Surgery for Obesity and Related Diseases 11 (2015) 335–342

Original article

Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization) Lionel Rebibo, M.D.a, Abdennaceur Dhahri, M.D.a, Rachid Badaoui, M.D.b, Hervé Dupont, M.D., Ph.D.b, Jean-Marc Regimbeau, M.D., Ph.D.a,* a

Department of Digestive Surgery, Amiens University Hospital and Jules Verne University of Picardie, Amiens, France b Department of Anesthesia, Amiens University Hospital and Jules Verne University of Picardie, Amiens, France Received April 20, 2014; accepted August 29, 2014


Background: Day-case surgery (DCS) has boomed over recent years, as has laparoscopic sleeve gastrectomy (SG) for the treatment of morbid obesity. The objective of this study was to evaluate the safety and feasibility of day-case SG. Methods: This was a prospective, nonrandomized study of 100 patients undergoing day-case SG from May 2011 to July 2013. All patients met the criteria for DCS and for the treatment of morbid obesity. Standard surgical, anesthetic, and analgesic protocols were used. The primary study endpoint was the unplanned overnight admission rate. Secondary endpoints were standard DCS criteria, frequency and type of complications, and satisfaction rate of performing day-case SG. The shortterm postoperative course of patients undergoing day-case and conventional SG also were compared. Results: A total of 416 patients were screened and 100 (24%) were included. There were 8 unplanned overnight admissions. Seven unexpected consultations, 7 hospital readmissions, and 5 major complications were recorded, including 3 cases of unexpected surgery for gastric leak. At follow-up, 96% of the patients were satisfied with day-case SG. The short-term postoperative course was similar among patients undergoing DCS and conventional management. Conclusion: In selected patients, day-case SG is feasible with acceptable complication and readmission rates. The postoperative course was similar to that observed for standard SG. (Surg Obes Relat Dis 2015;11:335–342.) r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.


Laparoscopic sleeve gastrectomy; Day-case surgery; Ambulatory surgery; Outpatient surgery; Morbid obesity

Day-case surgery (DCS) (also known as ambulatory surgery, outpatient surgery, same-day surgery, or day surgery) does not require an overnight hospital stay. This affords patients the opportunity to receive postsurgical care in a nonhospital setting. DCS is distinct from * Correspondence: Professor J.-M. Regimbeau, Service de chirurgie digestive et métabolique, Hôpital Nord, CHU dʼAmiens, Place Victor, Pauchet, F-80054 Amiens cedex 01, France. E-mail: [email protected]

overnight-stay surgery, in which the patient is discharged to home the day after the operation (i.e., after a night as an inpatient) [1]. The use of DCS reduces hospital costs and enables staff to devote more time to hospitalized patients requiring more demanding care. In 2010, DCS was designated as a national healthcare priority in France. In the field of gastrointestinal surgery, DCS has been validated primarily for inguinal hernia repair, cholecystectomy [2], and the treatment of gastroesophageal reflux disease [3–5]. In terms of bariatric procedures, laparoscopic 1550-7289/r 2015 American Society for Metabolic and Bariatric Surgery. All rights reserved.


