ABSTRACT
Objectives:
Laparoscopic bariatric techniques and improved postoperative
recovery regimens have reduced hospital stay; some patients continue to have
prolonged admission for various reasons. This paper explores Objectives:
whether postoperative oral feeding is a potential risk factor for lengthened
hospitalization and readmission.
Methods:
A prospective, double blinded, randomized investigation of 250
postoperative patients at King Hussein Hospital, King Hussein Medical City,
Amman, Jordan, during the period March 2019-September 2021. Subjects (155 women
and 95 men, aged 31-49, with an average of 36 years) were managed for morbid
obesity, and were assigned to laparoscopic sleeve gastrectomy (LSG) or
laparoscopic Roux-en-Y gastric bypass (LRYGB) groups. Subjects with perioperative
hazards and previous bariatric techniques were ruled out. Early oral feeding
with light hospital diet on the first day after surgery and full hospital diet
in the second day after surgery were encouraged included subjects with hospital
admission (3 days) and group II included subjects with (>3 days) readmission
spanned 30days after surgery. Univariate and multivariate logistic regression
were used to evaluate effect induced parameters on lengthened hospital
admission and readmissions.
Results:
The average period of hospitalization was 3 (2–4) days of hospital
admission(HD), more days were recorded in 75/250 (30%) subjects: 40/150 (26.7%)
LSG, and 35/100 (35%) LRYGB (P < 0.005). Reduced postoperative oral feeding
lengthened hospitalization, and increased readmission risk. Readmission
incidence was 6% (15/250 readmissions): 6/150 (4%) LSG, and 9/100 (9%) LRYGB (P
> 0.05).
Conclusion:
Reduced oral feeding is a risk factor for lengthened
hospitalization and readmission.
Keywords:
Bariatric; Readmission; oral feeding.
RMS August 2023; 30 (2): 10.12816/0061603
Introduction
Bariatric surgery is the most efficient method
for patients with obesity to attain substantial long-standing weight reduction,
and it is correlated with a reduction of obesity-induced co-diseases.
Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass
(LRYGB) are used for bariatric surgery in morbid obesity cases, with decreased
risk for morbidity after surgery compared to alternative surgical techniques (1).
Although postoperative improved recovery regimens, minimized
morbidity (2), some subjects do not meet discharge criteria and
remain hospitalized longer than expected for such surgical patients. Lower .HD
is correlated with a higher incidence of readmission, as well as increased
costs for health systems and service users (3).
There is a strong link between perioperative hazards and lengthened
HD. Risk factors for lengthened HD and readmission should be determined to
anticipate subjects who could need more hospital period admission. Although
bariatric techniques are safe, a small proportion of patients have a major side
event during the first postoperative month resulting in costly hospital
readmissions. Readmission rates for bariatric surgery patients range between
0.6% to 11.3% in various contexts. In 2008, the US National Quality Forum
identified hospital readmission as a central concern in the assessment of
hospital performance (4). It is important to identify factors
anticipating readmission in order to improve patient outcomes and decrease
health system costs.
The goal of this investigation is to determine risk factors for
lengthened HD and unscheduled readmission for postoperative patients after
uncomplicated bariatric surgery.
Methods
This prospective,
double-blinded, randomized investigation included 250 subjects assigned for
bariatric surgery, after obtaining written informed consent from all
participants and obtaining approval from the local ethical research board
review committee of the Jordanian Royal Medical Services. Subjects were
assigned to LSG or LRYGB groups. They were aged 31-49 years with an average age
of 36. They included 155 women and 95 men who received surgery at King Hussein
Hospital, King Hussein Medical City, Amman, Jordan, during the period March
2019-September 2021 (Table I).
Table
I: Demographic characteristics.
|
Variable
|
N
(%)
|
|
Total study group
|
250 (100)
|
|
Female
|
155 (62)
|
|
Male
|
95 (38)
|
|
Average age(yrs.)range
|
36(31-49)
|
|
Average BMI(kg/m2)
|
47.2(45.1-49.3)
|
Included patients underwent bariatric surgery if their body mass
index was more than 35 kg/m2 and they did not have co-morbidities (as per
IFSO-EC and EASO guidelines) (4). Subjects with perioperative
hazards and previous bariatric techniques were ruled out from participating in
this study.
Subjects were managed in terms of multimodal
postoperative improved recovery regimen (1,2,5). Early feeding was
encouraged after surgery. Balanced intravenous fluid (IV) (less than 2.5 L on
the day of operation) was encouraged in cases of vomiting, inadequate oral
feeding (less than 0.5L, 6 hrs. postoperatively) or inadequate diuresis (less
than 0.5 L of urine, 6 hrs. postoperatively). Early feeding.
with light hospital diet on the first day after surgery and full
hospital diet the second day after surgery were encouraged.
