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Factors that Influence Length of Stay Following Bariatric Surgery
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Oral Presentations / Surgery for Obesity and Related Diseases 12 (2016) S1–S32
exclusion criteria were met was censored. Primary outcomes were reported as post-surgery rates of 1) unprotected intercourse (defined as not always using birth control while having intercourse with a male partner), and 2) conception. Mixed models were used to compare rates by time point and examine associations of baseline history of primary infertility (i.e., nulliparous and prior attempts at conception including at least 12 months of regular intercourse with a male partner and not using any form of birth control) with unprotected intercourse and trying to conceive post-surgery. Results: Of 741 women who met eligibility requirements, 711 reported a primary outcome. Baseline median (IQR) age was 37 (32-41) years. Approximately half (50.6%) did not plan to become pregnant post-surgery; future pregnancy was important to 30.3%. Eight percent had a history of primary infertility. In the year following surgery, 44.8% (95% CI, 39.8-49.9%) of women reported unprotected intercourse; whereas 39.6% (95% CI, 34.944.3%) always used birth control during intercourse and 12.2% (95% CI 9.2-15.2%) did not have intercourse with a male. These rates did not significantly differ between follow-up time points (p¼0.42, p¼0.22 and p¼0.66, respectively). In the first postoperative year, 3.5% (95% CI, 2.0-5.0%) of women reported trying to conceive. This rate significantly increased to 9.7% (95% CI, 5.4-14.1%) - 12.2% (95% CI, 4.8-19.5%) in years 2-7 (p for allo0.001). Women with a history of primary infertility versus those without were more likely to report unprotected intercourse (RR¼1.89 [95% CI¼1.64-2.19] po.0001) and attempting to conceive (RR¼5.29 [95% CI, 3.71-7.55]; po.0001) postsurgery. With regards to conception, 154 women had a total of 237 pregnancies, translating to a conception rate of 53.8 (95% CI, 40.0-71.1)/1,000 person-years. Among women with a history of primary infertility, the conception rate was 121.2/1,000 personyears (95%CI, 102.3-143.5).Conception rates were not significantly different among the following post-surgical intervals: 0o18 months, 18-o42 months and 42o90 months (p4.05). Conclusion: In this large multi-center cohort, 45% of women reported having unprotected intercourse in the first year following surgery, although the vast majority (495%) reported that they were not attempting to conceive. History of primary infertility was associated with greater risk of unprotected intercourse and higher rates of conception. Although data regarding pre-surgical contraceptive counseling was unavailable, our results provide important guidance regarding post-surgical fertility that may aid in presurgical counseling regarding contraception and conception.
A108
FACTORS THAT INFLUENCE LENGTH OF STAY FOLLOWING BARIATRIC SURGERY Arturo Garcia; Sahil Parikh; Aaron Carr; Mohamed Ali; UC Davis Medical Center, Sacramento CA Introduction: The safety of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic vertical sleeve gastrectomy (LVSG) have been well-documented, and the development of enhanced recovery after surgery (ERAS) protocols quickly gained traction for bariatric operations. At our institution, we implemented an ERAS protocol for primary bariatric surgery that begins to consider patient discharge as early as the first post-operative day (POD 1). The objective of this study was to identify the feasibility of early (POD 1) discharge as well as pre-operative and intra-
operative predictors of length of stay beyond POD 1 following LRYGB and LVSG. Methods: The study population consists of all patients who underwent primary LRYGB or LVSG between 2010 and 2015. Revisional and open procedures were excluded. At our institution, all primary bariatric surgery patients are managed based on our bariatric ERAS protocol, which allows patient discharge as early as POD 1. Prospectively collected data included demographic and anthropomorphic measurements, pre-operative comorbidities, intra-operative findings and events, and length of stay. Clinically significant associated factors were identified on univariate analysis. These factors were then used for multivariate analysis to identify predictors of hospital stay beyond POD 1. Results: During the study period, 647 consecutive patients underwent LRYGB and 310 consecutive patients underwent LVSG. The mean hospital length of stay for LRYGB and LVSG was 47.2þ-0.5 hours and 51.7þ-1.8 hours, respectively. The majority of LRYGB patients (57.2%) and LVSG patients (71.3%) required hospitalization longer than one day postoperatively. For LVSG, the only patient variable associated with longer hospitalization beyond POD 1 was body mass index (BMI) greater than 50 kg/m2 (6.7% vs. 17.6%, p ¼ 0.01). In contrast, a number of variables were significantly associated with hospitalization beyond POD 1 for LRYGB: age (44.1 years vs. 47.0 years, po 0.01), decreased functional status (4.3% vs. 12.2%, po0.01), insulin-dependent diabetes (7.2% vs.16.8%, po0.01), pulmonary hypertension (1.4% vs. 4.6%, p ¼ 0.03), dyslipidemia (23.5% vs. 35.1%, po0.01), ischemic heart disease (0.7% vs. 3.0 %, p ¼ 0.05), operative time (186.9 minutes vs. 207.5 minutes, po0.01), operative blood loss (55.6 mL vs. 75.9 mL, po0.01), and performing additional procedures along with the index case (21.7% vs. 34.3%, p o0.01). On multivariate analysis, insulindependent diabetes (OR 2.0, 95% CI: 1.1 to 3.6), decreased functional status (OR 2.0, 95% CI: 1.0 to 4.1), and additional procedures performed along with the index case (OR 1.5, 95% CI: 1.0 to 2.2) were significant predictors of hospitalization beyond POD 1 following LRYGB. Unlike LVSG, BMI was not associated with longer hospitalization after LRYGB. Conclusion: Bariatric surgeons were very early adopters of protocol-driven care based on best practices, well before ERAS methodology became popular in other fields of general surgery. Bariatric surgery patients undergo major operations and typically have numerous medical comorbidities. Despite routine utilization of enhanced recovery protocols following primary LRYGB and LVSG, only a minority of patients could be safely discharged from the hospital the day after bariatric surgery. We have identified several patient and operative factors that correlate to extended lengths of stay. Ultimately, optimal patient management following bariatric surgery is a balance between algorithmic care based on ERAS principles and the judgment of the experienced bariatric surgeon to advocate for the safety of the patient.
A109
LONG-TERM (410 YEAR) OUTCOMES AFTER LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS Shanu Kothari1; Andrew Borgert2; Kara Kallies2; Matthew Baker1; Brandon Grover1; 1Gundersen Health System, La Crosse Wisconsin; 2Gundersen Medical Foundation, La Crosse Wisconsin
Oral Presentations / Surgery for Obesity and Related Diseases 12 (2016) S1–S32
exclusion criteria were met was censored. Primary outcomes were reported as post-surgery rates of 1) unprotected intercourse (defined as not always using birth control while having intercourse with a male partner), and 2) conception. Mixed models were used to compare rates by time point and examine associations of baseline history of primary infertility (i.e., nulliparous and prior attempts at conception including at least 12 months of regular intercourse with a male partner and not using any form of birth control) with unprotected intercourse and trying to conceive post-surgery. Results: Of 741 women who met eligibility requirements, 711 reported a primary outcome. Baseline median (IQR) age was 37 (32-41) years. Approximately half (50.6%) did not plan to become pregnant post-surgery; future pregnancy was important to 30.3%. Eight percent had a history of primary infertility. In the year following surgery, 44.8% (95% CI, 39.8-49.9%) of women reported unprotected intercourse; whereas 39.6% (95% CI, 34.944.3%) always used birth control during intercourse and 12.2% (95% CI 9.2-15.2%) did not have intercourse with a male. These rates did not significantly differ between follow-up time points (p¼0.42, p¼0.22 and p¼0.66, respectively). In the first postoperative year, 3.5% (95% CI, 2.0-5.0%) of women reported trying to conceive. This rate significantly increased to 9.7% (95% CI, 5.4-14.1%) - 12.2% (95% CI, 4.8-19.5%) in years 2-7 (p for allo0.001). Women with a history of primary infertility versus those without were more likely to report unprotected intercourse (RR¼1.89 [95% CI¼1.64-2.19] po.0001) and attempting to conceive (RR¼5.29 [95% CI, 3.71-7.55]; po.0001) postsurgery. With regards to conception, 154 women had a total of 237 pregnancies, translating to a conception rate of 53.8 (95% CI, 40.0-71.1)/1,000 person-years. Among women with a history of primary infertility, the conception rate was 121.2/1,000 personyears (95%CI, 102.3-143.5).Conception rates were not significantly different among the following post-surgical intervals: 0o18 months, 18-o42 months and 42o90 months (p4.05). Conclusion: In this large multi-center cohort, 45% of women reported having unprotected intercourse in the first year following surgery, although the vast majority (495%) reported that they were not attempting to conceive. History of primary infertility was associated with greater risk of unprotected intercourse and higher rates of conception. Although data regarding pre-surgical contraceptive counseling was unavailable, our results provide important guidance regarding post-surgical fertility that may aid in presurgical counseling regarding contraception and conception.
