admission. The primary outcome was 30-day overall complication rate and secondary outcomes included major complication and reoperation rates. A multivariate logistic regression analysis was performed to evaluate each study outcome based on the day of discharge.
The sub-selected population consisted of 4798 and 25790 patients discharged on POD 1 and 2, respectively. No major clinical differences were found between the two groups with respect to relevant patient and operative characteristics. With respect to 30-day mortality, the POD 1 group had no deaths and the POD 2 group had 19 (0.06%). Using a multivariate logistic regression analysis, an odds ratio (OR) estimate was adjusted for potential patient and operative confounders. No statistical difference was found between “next-day discharge” and “standard discharge” with respect to the 30-day overall complication rate (OR 0.99, p=0.95, 95% CI [0.79-1.24]). The adjusted OR estimate also showed no statistical difference between day of discharge and the 30-day major complication rate (OR 0.78, p=0.22, 95 % CI [0.52-1.16]) or reoperation rate (OR 1.16 p=0.37, 95% CI [0.84-1.58]). Body mass index > 50 and medical co-morbidities such as diabetes, steroid use, dyspnea and hypertension were found to be predictors for complications in patients discharged the next day.
Using this large national surgical database, LRYGB patients discharged on POD 1 did not have a significantly higher rate of adverse events compared to patients discharged on POD 2. Understanding the important predictors of adverse events following LRYGB will help bariatric surgeons implement “next-day discharge” protocols based on the proper perioperative evaluation.