L. Rebibo et al. / Surgery for Obesity and Related Diseases 11 (2015) 335–342

adjustable gastric banding (LAGB) usually is performed in a day-case setting [6]. SG has become very popular [7]. It is a relatively short, simple procedure, with a mean operating time of 100 minutes [8]. The major complications are gastric leak [9] and hemorrhage along the gastric staple line. Gastric leak is found in fewer than 3% of cases and mostly occurs between postoperative day (POD) 5 and POD 8 [10]. Hemorrhage along the staple line occurs in fewer than 5% of cases [11]. Overall, SG is a reproducible, codified procedure with a short operating time and a low postoperative complication rate [9]; therefore, it meets the criteria for implementation as DCS. Given the popularity of SG with patients (with an average hospital stay of 3 days in the authors’ institution) [7], it was assumed that DCS would not increase the patientʼs level of risk as long as the patient was selected appropriately and keen to undergo this type of surgery. Hence, the objective of the present study was to determine the feasibility and outcomes of day-case SG as a treatment for morbid obesity. Material and methods This was a prospective, nonrandomized study of a group of patients undergoing day-case SG between May 2011 and July 2013. The study was part of a local research protocol registered as “Feasibility of Laparoscopic Sleeve Gastrectomy in Day Case Surgery (GASTRAMBU)” ( identifier: NCT01513005). The study was approved by the local investigational review board (Comité de Protection des Personnes Nord Ouest II). During a preoperative consultation, patients were given a study information sheet and a drug prescription for the days after surgery. All patients provided their informed, written consent to participation. The inclusion criteria were a body mass index (BMI) between 35 and 60 kg/m², the absence of a significant medical history (cardiovascular and/or pulmonary diseases, no previous history of abdominal surgery) and validation by a multidisciplinary obesity staff meeting [12], treatmentcompliant patients aged between 18 and 60 years, living within an hourʼs drive of a hospital and with an on-site support person available for the night after surgery, access to a telephone and an American Society of Anesthesiologists score of I or II [13]. Patients were excluded if they had heart disease (history of myocardial infarction, heart rhythm disorder), obstructive sleep apnea syndrome (OSA), or poorly controlled diabetes and if a prisoner or thought to be poorly compliant [14]. The indication for bariatric surgery was validated in accordance with French national guidelines and a multidisciplinary obesity staff meeting [12]. All patients attended a surgical as well as a nutritional and dietetics consultation and underwent pulmonary, endocrine, and psychological assessments. Hiatus hernia and Helicobacter pylori

infections were evaluated by esophagogastroduodenoscopy. Respiratory function tests, including sleep polysomnography, were used to screen for OSA in all patients before surgery. Metabolic syndrome was defined according to the National Cholesterol Education Program’s Adult Treatment Panel III report (NCEP ATP 3) when 3 of 5 of the listed characteristics are present: abdominal obesity, given as waist circumference 4102 cm in male patient and 488 cm in female patient; triglycerides Z150 mg/dL; HDL cholesterol o40 mg/dL in male patient and o50 mg/dL in female patient; blood pressure Z130/Z85 mm Hg; and fasting glucose Z110 mg/dL. During the preoperative consultation, all patients received a study information sheet with telephone numbers for the surgeon and the emergency department. Furthermore, the patients were taught how to accurately measure their heart rate once discharged to home after surgery. At the preoperative consultation, patients were also given a drug prescription for the days following surgery. The prescription featured oral analgesics (acetaminophen 1 gram qid and tramadol 100 mg tid, an antiemetic [metoclopramide 10 mg po tid],.an anticoagulant [subQ enoxaparin 40 IU bid for 10 days], in accordance with French national guidelines [15]), and a proton pump inhibitor (omeprazole 40 mg po qd). Patients were treated in a dedicated DCS unit. On the day of surgery, patients were admitted to the unit at 7:15 a.m. and entered the operating theater at 8:00 a.m.. Surgery began at approximately 8:30 a.m. The protocol for anesthesia was specifically developed for use in day-case SG [16].To prevent postoperative nausea and vomiting, patients received intravenous (IV) dexamethasone 4 mg and droperidol .625 mg upon induction of anesthesia and ondansetron 4 mg postoperatively. The nasogastric tube was always removed in the operating theater after surgery. All operations were performed by bariatric surgeons experienced with SG. SG was performed according to the procedure described by Dhahri et al. [17], with open laparoscopy for obese patients [18]. An intraoperative methylene blue test was always performed before the end of the procedure. Abdominal drains were never left in place. In all cases, 20 mL of 2 mg/mL ropivacaine were infiltrated into the left subdiaphragmatic area via a catheter. After surgery, patients were admitted first to the recovery room and then the DCS unit for an assessment of vital signs (temperature, heart rate, blood pressure, and oxygen saturation), any postoperative nausea and pain (according to the classification published by Serlin et al. [19]) and collection of a blood sample for determination of the hemoglobin level. In all cases, an upper gastrointestinal (UGI) study with oral contrast was used to screen for gastric leak in accordance with French national guidelines [12]; patients were hospitalized when abnormal test results were observed (unplanned overnight admission).

