EXPERIENCED HANDS Dr. Peter Billing (right) performs laparoscopic sleeve gastrectomy at the Puget Sound Surgical Center.

Laparoscopic sleeve gastrectomy (LSG) involves removing the body of the stomach and reshaping the remaining area to a tube shape. It retains bowel continuity and lets food enter the stomach and pass into the small bowel normally. Some studies show increased gastric emptying. This procedure limits the amount of food the patient can eat but, more importantly, it changes the hormonal feedback mechanisms for satiety. Many believe that this is the primary mechanism for weight reduction. It provides similar weight loss results as gastric bypass procedures, but with shorter operative times, shorter post-op stays, lower costs and fewer complications. All these factors make performing the procedures in a freestanding ASC reasonable and safe. In fact, we've been hosting the procedure for years at our freestanding ASC in the Seattle suburbs. Here are 3 keys to our success.

1. Patient selection
Patients who weigh more than the upper limits of OR tables (450 lbs. at our facility), have general immobility that prevents early post-op ambulation and present with complicated anatomy that would likely extend surgery beyond 2 hours, are not ideal candidates for outpatient LSG. We also exclude patients with comorbidities such as cardiac and pulmonary issues who'd require longer than an overnight stay.

Patients with scores of 2 or higher on the STOP-BANG sleep apnea screening tool must undergo a sleep study before being cleared for surgery. Patients who meet national guidelines for pre-op cardiac evaluations must undergo extensive cardiac screenings, and those with hypoxia or chronic metabolic alkalosis must undergo screening for pulmonary hypertension.

2. Perioperative precautions
Before surgery, patients are placed in the supine position, with a wedge positioner placed behind their backs to improve access to the upper abdominal cavity. Two bariatric surgeons perform the procedure through 5 ports, with the primary surgeon standing to the patient's right. Anesthesiologists experienced in sedating bariatric patients have quick access to difficult airway management tools, including fiber-optic scopes and video laryngoscopes.

I cannot over-emphasize the importance of having an experienced bariatric surgeon and an entire bariatric team well-versed in sleeve gastrectomy. Our operative times are routinely less than an hour.

RESEARCH REVIEW
250 Laparoscopic Sleeve Gastrectomies

ANESTHESIA ACE Sleep apnea is a key concern during bariatric surgery, making proper airway management paramount.

We reviewed the first 250 laparoscopic sleeve gastrectomies performed in our facility and published the results in the journal Surgery for Obesity and Related Disease (tinyurl.com/ks72ww9). The short- and long-term results were impressive.

• Operative times. They averaged 60 minutes and decreased as more cases were performed: an average of 85 minutes for the first 25 cases and 48 minutes for the last 25 cases. Patients spent a little longer than 2 hours in recovery, on average.
• Demographics. Patients averaged 47 years of age, had an average body mass index of 43 kg/m2 (32 patients with BMIs greater than 50 kg/m2 were considered super-obese) and had several documented attempts at unsuccessful weight loss.
• Complications. Both our transfer and readmission rates were similar to what other research has shown in the outpatient setting. Only 9 patients (3.6%) required hospital admission within 30 days of surgery. Two of the 9 were admitted the day after surgery for bronchitis and bleeding at the abdominal wall that required 2-unit blood transfusions. Two required day-of-surgery transfers to the local hospital for hypoxemia related to sleep apnea. No patients died, and none of the procedures were converted to open procedures.
• Results. Patients lost an average of 60% of excess weight at 1 year post-op and 63% at 2 years. A year after surgery, diabetes improved or was resolved in 97% of patients, hypertension improved (97%) or was resolved (59%) and hyperlipidemia improved (88%) or was resolved (48%). Additionally, 61% of patients said their sleep apnea remained resolved 1 year after surgery.

— Peter Billing, MD

3. Careful recoveries
Patients receive 2 to 3 liters of crystalloid IV fluids in recovery. They qualify for same-day discharge if they're able to ambulate after surgery, have normal room-air saturation, are PONV-free and can tolerate liquids. Patients discharged the day of surgery have IV cannulas placed and receive saline locks. They return the next morning for assessment and 1 to 2 more liters of crystalloid fluid therapy.

We have a transfer agreement with a community hospital near the surgery center. We currently require mandatory sleep apnea assessment for patients who register scores higher than 2 on the STOP-BANG assessment tool. (Before the review of our first 250 cases, the assessment was recommended, but not mandatory.) They must also document compliance with CPAP therapy and be cleared for surgery by their sleep-care providers. We now observe all patients with sleep apnea or suspected sleep apnea cleared for surgery overnight in the surgery center.

Proceed with caution
LSG performed in a surgery center requires consistent staffing (which has been shown to enhance patient care and improve outcomes), proper bariatric equipment, scheduling and protocols. All those factors lead to safer and more efficient surgeries than what's possible in inpatient ORs. Although LSG in the outpatient arena is far from novel, very little data supports its safety in a freestanding ASC.

Surgeons who want patients to remain hospitalized overnight following surgery are understandably concerned that several factors could jeopardize same-day discharges: nausea and vomiting, post-op pain, dehydration and a lack of monitoring to detect early-stage complications once patients are recovering at home. But we've shown that careful patient selection and extensive pre-op screenings identify patients who are without serious cardiac and pulmonary issues that increase risks of post-op issues. Outpatient LSG will improve access for many patients who can't undergo the life-changing surgery because of financial concerns. ASCs must have overnight 23-hour stay capabilities if they are going to perform these procedures.

Although we've shown it can be done, more clinical guidelines are needed to determine which patients can undergo the procedure safely in the ASC setting. Until then, proceed with caution and work with surgical professionals who are experienced in bariatric surgery to add these procedures to your case mix. We currently feel that these procedures should only be done in carefully selected centers committed to the care of the bariatric patient with only experienced bariatric surgeons and staff. Our experience now includes more than 1,000 patients and has resulted in improved bariatric care in regard to safety and outcomes.