Complex Bariatric Procedures in an Ambulatory Setting

Objectives. Gastric bypass and sleeve gastrectomy are highly standardized and the most frequent bariatric procedures. Published series with 90% of patients discharged within 24 hours can pave the way towards ambulatory care accounting for less than 1% of the laparoscopic gastric bypasses according to the US BOLD database.Methods. We developed a <24 hour stay protocol for every gastric bypass or sleeve on patients aged <60 years, body mass index <50 and surgery duration <2 hours aimed at ambulation and feeding 6 hours after surgery. For eligible patients without major comorbidities (type 2 diabetes on insulin, sleep apnea) ambulatory surgery is offered. At home, prevention of deep venous thrombosis allows for twice daily monitoring of heartbeat and temperature. Dietary support is provided and outpatient clinic with blood check are scheduled on day 2.Results. Since July 2013, 5 patients 36 <BMI<45 kg/m² (2 with blood hypertension) were scheduled for ambulatory gastric bypass. 3 were discharged as expected but 1 patient had to stay overnight. There was no complication or readmission.Discussion. Although large 24 hour stay laparoscopic gastric bypass series report no more than 1.2% bleeding and 0.25% leaks, there is a concern about severe complications occurring at home. The BOLD database found a 13 fold death risk increase for ambulatory compared to 2 day surgery.Conclusion. Ambulatory bariatric surgery other than gastric banding is feasible but requires close monitoring. Distant homes and comorbidities may limit eligibility. Less than 24 hour stay may be more suited for complex procedures.