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In the absence of clinical, biochemical, and radiological contradictions, the surgeon authorized oral refeeding. The patient was deemed suitable for discharge on the same day in the absence of any particular symptoms after food intake during recovery and after examination by both the surgeon and the anesthetist. If these conditions were not met, the patient was hospitalized overnight. Before leaving the DCS, the patients were provided with dietary advice, an information sheet describing symptoms that require emergency consultation (fever, tachycardia, and pain not relieved by analgesics prescribed), and the surgeonʼs 24-hour emergency telephone number. Patients were always contacted by the surgeon in the evening of the day of surgery and again on POD1. The patient was asked to report body temperature, heart rate, and any incident abdominal pain, nausea, and/or vomiting. Patients were always seen in the clinic on POD4 when they underwent a full clinical evaluation and analysis of additional complete blood count and C-reactive protein (CRP) level. They were seen again 3 months later, when they were queried regarding their level of satisfaction with day-case SG. Study criteria The studyʼs primary endpoint was the unplanned overnight admission rate (i.e., the percentage of intended daycase SGs in which the patient was admitted overnight). The secondary endpoints were variously related to DCS: the unexpected consultation rate, hospital readmission rate, unexpected reoperation, pain (graded according to Serlin et al. [20]), complications (according to the Clavien classification) [21], the frequency of major complications (with a Clavien score Z3), and levels of patient satisfaction with day-case SG at 3 months. The short-term postoperative course of patients undergoing day-case SG and conventional management also were compared to assess the impact of DCS. Intergroup comparisons of quantitative variables were performed with a Studentʼs t test, whereas intergroup comparisons of qualitative variables (including the primary endpoint) were performed with a chi-squared test. The results were expressed as the mean ⫾ standard deviation and range (for quantitative variables) or as the number and percentage (for qualitative variables). The threshold for statistical significance was set to P r .05. All statistical analyses were performed with SAS software (version 9.2, SAS Institute, Cary, NC). Results A total of 416 patients underwent primary SG during the study period; One hundred patients met all the study criteria and agreed to undergo day-case SG (24%). None of the patients meeting the criteria for day-case SG refused to


participate in the study. Of the 316 patients not selected for day-case SG, 25 had poorly controlled type II diabetes mellitus (T2DM) (7.9%), 95 had OSA (30.0%), 70 had a BMI Z60 kg/m2 (22.1%), and 126 did not meet the criteria for DCS (39.8%). Of the 316 patients not selected for daycase SG, 49 (15.5%) had requested DCS. The group of 100 patients consisted of 93 women and 7 men and had a mean (range) age of 35.9 ⫾ 10 years (22– 55) and a mean BMI of 42.4 ⫾ 3.3 kg/m2 (37.5–50.8). Two patients had a BMI Z50 kg/m2. In terms of co-morbidities, there were 13 cases of hypertension, 6 controlled T2DM, 7 with dyslipidemia, and 2 with metabolic syndrome (NCEP ATP3). In view of the exclusion criteria, no cases of OSA were observed. All procedures were performed laparoscopically. The mean ⫾ SD (range) operating time was 58.7 ⫾ 11.5 minutes (30–105 min) (Table 1). One patient required the introduction of an additional trocar (due to a difficult exposure), and 6 patients required a suture for arteriolar bleeding on the gastric staple line. One patient developed erythema in the absence of hypotension upon anesthetic induction, but this did not affect the surgical procedure. Orotracheal intubation was difficult in one other patient. After surgery, all patients were admitted to the recovery room. The mean (range) length of stay in the recovery room was 82 ⫾ 22 minutes (35–240 min). On entering the recovery room, 89 patients had little or no pain (89%). On leaving the recovery room, 95 patients (95%) had little or no pain and 81 (81%) had no postoperative nausea. Lastly, on entering the DCS unit, the groupʼs mean (range) vital sign and laboratory test values were as follows: heart rate: 84.2 ⫾ 12 bpm (59–115 bpm); arterial blood pressure: 140/80 mm Hg (110/70–178/90 mm Hg); body temperature: 36.51C (361C –37.51C); hemoglobin level: 14 g/dL ⫾ .6 Table 1 Intraoperative data, postoperative data, and complications (according to the Clavien classification) for patients having undergone day-case SG Day-case laparoscopic sleeve gastrectomy Operating time (minutes), mean (range) Time to oral refeeding (minutes), mean (range) Length of presence in the DCS unit (minutes), mean (range) Patients with no complications (n, %) Patients with complications (n, %) Clavien classification: Clavien 1 (n, %) Clavien 2 (n, %) Clavien 3 (n, %) Clavien 4 (n, %) Clavien 5 (n, %) *

