Evaluation of Postoperative Care Protocol for Roux-en-Y Gastric Bypass Patients with Same-Day Discharge

Abstract

Introduction
Same-day discharge (SDD) after bariatric surgery is increasingly being performed and is safe with careful patient selection. However, detecting early complications during the first postoperative days can be challenging. We developed a postoperative care protocol for these patients and aimed to evaluate its effectiveness in detecting complications and monitoring patient recovery.

Methods
A single-center retrospective observational study was conducted with patients with who underwent Roux-en-Y Gastric Bypass (RYGB) with successful SDD. The study evaluated the effectiveness of the safety net that included simple remote monitoring with a pulsoximeter and thermometer, a phone consultation on postoperative day (POD) 1, and a physical consultation on POD 2–4. Furthermore, an analysis was performed on various factors including pain scores, painkiller usage, and incidences of nausea and vomiting on POD 1.

Results
In this study, 373 consecutive patients were included, of whom 19 (5.1%) were readmitted until POD 4. Among these, 12 patients (3.2%) reached out to the hospital themselves, while 7 (1.9%) were readmitted after phone or physical consultations. Ten of the readmitted patients had tachycardia. On POD 1, the mean numeric rating scale was 4 ± 2, and 96.6% of the patients used acetaminophen, 35.5% used naproxen, and 9.7% used oxynorm. Of the patients, 13.9% experienced nausea and 6.7% reported vomiting.

Conclusion
A postoperative care protocol for SDD after RYGB, comprising simple remote monitoring along with a phone consultation on POD 1 and a physical checkup on POD 2–4, was effective in monitoring patient recovery and detecting all early complications.

Graphical Abstract

Full text

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Obesity Surgery
https://doi.org/10.1007/s11695-023-06697-x
ORIGINAL CONTRIBUTIONS
Evaluation ofPostoperative Care Protocol forRoux‑en‑Y Gastric Bypass
Patients withSame‑Day Discharge
SuzanneC.Kleipool1 · PimW.J.vanRutte1· LaurensD.EeftinckSchattenkerk1· H.JaapBonjer2·
HendrikA.Marsman1· SteveM.M.deCastro1· RubenN.vanVeen1
Received: 13 April 2023 / Revised: 8 June 2023 / Accepted: 16 June 2023
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2023
Abstract
Introduction Same-day discharge (SDD) after bariatric surgery is increasingly being performed and is safe with careful
patient selection. However, detecting early complications during the first postoperative days can be challenging. We devel-
oped a postoperative care protocol for these patients and aimed to evaluate its effectiveness in detecting complications and
monitoring patient recovery.
Methods A single-center retrospective observational study was conducted with patients with who underwent Roux-en-Y
Gastric Bypass (RYGB) with successful SDD. The study evaluated the effectiveness of the safety net that included simple
remote monitoring with a pulsoximeter and thermometer, a phone consultation on postoperative day (POD) 1, and a physi-
cal consultation on POD 2–4. Furthermore, an analysis was performed on various factors including pain scores, painkiller
usage, and incidences of nausea and vomiting on POD 1.
Results In this study, 373 consecutive patients were included, of whom 19 (5.1%) were readmitted until POD 4. Among
these, 12 patients (3.2%) reached out to the hospital themselves, while 7 (1.9%) were readmitted after phone or physical
consultations. Ten of the readmitted patients had tachycardia. On POD 1, the mean numeric rating scale was 4 ± 2, and 96.6%
of the patients used acetaminophen, 35.5% used naproxen, and 9.7% used oxynorm. Of the patients, 13.9% experienced
nausea and 6.7% reported vomiting.
Conclusion A postoperative care protocol for SDD after RYGB, comprising simple remote monitoring along with a phone
consultation on POD 1 and a physical checkup on POD 2–4, was effective in monitoring patient recovery and detecting all
early complications.
Keywords Roux-en-Y gastric bypass· Same-day discharge· Postoperative care· Safety net· Monitoring
Introduction
The prevalence of obesity has surpassed one billion individ-
uals worldwide and continues to rise [1]. Bariatric and meta-
bolic surgery has been demonstrated to be effective and safe
as a treatment for obesity, leading to an increase in the num-
ber of bariatric procedures performed [2, 3]. The COVID-19
pandemic and local staff shortages have increased the burden
on hospital capacity globally, necessitating the development
of innovative care pathways to address this high demand.
The development of enhanced recovery after bariatric
surgery (ERABS) has led to guidelines regarding optimal
perioperative care in bariatric and metabolic surgery. This
includes a multimodal approach for analgesia and postop-
erative nausea and vomiting (PONV) and early mobiliza-
tion after surgery [4]. One key benefit of implementing
Key Points
The safety net includes remote monitoring, a phone and physical
consultation.
Early complications following SDD are effectively detected using
the safety net.
We reported low use of NSAIDs and opioids among SDD patients.
The extent of the role of remote monitoring requires further
investigation.
* Suzanne C. Kleipool
s.c.kleipool@olvg.nl
1 Department ofSurgery, OLVG Hospital, Amsterdam,
TheNetherlands
2 Department ofSurgery, Amsterdam UMC, Amsterdam,
TheNetherlands

