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Jaime Ponce, MD FACS FASMBSDirector of Bariatric Surgery

Hamilton Medical CenterDalton GA

Outpatient Bariatric Surgery:

Is it Here?

MISS Morbid ObesitySalt Lake City, Utah. February 24-26, 2011

Disclosures

• Allergan: speaker, proctor, consultant, research

• Vibrynt: consultant

• ReShape: research

• Cavu Medical: consultant

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Have we done outpatient bariatric surgery?

For how long?

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LAGB data

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LAGB outpatient

• “AGB as an Outpatient Procedure: A Multi-Institutional Experience of 700 Patients” Horgan, Ponce, et al. UIC and Dalton GA - SSAT meeting 2004.

– 2001-2003; 700 LAGB outpatients– BMI<55, no significant cardiac disease or

severe OSA– LOS 4hrs– 29 pts had stoma obstruction requiring

hospitalization 1-5 days

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LAGB outpatient

• “AGB in an Ambulatory Surgery Center” Watkins, Montgomery, et al. Seattle WA- Obes Surg 2005.

– 2003-2005; 343 LAGB outpatients– 89% F, Age 43, BMI 44.5– OR time 52’– 3 pts hospitalization: nausea, dysphagia– 45%EWL at 1-yr

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LAGB outpatient

• “Outpatient LAGB in Super-Obese pts” Montgomery, Watkins, et al. Seattle WA- Obes Surg 2007.

– 2002-2006; 330 SO LAGB outpatients– BMI 55.4(50-71); 53 pts BMI>60 (16.6%)– 3 pts postop obstruction; delayed colon

perforation (LOA cautery injury)– Severe OSA: discharged with CPAP

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LAGB outpatient

• “LAGB in ASC” Watkins, et al. Seattle WA- SOARD 2008.

– 2002-2007; 2,027 LAGB outpatients– 83%F, Age 44.1, BMI 45.7– 1 conversion to open (0.04%); 1 death

(0.04%)– 41%EWL at 1 year– Slippage rate: 0.4, 2.4 and 10% (1,2,3 yrs)– 2.3% port related problems– 0.54% band explantations

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LAGB outpatient

• “LAGB in Outpatient Surgery Center” Cobourn, et al. Canada- Obes Surg 2010.

– 2005-2009; 1,641 LAGB outpatients– BMI 46.7– 3 hospitalizations– Cx: dysphagia 5, wound infection 3, port

infection 2– Explantations 2– LOS <4hrs

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RNY data

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RNY outpatient

• “Outpatient Laparoscopic Gastric Bypass” McCarty, et al. Baylor Univ Dallas TX- Ann Surg 2005.

– Single Institution; 2,000 LRNY outpatients– 84% d/c <24 hrs– 1.7% (n=34) 30-day readmission rate– 0.1% (n=2) 30-day mortality rate (pts died before

d/c)– Successful outpatient d/c predictors:

• Experience (>50 cases), Age (<56 yrs), BMI (<60), weight (<400 lbs), comorbidities (<5) and intraop steroid bolus

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RNY outpatient

• “Weight Loss ASC: Outpatient LRNY and LAGB” Sasse, et al. Westrn Bariatric Institute Reno NV- JSLS 2009.

– 2002-2008: 38pts LRNY (<24hrs) and 210 pts LAGB (same day) outpatient

– LOS: 22.75 hrs (LRNY), 7.3 hrs (LAGB) – 5 pts (2%) readmitted: 3 band obstructions, 1

band infection, 1 SBO RNY– Careful selection:

• No Pulmonary HTN, ASA III or less, no severe OSA

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Sleeve outpatient

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• No data published

Milliman

• Industry leader in setting payor standards around the country

• Their guidelines are the “bible” for insurance companies

• World largest independent actuarial/consulting firm

• Rigorous standards: professional excellence, peer review and objectivity

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Milliman Care Guidelines® LOS recommendations14th Edition June 2010

• Gastric Bypass RNY:– Ambulatory (23 hrs) if:

• < 5 serious comorbidities

– Inpatient if: • Complications (PE, leak, evisceration, etc.)• Complex comorbidities (>5 severe, heart failure)• BMI >60• Age>65• Combined procedure

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Milliman Care Guidelines® LOS recommendations14th Edition June 2010

• Gastric Restrictive procedure (Band, Sleeve):– Ambulatory (same-day)– Inpatient if:

• Conversion to open• Complications (PE, leak, band malposition, etc.)• Complex comorbidities (heart failure, severe

diabetes)• BMI >60• Age>65

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Insurance Companies

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Insurance Companies

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Are Milliman guidelines evidence based?

• 5 papers:– 2 LAGB from Montgomery, Watkins– McCarty paper: not duplicated since

publication– Rutledge paper with loop bypass: different

operation not recognized by ASMBS– Ballentyne paper: description LRNY median

2-day hospital stay, single center– No sleeve data to support same-day d/c

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LRNY current evidence

• Nationwide Inpatient Sample (Agency for Healthcare Research and Quality) national dataset (7 mill admissions annually):– Median LOS 2.7 days– <1% pts had <1 day LOS

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LRNY current evidence

• BOLD from ASMBS COE’s:– Median LOS 2.4 days– <1% pts had <24hrs LOS

• University Health Consortium:– 8.3% had <24 hrs LOS– 30-day readmission rate 36% higher in this

group (2.15% vs 1.58%)

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Conclusions

– LAGB large series support outpatient LOS– Only one large LRNY series, single

center/surgeon documents 23 hrs LOS in 84% pts

– No data on sleeves

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Conclusions

– Selected bariatric cases can be done in outpatient setting

– Surgeons should decide this based on clinical evaluation

– Insurance companies should not mandate

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And Endoluminal / Restrictive Procedures

Third Annual

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Thank you!