58.7 (30-105) 485 (375-585) 630 (575-675) 91 (91%) 9 (9%) 2 2 5 0 0

(2%)* (2%)† (5%)‡ (0%) (0%)

One case of poor scar closure and one case of recurrent vomiting. One case of ischemia of the upper pole of the spleen and one case of lung infection. ‡ Gastric fistulas, 1 postoperative hematoma, and 1 gastric stricture. †


L. Rebibo et al. / Surgery for Obesity and Related Diseases 11 (2015) 335–342

(11.3–17.2 dL); white blood cell count: 14,293 ⫾ 1,350 (8,400–21,700). All patients underwent an UGI; no abnormalities, including any sign of gastric leak or gastric stenosis, were visible. Two patients had their UGI the day after performing SG (2%) due to postoperative nausea and somnolence in the day-case unit (these 2 patients underwent unplanned overnight admission). Oral feeding was resumed an average of 485 ⫾ 54 minutes (375–585 min) after admission to the DCS unit. Ninety-two patients were discharged on the evening of the day of surgery, after a mean length of stay (LOS) in the DCS unit of 630 ⫾ 37 minutes (575–675 min) (Table 1 and Fig. 1). There were no postoperative deaths. There were 8 unplanned overnight admissions due to discomfort after performing the UGI in 3 cases, pain in 2 cases, nausea in 1 case, somnolence in the day-case unit in 1 case, and difficulty of intubation during surgery in the last case. There were 7 unexpected consultations (unscheduled consultations) on 6 different patients for abdominal pain (2 patients), dysphagia (3 consultations by 2 patients), chest pain (1 patient), and poor wound closure (1 patient). Four of these unexpected consultations (by 4 patients) led to hospitalization. Three patients underwent hospitalization after scheduled consultation. The hospital readmission rate was 7% (n ¼ 7). Causes of hospitalization were as follows: 3 cases of gastric leak, 1 case of gastric stricture, 1 case of pneumonia, 1 case of hematoma needing radiological drainage, and 1 case of abdominal pain secondary to ischemia of the upper pole of the spleen requiring analgesic treatment using morphine for 2 days (Table 1). Three of the latter patients underwent an unscheduled surgical procedure for gastric leak (Fig. 2). Three of the patients requiring unplanned consultations were not hospitalized. All 100 patients were examined on POD4. Ninety-six did not have any specific somatic complaints. Laboratory tests

performed on POD4 revealed a mean (range) hemoglobin level of 14.2 ⫾ .5 g/dL (11.1–18 g/dL), a mean white blood cell count of 10,219 ⫾ 1,480 (6,100–23,200), and a mean serum CRP level of 51.1 ⫾ 26 mg/dL (7–355). During scheduled consultation on POD4, 2 patients with high CRP levels of 158 and 124 mg underwent abdominal computerized tomographic (CT) scan with oral contrast study, which showed absence of gastric leak in one and the presence of ischemia of the upper pole of the spleen in the other. These 2 patients were not re-admitted. However, a third patient with an elevated CRP did have a leak (vide infra).

Complications Major complications Five major complications (Clavien score Z3) were recorded, with 3 cases of gastric leak, 1 case of postoperative hematoma, and 1 case of gastric stricture. Regarding the patients with gastric leak, the median SG operating time was 50 minutes (45–60 min), and the surgical procedure was unremarkable in all cases. The postoperative data were also unremarkable (median heart rate: 74 bpm; median arterial blood pressure: 145/85 mm Hg; median body temperature: 37.31C). The laboratory tests performed on the day of surgery revealed a hemoglobin level of 15.3 g/dL and white blood cell count of 16,600. The UGI did not reveal any signs of gastric leak in any case. All 3 cases were discovered on POD 4. One patient felt nauseous and experienced 2 episodes of vomiting, 1 patient had hyperthermia, and the last patient was free of symptoms but had an elevated CRP pf 310 mg/dL. An abdominal CT scan revealed the gastric leak in all cases. It was not possible to perform radiological drainage. Laparoscopic exploration consisted of peritoneal lavage, an intraoperative

Fig. 1. Operating schedule for day-case SG.

