2024 General Surgery/Global Health Engagement/Quality Improvement Presentations

Hannah M Palmerton, MD; Os Nakayama; Grace Pak, MD; Bobby Zhang, MD; Christopher R Porta, MD; Madigan Army Medical Center

Objectives: The laparoscopic sleeve gastrectomy (LSG) has become the most common bariatric surgery. Due to its relative safety and low complication rate, it has been increasingly more common to be performed as an outpatient surgery. Same day (SD) discharge, or discharge from PACU within 23 hours has been well studied in the civilian sector, and in this setting has been shown to result in reduced costs, hospital-acquired infections, and improved patient satisfaction1,2. Though there are numerous benefits to SD-LSG, the military health system has been slow to adopt this practice. This study represents the first and only series on SD-LSG within the Military/ DHA and demonstrates our protocol, experience, and initial outcomes at Madigan Army Medical Center (MAMC).

Methods: 28 patients underwent SD-LSG between 4/28/2021 and 5/22/2023. Prior to initiation of the SD-LSG, a multidisciplinary protocol to include all phases of care (surgical clinic, operating room, and the post-anesthesia care unit) was created. Data was prospectively collected with a mean follow-up of 473 days. Exclusion criteria included BMI > 50, expected operative time > 2 hours, non-ambulatory, high cardiac risk, severe OSA, immunocompromised, or dialysis dependent. Primary outcomes included mortality, complication, and readmission rates. Secondary outcomes included patient satisfaction.

Results: Our patient demographics were similar to national demographics for all LSG in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) reported for the same time period, with the exception of being younger, and more likely to report an “other/unknown” race. BMI of our population was lower than MBSAQIP population (41.1 +/- 5.7 vs. 44.7 +/- 7.9; p < .05). We had no mortality, re-operations, or re-admissions. MBSAQIP data for the same time frame showed 2.4% readmissions, 0.4% re-operations, and 0.1% mortality. We had one Clavien Dindo class 2 complication of postoperative hematoma requiring transfusion (3.6%, n = 1/28), which is comparable to reported minor complication rates for LSG ranging from 2.5%3 to 5.8%4 in the literature. Average OR time was 81.6 +/- 29.1 minutes (MBSAQIP 76.1 +/- 108.6 minutes). Patients overwhelmingly preferred SD-LSG.

Conclusion: SD-LSG is a safe and feasible practice in the military health system, helping to offload the inpatient census. Initiating this protocol requires careful patient selection, a multi-disciplinary approach, and appropriate coordination with all phases of patient care. SD-LSG has comparable risks to inpatient LSG, while reducing hospital cost and improving patient satisfaction.