After 500 outpatient lap bands, <1% admissions
After 500 outpatient lap bands, <1% admissions
Experienced physicians move procedure outpatient
With more than 95,000 laparoscopic adjustable gastric band (LAGB) procedures performed since its introduction in 1993,1 this approach to bariatric surgery began moving into the outpatient arena a few years ago. With the right approach to patient selection, the proper choice of anesthesia, and an experienced surgeon, the LAGB is appropriate for same-day surgery settings, according to a surgeon who has performed nearly 500 LAGBs with only four admissions to the hospital.
His success with LAGB on an outpatient basis can be attributed to a combination of several things, says Brad M. Watkins, MD, a bariatric surgeon at Northwest Weight Loss Surgery in Kirkland, WA. "First, all of the surgeons in our practice have a lot of laparoscopic experience," he notes. "While some surgeons might take as long as four hours to perform a lap band procedure, we usually complete the procedure in 30 to 40 minutes," Watkins explains.
The shorter procedure time increases the likelihood that the patient can go home the same day of surgery, he adds. Watkins shared his experience with bariatric surgery at the most recent meeting of the Federated Ambulatory Surgery Association (FASA), where some predicted that bariatric surgery will be one of the most popular outpatient procedures in the future.
"We also have an anesthesiology group that has a lot of experience with morbidly obese patients and the ways in which anesthesia affects them," he adds.
One of the key reasons for an overnight stay for a patient who undergoes lap band surgery is nausea, he explains. "With the use of a scopolamine patch, Zantac [Warner-Lambert Co., Morris Plains, NJ], or Pepcid [Johnson & Johnson-Merck Consumer Pharmaceuticals, Fort Washington, PA] prior to the surgery, and a steroid shot as the patient wakes up, we are able to reduce nausea and improve the opportunity to go home the same day," Watkins points out.
Pain control is important if the patient expects to go home the day of surgery, he adds. The less pain a patient experiences, the less narcotic medication will be needed, and that reduction means there will be less nausea, Watkins notes.
"We use Marcaine with epinephrine to numb the skin where the trocar enters the body so that the stress response is impaired and the patient feels less pain when he or she wakes," he explains. "We also inject the same anesthetic in the area around the port where we place stitches."
The benefits of outpatient bariatric surgery are similar to other outpatient procedures with a more comfortable recovery at home and a quicker return to normal activities, but the real issue driving the increased patient interest in outpatient procedures is cost, Watkins admits.
"Because most insurance companies won’t pay for bariatric surgery except in specific cases, the majority of patients seeking the lap band procedure are paying out of their pocket," he says. "I’ve seen patients withdraw money from their retirement accounts to pay for the surgery because they say that the retirement fund is no good to them if they die before they need it."
A lap band procedure with an overnight stay in the hospital can run about $26,000, but the outpatient procedure costs about $17,000, Watkins continues. "When patients are paying cash for the surgery, they are motivated to follow instructions carefully so that they can go home the same day," he adds.
Watkins’ record of only four hospitalizations following nearly 500 lap band procedures can be attributed to careful patient selection, he says. Hospitalizations were related to observation of bloody nasogastric tube drainage, suspected stoma occlusion, and nausea.
"The patient with nausea could have gone home the same day with oral antiemetics, but she lived alone and felt more comfortable staying overnight in the hospital," Watkins explains. All of the patients hospitalized for complications recovered quickly and were discharged, he adds.
Patient selection is the most important indicator of patient outcomes, says Carol Burkhardt, RN, MS, CNP, consultant with the AIG Healthcare Management Division of AIG Consultants in Chicago. Because these patients are high risk with existing comorbidities, it’s important to use a multidisciplinary approach to screening candidates for outpatient procedures, she says.
Patients with a history of significant cardiac problems, chronic obstructive pulmonary disease, emphysema, or known coagulopathy are not candidates for outpatient LAGB, Watkins notes. "We also don’t consider patients with impaired mobility good candidates if they require a wheelchair, scooter, or walker because they won’t be able to ambulate as needed after surgery," he explains. (See full list of contraindications, below.)