On admission, all subjects were briefed on the proposed HD of 3
days. Discharge criteria included oral diet tolerance (solid food and drinking
minimum of 1.5 L), no requirement for IV, and balanced diuresis. Postoperative
oral feeding as a potential risk factor of lengthened HD and readmission was
determined in subjects with no hazards. HD included from the day of admission
to the day of discharge. Subjects were divided into two groups: group I, with
hospital admission less or equal to the proposed HD (less than or equal to 3
days); and group II, with subjects with a lengthened HD ( 3 days or more).
Readmission was monitored for those readmitted after discharge during 30 days
following surgery.
Student’s t or Mann-Whitney’s test were used for quantitative
parameters, and χ2 was used for qualitative parameters. Univariate and
multivariate logistic regression were used to evaluate effect induced
parameters on lengthened hospital admission and readmissions. A P value of less
than 0.05 was considered statistically significant.
Table
II Study group analysis.
|
Bariatric
surgery
|
LSG
|
LRYGB
|
|
|
No.
|
150
|
100
|
|
|
Hospitalization
more than 3 days
|
40
|
35
|
0.01
|
|
Hospitalization
less than 3 days
|
110
|
65
|
|
Readmission
(N)
|
6
|
9
|
0.000
|
Results
The average HD was 3 days,
ranging from 2-4. Average HD of more than 3 days was recorded for 75/250 (30%)
subjects, of whom 40/150 had received LSG (26.7%), and 35/100 had received
LRYGB (35%) (P < 0.005). Factors lengthening HD were investigated in
univariate logistic regression. BMI more than 49.30 kg/m2, LRYGB,
increased volume of infused fluids during and after surgery, low oral fluid
intake, and diuresis after surgery were highly associated with the risk of
lengthened HD, These factors were investigated in multivariate logistic
regression (Table III).
Reduced oral feeding and increased IV infused on the day of surgery
were found to lengthen HD. The readmission incidence was 6% (15/250
readmissions), of whom 6/150 subjects had received LSG (4%), and 9/100 had
received LRYGB (9%) (P > 0.05) (Table IV). Univariate logistic regression
showed an impact of volume infused fluids during and after surgery, oral
feeding after surgery and lengthened HD (more than 3 days) on the risk of
hospital readmission (Table III). Multivariate logistic regression
demonstrated an effect of reduced oral feeding on the day of surgery on the
risk of hospital readmission (Table III).
Table
III: Univariate and multivariate logistic
regression of hospitalization duration.
|
Factor
|
Beta
|
P
(Univariate)
|
P
(multivariate)
|
|
Subject
|
Gender
|
0.016
|
0.889
|
0.350
|
|
Age
|
-0.08
|
0.570
|
|
BMI (more or less than 49.30 kg/m2)
|
-0.140
|
0.002
|
|
Bariatric
surgery
|
Type
|
0.135
|
0.001
|
0.278
|
|
Surgical duration (more or less than
165 min.)
|
0.228
|
0.002
|
0.115
|
|
Fluid volume infused during surgery
|
-0.140
|
0.000
|
0.08
|
|
Oral feeding on day of operation
|
0.500
|
0.025
|
0.003
|
|
Oral feeding on day 1
|
|
<0.005
|
|
Oral feeding on day 2
|
|
<0.005
|
|
Oral feeding on day 3
|
|
>0.05
|
|
Nausea and vomiting
|
|
<0.05
|
Table
IV: Readmissions analysis.
|
|
LSG
|
LRYGB
|
|
Operation
site hernia
|
1 (0.7%)
|
2 (2%)
|
|
Cholecystitis
|
1 (0.7%)
|
2 (2%)
|
|
Gastroesophageal
reflux disease
|
2 (1.3%)
|
|
|
Fever
of undetermined origin
|
1 (0.7%)
|
|
Chronic
diarrhea
|
1 (0.7%)
|
|
Suspected
ileus
|
|
|
Perforated
gastric ulcer
|
|
1 (1%)
|
|
GI
bleeding
|
2 (2%)
|
|
Perianal
abscess
|
1 (1%)
|
|
Lower
abdomen pain
|
1 (1%)
|
|
Overall
|
6/150 (4%)
|
9/100 (9%)
|
Table V: Univariate and multivariate logistic
regression of factors of hospital readmission.
|
Factor
|
Beta
|
P
(Univariate)
|
P
(multivariate)
|
|
Subject
|
Gender
|
-0.002
|
0.901
|
0.750
|
|
Age
(more or less than 47 yrs.)