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Fig. 2. Study synopsis.

methylene blue test that found a leak at the upper edge of the staple line that was then sutured, placement of a drainage tube, and placement of a feeding jejunostomy. Seven days after reoperation (POD 11 after initial SG), EGD was followed by placement of 2 double-pigtail stents. Abdominal drainage was then removed progressively the days after implementation of double-pigtails stents. Patients were discharged home a median of 15 days (14–16) after reoperation, with jejunal feeding. Six weeks after implementation of double-pigtails stent, a CT scan was performed to see the closure of gastric leak, and the double pigtails were removed the day after CT scan. Another CT scan performed 1 month after removal of the double pigtail stent showed the absence of collections for any of these patients and allowed removal of the feeding tube on the following day and resumption of oral feeding. Patients were discharged home with favorable outcomes in all patients. One patient was seen on POD7 for abdominal pain in the absence of fever when an abdominal CT scan revealed an intra-abdominal hematoma. The patient underwent radiological drainage and was discharged 5 days later. The patient with gastric stricture underwent 3 pneumatic dilations, which was effective but required total parenteral intravenous nutritional support for 4 days.

ischemia of the upper pole of the spleen was hospitalized for pain control with intravenous morphine required for the first 24 hours. The patient was discharged to home after 2 days in hospital with satisfactory pain control using oral analgesics. The patient with pneumonia was hospitalized for 2 days, during which time antibiotic treatment was initiated and then maintained per oram as an outpatient. A patient was seen for poor scar closure at the position of the right flank trochar; local treatment was sufficient and the condition did not require hospitalization. Three months after surgery, another patient presented with recurrent vomiting. An abdominal CT with oral contrast did not reveal a gastric leak or stenosis. The patient was not hospitalized and her problem resolved with dietary modification.

Minor complications

During the study period, 316 patients underwent SG without DCS: 253 women (80.1%) and 63 men (19.9%), age 41.8 ⫾ 11.3 years (18–65), and BMI of 47.2 ⫾ 18.3 kg/m2 (35–74.5). Seventy patients had a BMI Z60 kg/m2 (22.1%). The recorded co-morbidities were T2DM (24%; n ¼ 76), hypertension (33.8%; n ¼ 107), dyslipidemia

In terms of minor complications, there were 2 cases with a Clavien score of 2 (ischemia of the upper pole of the spleen and lung infection) and 2 with a Clavien score of one (poor wound closure and recurrent vomiting). The patient with

Patient satisfaction with day-case SG The patient satisfaction rate after day-case SG was 96%. The 4 dissatisfied patients were those having suffered a gastric leak or stricture.

SG performed as conventional management during the period study


L. Rebibo et al. / Surgery for Obesity and Related Diseases 11 (2015) 335–342

(26.9%; n ¼ 85), OSA (30%; n ¼ 95), and metabolic syndrome (19%, n ¼ 60). All procedures except one were performed laparoscopically. The operating time was 79 ⫾ 23.2 minutes (30–240 min) and LOS 2.7 ⫾ 2.1 days (1–4 d). The major complication rate was 5.7% (n ¼ 18). There were 7 (2.2%) cases of gastric leak, 3 (1%) of postoperative bleeding, 4 (1.2%) abdominal hematomas, 3 (.9%) gastric strictures, and 1 (.3%) diabetic ketoacidosis due to inadequate oral antidiabetic medications. Nine (2.8%) required early reoperation. There were no significant differences in terms of the rates of major complications (P ¼ .35), gastric leaks (P ¼ .18), and reoperations (P ¼ .38) comparing SG as DCS and conventional hospitalization. Discussion Obesity is increasing worldwide, with a prevalence of around 30% in France [22]. This constitutes a public health problem, particularly because obesity affects all ages, socioeconomic classes, and geographic regions [23]. Bariatric surgery has yielded good results in terms of weight loss, a correction of cardiovascular risk factors, and change in lifestyle [24]. Day-case surgery is becoming increasingly popular for 3 main reasons. Firstly, the avoidance of overnight hospitalization reduces the risk of hospitalacquired infections. Secondly, day-case management can improve the quality of care and raise levels of patient satisfaction without adding additional risk. Lastly, the cost of admission to a DCS unit is undoubtedly lower than that of conventional hospitalization. Day-case surgery now accounts for 80% of the hernia repairs and 50% of the cholecystectomies performed in our institution. Our university medical center is also part of a national network of reference centers for the surgical treatment of morbid obesity with SG; our activity has generated a large number of publications on the results of SG [7,8,19], the description and management of post-SG complications [25–27], and the description of a series of

