Same-Day Discharge in Bariatric Surgery: A novel healthcare pathway

This thesis explored a novel healthcare pathway for bariatric surgery with same-day discharge (SDD) in response to ongoing challenges like staff shortages, the recent COVID-19 pandemic and a growing number of patients with obesity. The implementation of Enhanced Recovery After Bariatric Surgery (ERABS) in recent years has already resulted in a decrease in the length of hospital stay. This success gave the opportunity for further reducing admission time by introducing SDD. In this thesis, three crucial aspects of SDD were analyzed: patient selection, safety and complications, and patient satisfaction. In the first part of this thesis, focusing on patient selection, two studies were conducted. In Chapter 2, a study was performed to assess the feasibility of Roux-en-Y Gastric Bypass (RYGB) with SDD for patients with well-regulated obstructive sleep apnea using continuous positive airway pressure . The study demonstrated a high rate of successful discharge of 92% on the day of surgery. There were no severe complications in the first 48 hours after surgery, and no pulmonary complications were observed within the study population. The implementation of SDD after bariatric surgery began with RYGB, the most performed bariatric procedure in our hospital. As sleeve gastrectomy (SG) is the second most performed procedure, Chapter 3 investigated the feasibility of SDD for SG. The study revealed a high success rate of 90% for SDD with low complication rates in SG patients and no severe complications in the study population. Part 2 of this thesis explores safety and complications. Chapter 4 outlines a retrospective study involving 500 consecutive patients scheduled for RYGB with SDD, achieving a discharge success rate of 93%. There was a variety of reasons for overnight hospitalization, including pain and nausea. Bleeding emerged as the most common cause of readmission within the initial 48 hours following surgery. However, all these cases were managed conservatively. Chapter 5 presents a study based on the national database, comparing patients with similar characteristics. Patients who underwent SDD were compared to those who stayed overnight after bariatric surgery. The occurrence of severe complications, reoperations and mortality was found to be similar in both groups. However, SDD was associated with a higher 30-day readmission rate. The postoperative care protocol, or our “safety net”, was analyzed in Chapter 6. This safety net includes comprehensive patient education, simple remote monitoring and two consultations postoperatively. All early complications in this study were effectively detected. While the role of remote monitoring was limited, it is recommended to be integrated into the safety net. In a mixed-methods study in Chapter 7, patient satisfaction was evaluated using both validated questionnaires and interviews. Patients expressed great appreciation for SDD. A key strength of the SDD pathway was the role of healthcare providers. There was room for improvement regarding the information provision, particularly concerning the day of surgery. Additionally, not every medically eligible patient appeared suitable for this pathway, as responsibilities for detecting complications are partially shifted from healthcare providers to patients. In Chapter 8, the clinical implications of the conducted studies in this thesis are discussed. The chapter elaborates on the implementation of a SDD healthcare pathway, where several critical factors must be considered, including the implementation of ERABS as a prerequisite. It explains how to implement a similar SDD pathway. Future perspectives are discussed, including the role of digitalization. In this chapter it is concluded that the SDD pathway has proven to be safe and efficient, when strict criteria are followed, and that the pathway is appreciated by patients. Given the ongoing challenges in healthcare, bariatric surgery with SDD emerges as a potential solution to ensure the future sustainability of bariatric surgery.