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Note contraindications, complications for lap band You can minimize the risk of complications for outpatient lap band surgery by ruling out patients with significant cardiac history and other comorbidities that can affect outcomes negatively, suggests Brad M. Watkins, MD, a bariatric surgeon at Northwest Weight Loss Surgery in Kirkland, WA. While these contraindications used by Watkins are similar to those considered for many outpatient procedures, the morbidly obese patient with some of these conditions may be especially at risk for complications in an outpatient setting, he emphasizes. Contraindications include:
Potential post-op complications include:
Reference 1. MacGregor A. The Story of Surgery for Obesity. Gainesville, FL: American Society for Bariatric Surgery; 2002. |
While Watkins doesn’t use age as a factor when choosing candidates for the outpatient lap band procedure, he says he has noticed that his patients may be slightly younger than patients who undergo inpatient treatment.
"The difference is not as dramatic as we would have thought, but outpatients are a bit younger on the average and have a smaller body mass index [BMI] as well," he explains. The reason for the slightly younger age and smaller BMI is due more to the fact that lap band patients are seeking treatment earlier in their lives than morbidly obese patients who do not qualify as outpatient candidates, Watkins suggests. By seeking treatment earlier, they have fewer comorbidities that disqualify them as outpatients, he adds.
Watkins doesn’t consider sleep apnea itself a contraindication for the outpatient procedure, but he does think it’s important that surgeons recognize the serious risk of sleep apnea in this group of patients.
"While some of these patients may have been diagnosed with sleep apnea, the majority of them who have sleep apnea are undiagnosed," he says.
"We screen for sleep apnea in patients who have experienced witnessed episodes of apnea, have a neck circumference of more than 43 cm, who are males with diabetes, and who have a Dixon’s2 BASH’IM score of greater than or equal to 3," Watkins explains. If the patients are diagnosed with sleep apnea, they must be treated prior to the surgery, he adds.
"The risk I fear most is a pulmonary embolism," Watkins admits. "We do administer subcutaneous heparin prior to surgery to reduce the risk of clots, and we use compression boots and stockings."
A surgeon’s experience is essential, Burkhardt points out. "Volume matters when the surgeon is performing laparoscopic bariatric surgery.
For example, one surgeon reports that his rate of stomach slippage when he first began performing the procedure was 30%, but 200 procedures later, his stomach slippage rate had dropped to 2½%," she adds. Therefore, same-day surgery managers must evaluate a surgeon’s experience carefully before granting privileges for laparoscopic bariatric surgery, Burkhardt recommends.
There is no specific number of procedures that guarantee a surgeon’s competence with this procedure, but a manager should look at outcomes from the same procedure performed in an inpatient setting, she suggests.
Watkins agrees there is no specific number of procedures that a surgeon should have completed before he or she should be credentialed to perform the procedure on an outpatient basis, but he suggests 100 procedures as "a good generic starting point to consider." That number might vary according to the individual surgeon, he adds.
Although Watkins is a proponent of the outpatient lap band procedure, he does not recommend that a surgeon perform the procedure on an outpatient basis until he or she has extensive experience with the procedure as an inpatient procedure.
"Outpatient surgery should not be the new standard for the lap band procedure," he says.
"However, with an experienced surgeon, anesthesiologist, and nurses, it can be a very appropriate and effective approach to bariatric surgery for selected patients," Watkins explains.
References
- Statistics on Bariatric Surgery. Bariatric-Surgery.info 2004-2005. Web: www.bariatric-surgery.info/statistics-bariatrics.htm.
- Dixon JB, Schachter LM, O’Brien PE. Predicting sleep apnea and excessive day sleepiness in the severely obese. Chest 2003; 123:1,134-1,141.
Sources
For more information, contact:
- Carol A. Burkhardt, RN, MS, CNP, AIG Healthcare Management Division, AIG Consultants, Chicago. E-mail: [email protected].
- Brad M. Watkins, MD, FACS, Northwest Weight Loss Surgery, 12333 N.E. 130th Lane, Suite 415, Kirkland, WA 98034. Phone: (425) 899-4610. Web: www.thelapband.com.
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