gastric leaks (showing that median onset of gastric leakage was 6 days after SG) [9]. It is therefore probable that our center fulfills the main criteria for the performance of daycase SG. Bariatric surgery can be performed on a day-case basis, as suggested by 7 studies on GB [28] and one on RYGB [29]. These studies concluded that bariatric surgery is feasible as DCS, although some unplanned overnight admissions and unplanned hospitalizations must be expected [6]. The functional results appear to be similar to those obtained with surgery and conventional hospitalization [29]. Performance of day-case SG was prompted by the report by Mariette et al. [4] on the feasibility of day-case laparoscopic fundoplication for gastroesophageal reflux disease. Patients with a low risk of complications (according to the literature data) were deliberately selected, with a great majority (93%) of women [30], no patients with a BMI over 60 [31], and no patients with lung disease (and OSA in particular) [28]. The unplanned overnight admission rate (8%) was similar to those published for other series of day-case digestive tract surgery (Table 2) and for bariatric surgery (where the rates ranged from 0% to 24% [6,28]). The low proportion of unplanned overnight admissions in this series may have been due to good selection, systematic infiltration of the peritoneal cavity with ropivacaine [32], and use of a corticosteroid bolus to induce anesthesia and reduce postoperative nausea—a common cause of unplanned overnight admission, as observed in the series reported by Mariette et al. [4]. Furthermore, the standardization of analgesic and antiemetic regimens in a DCS-specific protocol may have helped to reduce discomfort—a frequent source of conversation to conventional hospitalization. However, the unplanned overnight admission rate would probably have been lower still if an UGI has not been performed, because almost 50% of the unplanned overnight admissions occurred after performance of this test. Furthermore, a recent study has shown that this test does not reliably detect gastric leak [33]. The use of routine UGI was

Table 2 A comparison of day-case laparoscopic sleeve gastrectomy and other types of day-case laparoscopic surgery

Number of patients (n) Mean operative time (minutes) Unplanned overnight admission (%) Unexpected consultations (%) Hospital readmission (%) Unexpected reoperation (%) Complications (%) Satisfaction (%)


Laparoscopic cholecystectomy

Laparoscopic fundoplication

Laparoscopic gastric banding

Laparoscopic RYGBP


This study 100 58 8

Mjaland et al. [6]

Mariette et al. [8]

Kormanova et al. [10]

Morton et al.

Billing et al.

200 55 6

40 70 17.5

20 91 MD

507 MD MD

250 60 .8

7 7 3 9 96

8 8 .5 7 98

14.3 2.5 2.5 2.5 92.5

5 5 5 5 MD

MD 2.4 MD 1.0 MD


Abbreviations: SG ¼ laparoscopic sleeve gastrectomy; RYGBP ¼ Roux-en-Y gastric bypass; MD ¼ missing data.

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performed in accordance with French national guidelines [12]; this exam is recommended after SG only for medicolegal reasons in France. In the present series, the only reoperations were due to 3 cases of gastric leak (3%); this proportion is similar to the literature, which ranges from 0% to 7% [7,34], but is a little higher than currently achieved in our institution where we had a gastric leak rate of 2.2% of SG performed without DCS during the study period. Moreover, all gastric leaks were discovered on POD4, the day of the first postoperative clinic visit. We conclude that the performance of day-case SG was not responsible per se for this event, since the average length of hospitalization in our institution after conventional SG was 2.7 days. The literature data suggests that the mean LOS for SG is about 4 days [35] and can extend up to 8 days; this is one reason why we scheduled the postoperative visit on POD4. Morton et al. [36] reported on a large prospective clinical database of patients undergoing RYGB, 507 patients as DCS, representing 1.0% of their RYGB. The majority of these patients were females (78.5%) with the lowest BMI compared to conventional management and with a lower number of co-morbidities. Patients with DCS had an increase in 30day readmissions. Patients discharged on an ambulatory basis had a 13-fold increased risk of death (.8%) when compared with the reference LOS of 2 days, mortality rate of .1%. In addition, ambulatory discharge was associated with a trend toward increased serious complications (OR: 1.9). However, this report did not provide the number of bariatric centers performing RYGB as DCS and, therefore, the number of surgical procedures performed as DCS by each center. Standardization of perioperative management was not described, which may affect the findings of the study. Recently, one other series [37] has suggested that SG can be performed as DCS. However, day-case SG should not be offered to all patients. In the retrospective series reported by Billing et al. [37], there were no patient selection criteria provided for day-case SG. They had a high upper range of BMI (71 kg/m²), older patients (up to 74), and long operating times (161 minutes). Furthermore, in our opinion, day-case SG should require standardized anesthesia and surgical procedures, without the need for abdominal drainage and performance of an intraoperative methylene blue test. The Billing et al. series did not feature standardized postoperative protocol, particularly with respect to postoperative laboratory tests. In the series reported by Billing et al., 2 patients were unexpectedly admitted overnight because of OSA that had not been diagnosed before surgery. They also did not state how many patients underwent conventional SG during the same time period. Despite the absence of patient selection criteria, the Billing et al. results for day-case SG were excellent, with a gastric leak rate of .4% and a hospital readmission rate of 3.6%. Furthermore, the unplanned admission rates and readmission rates reported by Billing et al. are even lower than for other types of DCS (Table 2). In