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ERABS protocols in bariatric and metabolic surgery is that
it has been shown to effectively shorten the length of hos-
pital stay, without increasing morbidity or compromising
patient safety [5–8]. Expanding on the success of ERABS,
a new and promising healthcare pathway has emerged that
enables same-day discharge (SDD) following laparoscopic
Roux-en-Y Gastric Bypass (RYGB). Same-day discharge
involves discharging patients on the same day as their
surgery, without requiring overnight hospitalization. An
increasing amount of published data suggests that bariatric
surgery with same-day discharge is a safe option, as long
as the patients are carefully selected [9–18].
A key component of the SDD care pathway is the estab-
lishment of a safety net for patients after discharge, includ-
ing monitoring for early detection of complications and hos-
pital accessibility. Currently, there is a lack of knowledge
and experience on the best approach for remote monitoring
following bariatric surgery, and this uncertainty may cause
hesitation among hospitals to adopt same-day discharge.
While numerous modalities are available and ongoing inno-
vations are being developed, there is no consensus on the
optimal method for remote monitoring [12, 13, 19–22].
Same-day discharge after laparoscopic RYGB was imple-
mented in 2020 in our hospital, and over 800 patients have
been treated since implementation. We hypothesize that the
postoperative care protocol that we have implemented, which
includes a simple approach to remote monitoring in combina-
tion with two consultations, is adequate and can enhance the
safety of same-day discharge following laparoscopic RYGB.
Methods
A retrospective observational study was performed in a
high-volume bariatric center in the Netherlands. All patients
undergoing laparoscopic Roux-en-Y gastric bypass with suc-
cessful same-day discharge and a registered phone consulta-
tion on POD 1 were included. For this study, the local Medi-
cal Ethics Committee waived the need to obtain informed
consent.
Same‑day Discharge Protocol
The study population consisted of patients with same-day
discharge after primary laparoscopic RYGB. Patients had to
meet the criteria for bariatric surgery according to the Inter-
national Federation for the surgery of obesity and metabolic
disorders (IFSO) [23]. The protocol for SDD has been previ-
ously published [17]. To summarize, strict selection criteria
had to be met in order to be discharged on the same day of
the surgery, as presented in Table1. These criteria aimed to
exclude patients at high risk of complications, such as those
with cardiovascular diseases, those taking anticoagulants,
or those with a body mass index (BMI) greater than 50 kg/
m2. In addition, it was required that an informal caregiver be
present during the first 24 h after surgery, and the maximum
travel time to the hospital was set at 45 min. The SDD in our
study was based on the ERABS concept, which emphasizes
early mobilization, optimizing pain management by using
multimodal analgesia, and standardized oral medication
Table 1 Selection and discharge criteria
a Clinically important PONV is defined as: a continuous feeling of nausea with vomiting more than once [24]
b Divergent vital signs defined as: tachycardia > 100 bpm, temperature > 38 °C, oxygen saturation < 95% [25]
BMI, body mass index; CPAP, continuous positive airway pressure; NRS, numeric rating scale; OSA, obstructive sleep apnea; PONV, postopera-
tive nausea and vomiting; SDD, same-day discharge
Preoperative selection criteria for intended SDD
- BMI 35–50 kg/m2
- Age 18–65 years
- No cardiovascular disease (i.e., history of myocardial infarction, heart rhythm disorder), poorly controlled diabetes mellitus or use of insu-
lin, and coagulation abnormalities or use of anticoagulants
- No severe pulmonary disease or OSA with AHI > 15 without the use of CPAP
- No history of major abdominal surgery, including laparotomy
- Approval of intended SDD by both surgeon and anesthesiologist
- Ability to understand and use the remote medical devices
- Residing within a maximum of 45-min travel time to the hospital
- An informal caregiver is available for the first 24 h following hospital discharge
Postoperative criteria for approval of SDD
- No abnormalities or complications during the surgical procedure
- No anesthetic abnormalities or complications
- No severe pain (NRS > 4 with analgesics) or clinically important PONVa
- Minimum oral intake of 200 ml of fluids postoperatively
- Normal vital signs after 6 h of observationb
- Maximum decrease in hemoglobin-level postoperative of 1.0 mmol/L
- Approval of bariatric surgeon and patient for discharge