A108
FACTORS THAT INFLUENCE LENGTH OF STAY FOLLOWING BARIATRIC SURGERY Arturo Garcia; Sahil Parikh; Aaron Carr; Mohamed Ali; UC Davis Medical Center, Sacramento CA Introduction: The safety of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic vertical sleeve gastrectomy (LVSG) have been well-documented, and the development of enhanced recovery after surgery (ERAS) protocols quickly gained traction for bariatric operations. At our institution, we implemented an ERAS protocol for primary bariatric surgery that begins to consider patient discharge as early as the first post-operative day (POD 1). The objective of this study was to identify the feasibility of early (POD 1) discharge as well as pre-operative and intra-
operative predictors of length of stay beyond POD 1 following LRYGB and LVSG. Methods: The study population consists of all patients who underwent primary LRYGB or LVSG between 2010 and 2015. Revisional and open procedures were excluded. At our institution, all primary bariatric surgery patients are managed based on our bariatric ERAS protocol, which allows patient discharge as early as POD 1. Prospectively collected data included demographic and anthropomorphic measurements, pre-operative comorbidities, intra-operative findings and events, and length of stay. Clinically significant associated factors were identified on univariate analysis. These factors were then used for multivariate analysis to identify predictors of hospital stay beyond POD 1. Results: During the study period, 647 consecutive patients underwent LRYGB and 310 consecutive patients underwent LVSG. The mean hospital length of stay for LRYGB and LVSG was 47.2þ-0.5 hours and 51.7þ-1.8 hours, respectively. The majority of LRYGB patients (57.2%) and LVSG patients (71.3%) required hospitalization longer than one day postoperatively. For LVSG, the only patient variable associated with longer hospitalization beyond POD 1 was body mass index (BMI) greater than 50 kg/m2 (6.7% vs. 17.6%, p ¼ 0.01). In contrast, a number of variables were significantly associated with hospitalization beyond POD 1 for LRYGB: age (44.1 years vs. 47.0 years, po 0.01), decreased functional status (4.3% vs. 12.2%, po0.01), insulin-dependent diabetes (7.2% vs.16.8%, po0.01), pulmonary hypertension (1.4% vs. 4.6%, p ¼ 0.03), dyslipidemia (23.5% vs. 35.1%, po0.01), ischemic heart disease (0.7% vs. 3.0 %, p ¼ 0.05), operative time (186.9 minutes vs. 207.5 minutes, po0.01), operative blood loss (55.6 mL vs. 75.9 mL, po0.01), and performing additional procedures along with the index case (21.7% vs. 34.3%, p o0.01). On multivariate analysis, insulindependent diabetes (OR 2.0, 95% CI: 1.1 to 3.6), decreased functional status (OR 2.0, 95% CI: 1.0 to 4.1), and additional procedures performed along with the index case (OR 1.5, 95% CI: 1.0 to 2.2) were significant predictors of hospitalization beyond POD 1 following LRYGB. Unlike LVSG, BMI was not associated with longer hospitalization after LRYGB. Conclusion: Bariatric surgeons were very early adopters of protocol-driven care based on best practices, well before ERAS methodology became popular in other fields of general surgery. Bariatric surgery patients undergo major operations and typically have numerous medical comorbidities. Despite routine utilization of enhanced recovery protocols following primary LRYGB and LVSG, only a minority of patients could be safely discharged from the hospital the day after bariatric surgery. We have identified several patient and operative factors that correlate to extended lengths of stay. Ultimately, optimal patient management following bariatric surgery is a balance between algorithmic care based on ERAS principles and the judgment of the experienced bariatric surgeon to advocate for the safety of the patient.
A109
LONG-TERM (410 YEAR) OUTCOMES AFTER LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS Shanu Kothari1; Andrew Borgert2; Kara Kallies2; Matthew Baker1; Brandon Grover1; 1Gundersen Health System, La Crosse Wisconsin; 2Gundersen Medical Foundation, La Crosse Wisconsin