view of these considerations and, in particular, the differences between our present series and the only other series of this type in the literature [37], surgeons must be aware of the specific features of performing day-case SG and must have clear patient selection criteria for this procedure. Conclusion Day-case SG was feasible and, as long as patients were correctly selected, was not associated with elevated morbidity and mortality rates compared with conventional management. Patient satisfaction was high, 96%. In view of the study results, our institution is continuing to offer day-case SG. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. Acknowledgments We thank Jean-Baptiste Deguines, Delphine Lignier and whole day-case team for their valuable help with this work. References [1] Lemos P, Jarrett P, Philip B. Day surgery: Development and practice. London: The International Association for Ambulatory Surgery (IAAS), 2006. [2] Mjåland O, Raeder J, Aasboe V, Trondsen E, Buanes T. Outpatient laparoscopic cholecystectomy. Br J Surg 1997;84:958–61. [3] Trondsen E, Mjâland O, Raeder J, Buanes T. Day-case laparoscopic fundoplication for gastro-oesophageal reflux disease. Br J Surg 2000;87:1708–11. [4] Mariette C, Piessen G, Balon JM, Guidat A, Lebuffe G, Triboulet JP. The safety of the same-day discharge for selected patients after laparoscopic fundoplication: a prospective cohort study. Am J Surg 2007;194:279–82. [5] Mariette C, Boutillier J, Arnaud N, Piessen G, Ruolt N, Triboulet JP. Outcome of day-case laparoscopic fundoplication for gastroesophageal reflux disease. J Visc Surg 2011;148:50–3. [6] Kormanova K, Fried M, Hainer V, Kunesova M. Is laparoscopic adjustable gastric banding a day surgery procedure? Obes Surg 2004; 14:1237–40. [7] Fuks D, Verhaeghe P, Brehant O, et al. Results of laparoscopic sleeve gastrectomy: A prospective study in 135 patients with morbid obesity. Surgery 2009;145:106–13. [8] Chazelet C, Verhaeghe P, Perterli R, et al. Longitudinal sleeve gastrectomy as a stand-alone bariatric procedure: Results of a multicenter retrospective study [article in French]. J Chir (Paris) 2009;146: 368–72. [9] Pequignot A, Fuks D, Verhaeghe P, et al. Is there a place for pigtail drains in the management of gastric leaks after laparoscopic sleeve gastrectomy? Obes Surg 2012;22:712–20 [10] Nocca D, Krawczykowsky D, Bomans B, et al. A prospective multicenter study of 163 sleeve gastrectomies: results at 1 and 2 years. Obes Surg 2008;18:560–5. [11] Lalor PF, Tucker ON, Szomstein S, Rosenthal RJ. Complications after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2008;4: 33–8. [12] Gastrectomie Longitudinale [sleeve gastrectomy] pour obésité. Hautes autorité de la santé. Recommandations; 2008.


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Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization).

Day-case surgery (DCS) has boomed over recent years, as has laparoscopic sleeve gastrectomy (SG) for the treatment of morbid obesity. The objective of...
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