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postoperatively [4, 5, 26]. Upon discharge, patients were pre-
scribed acetaminophen 1000 mg four times daily, naproxen
500 mg twice daily (maximum of 3 days), and if necessary,
rescue medication oxynorm 5 mg with a maximum of four
times daily (maximum of 3 days). To prevent postoperative
nausea and vomiting (PONV), all patients received antiemet-
ics (dexamethasone and granisetron) during and after sur-
gery. The patients were discharged only after ensuring the
absence of complications, including stable hemoglobin lev-
els and normal vital signs, and obtaining agreement from
both the surgeon and patient regarding the discharge plan.
Postoperative Care Protocol
Upon discharge, patients and their informal caregiver (e.g.,
partner, family member, friend) were provided with an infor-
mation sheet detailing symptoms that require emergency
consultation and the hospital’s 24-h emergency telephone
numbers. Additionally, all patients were given a Nonin Onyx
Vantage 9590 pulse oximeter and a Covidien Genius 2 tym-
panic thermometer. Patients were instructed to record their
pain, heart rate, oxygen saturation, and body temperature three
times daily on the information sheet to detect early complica-
tions for 48 h. Patients were advised to contact the hospital for
severe pain (numeric rating scale, NRS > 4), hematemesis,
rectal blood loss, divergent vital signs, or any further con-
cerns. Divergent vital signs were defined as tachycardia > 100
bpm, temperature > 38 °C, or oxygen saturation < 95% [25].
On the first day after surgery, the operating surgeon called
each patient using a standardized questionnaire to assess
pain score (NRS), painkiller use, nausea/vomiting, mobili-
zation, and vital signs. During the phone consultation, any
patient questions were addressed, mobilization was encour-
aged, and complications signs were reiterated. The standard-
ized questionnaire was recorded in the patient’s electronic
file. Patients whose phone consultation was not registered
were excluded from this study. On POD 2 to 4, depending
on which day of the week the surgery was performed, a spe-
cialized bariatric nurse conducted a physical consultation
at the outpatient clinic using a standardized consult format.
Outcomes
The outcomes of this study included the presence of early
complications, classified according to the Clavien-Dindo
classification system [27], as well as the part of the post-
operative care protocol in which they were detected. This
analysis included suspected complications identified during
consultations and the number of patients who contacted the
hospital before their scheduled phone or physical consulta-
tion. In addition, the study evaluated pain scores, analgesic
use, the incidence of nausea and vomiting, vital signs, and
degree of mobilization.
Statistical Analysis
All data were analyzed using SPSS version 22.0 for Windows
(SPSS Inc., Chicago, IL, USA). Patient characteristics were pre-
sented as mean ± standard deviation (SD), median (interquartile
range), and categorical data as counts and percentages. The nor-
mality of the variables was assessed through visual inspection
of histograms and Q-Q plots. Missing data were not imputed.
Results
There were 373 consecutive patients included in this study,
who underwent surgery between November 2021 and
December 2022. The mean age was 38 ± 11 years, and the
mean preoperative BMI was 41 ± 4 kg/m2. The majority
of participants were female (83.4%). Table2 presents the
baseline characteristics of the participants.
During the follow-up period (up to and including the physi-
cal consultation on postoperative days 2 to 4), a total of 19
patients (5.1%) were readmitted to the hospital due to a com-
plication, either after initiating contact themselves or after the
scheduled consultations. This sequence of events is presented
in Fig.1. Before the phone consultation, nine patients con-
tacted the hospital, out of whom five were readmitted (1.3%).
Four of them had hematemesis, while the fifth patient had an
intra-abdominal hematoma. All five patients were managed
conservatively and discharged within a few days (Clavien-
Dindo grade 1 or 2). The other four patients who contacted
Table 2 Baseline characteristics
AHI, apnea-hypopnea index; ASA, American Society of Anesthesiolo-
gists; BMI, body mass index; CPAP, continuous positive airway pres-
sure; IQR, interquartile range; NIDDM, non-insulin-dependent diabe-
tes mellitus; SD, standard deviation
Age at surgery, years (mean, SD) 38 ± 11
Female (n, %) 311 (83.4)
Weight, kg (mean, SD) 118 ± 16
BMI, kg/m2 (mean, SD) 41 ± 4
ASA classification (n, %)
2 102 (27.3)
3 271 (72.7)
AHI (median, IQR) 6.7 (2.8–15.9)
Use of CPAP (n, %) 107 (28.7)
Associated medical problems (n, %)
Hypertension
NIDDM
43 (11.5)
18 (4.8)
Dyslipidemia 19 (5.1)
Operation time, minutes (mean, SD) 44 ± 11
Duration of hospital admission, hh:mm (mean, SD) 10:15 ± 00:55
Perioperative complications (n, %) 0
Mortality (n, %) 0

