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Archive May 2014 XV, No. 5

Sleeve Gastrectomy's Outpatient Potential

The weight-loss surgery is safe and efficient when performed in ASCs.

Peter Billing, MD


laparoscopic sleeve gastrectomy 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.

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