|
-0.087
|
0.758
|
|
BMI
(more or less than 49.30 kg/m2)
|
-0.105
|
0.582
|
|
Bariatric
surgery
|
Type
|
0.111
|
0.113
|
|
|
Surgical
duration (more or less than 165 min.)
|
-0.432
|
0.000
|
|
Fluid
volume infused during surgery
|
0.331
|
0.02
|
|
After
surgery
|
Oral
feeding on day of operation
|
0.500
|
0.000
|
0.001
|
|
Oral
feeding on day 1
|
0.015
|
0.930
|
0.289
|
|
Oral
feeding on day 2
|
0.012
|
0.959
|
0.966
|
|
Oral
feeding on day 3
|
0.014
|
0.943
|
0.970
|
|
Nausea
and vomiting
|
0.101
|
0.200
|
0.350
|
|
Lengthened
hospitalization duration (more or less than 3 days)
|
0.09
|
0.357
|
0.555
|
Discussion
The goal of this study (as
well as the healthcare services provided to participants as postoperative
patients) was to recognize risk factors of lengthened HD. We tried to discharge
the subjects as soon as they gained complete functional recovery. With every
100 ml of oral feeding on day of operation, the risk for lengthened HD was
reduced by 23% (6). Increased oral feeding on day of operation was a
protective factor reducing risk of readmission 0.54 times (6). The
period of admission differs between bariatric institutes because of
discrepancies in perioperative and discharge criteria. A study of LRYGB
reported that the average period of hospitalization was 2 days, whereas 26% of
subjects needed or more(7). 48% of bariatric subjects were
discharged by day 1 after surgery, 85% by day 2, and 96% by day 3 (8).
HD of more than 3 days is generally considered lengthened (as in this study) (9-11).
Bariatric techniques are performed as a fast-track
surgery with more therapeutic actions during one-day hospital admission (12).
Hospital admission was scheduled for 3 days, and subjects followed the unit
criteria for discharge (comparison between various bariatric units is difficult
due to qualitative discrepancies). The total readmission incidence following
bariatric surgery was 5.7% (9), and total 30-day readmission incidence
following LSG or LRYGB was 5.1% (13). Readmission incidences following these
two techniques vary widely, between 1.87 and 14.16% (8,14,15). Most previous
studies reported more frequent readmissions following LRYGB in comparison to
LSG (13-16), but other data suggest more frequent readmissions following LSG
(9). In our investigation, the total readmission incidence was approximately
6%. Factors correlated with lengthened period of hospitalization included age,
increased BMI, male gender, comorbidities, and surgical duration (8,17).
None of the demographic factors were significantly associated with HD risk. A
previous study found that demographic factors were not associated with longer
admission following gastric by-pass(7). In this investigation, LRYGB
was not significantly associated with lengthened HD compared to LSG, affirming
previous research (18). Many
studies found that longer surgical duration was correlated with
increased risk of lengthened HD (7-8,10), but the multivariate
analysis in our investigation showed that it actually reduced this risk. The
volume of IV infused during laparoscopic bariatric surgery significantly
affects HD, with lower volumes being correlated with HD (6).
Subjects in our investigation who needed increased IV during surgery were more
liable to longer admission, but not in the multivariates study. In this
investigation, reduced oral feeding after surgery on the day of operation was
highly correlated with lengthened HD.
There are important associations between some patient-related
factors and increased risk of readmission (11,13,16,17). Previous
studies have found that managing subjects with improved recovery is linked to
moderately reduced risk of postoperative readmissions (2,5,19,21),
and that BMI is not an anticipator of readmission (16,20), while
readmissions are higher following LRYGB compared to LSG (13).
Subjects who had LRYGB experienced 60% more risk of readmission in the 30-day
after surgery than those who had LSG, while surgical duration increased risk of
readmission (16). In this investigation, multivariate study
demonstrated that the independent impact of oral feeding on the day of operation
is correlated with readmission risk. One of the most frequent causes of
readmission following bariatric surgery is nausea/vomiting (12.95%) (15),
and the reduced volume of oral feeding is a risk factor of readmission.
In subjects with HD of more than 3 days, the risk of readmission
was more than in one-day admission (8,9). Longer HD was an
anticipator of readmission (6). In this investigation, subjects with
lengthened HD (more than 3 days) were more likely to be readmitted than with
subjects with HD of less than 3 days only in the univariate study. The factors
increasing the risk of readmission are correlated with first 1-2 days following
the surgery.
Conclusion
Reduced oral feeding
and requirement of high intravenous fluid infusion on the day of operation are
potential risk factors of lengthened HD. More oral feeding on the day of
operation is correlated with less risk for readmission.
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