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the hospital prior to the consultation were examined in the
emergency department (ED) and found to have no compli-
cations. They were not readmitted. Consequently, the phone
consultation was canceled for these nine individuals. Out of
the remaining study population consisting of 364 patients, the
vast majority, 353 patients (94.6%), showed no signs of com-
plications during the phone consultation. Three patients did
not initially respond, but upon follow-up consultation on POD
2 to 4, they were also found to have no complications. Subse-
quent to the phone consultation, seven patients were referred
to the ED for a physical examination. Three of them were
readmitted (0.8%). The first had hematemesis and was treated
conservatively and discharged after one night of hospitaliza-
tion (Clavien-Dindo grade 1). The second patient had an early
anastomotic leakage and was reoperated (Clavien-Dindo grade
3b). The third patient had intra-abdominal bleeding, which was
managed with surgical diathermy (Clavien-Dindo grade 3b).
After the phone consultation on POD 1, an additional seven
patients (1.9%) independently contacted the hospital before
their scheduled physical consultation on POD 2 to 4. These
patients were all readmitted. Four patients had rectal blood loss
and needed pharmacological treatment, such as tranaxamic
acid or blood transfusion (Clavien-Dindo grade 2). The other
three patients had anastomotic leakage and required radiologi-
cal or surgical intervention (Clavien-Dindo grade 3a, 3b, and
4a). All other (not currently admitted) patients in the cohort
received their physical follow-up consultation on POD 2 to
4. Four patients (1.1%) were identified with suspected com-
plications during the checkup and required redirection to the
ED, where they were readmitted for conservative treatment
(Clavien-Dindo grade 1–2).
On the morning of POD 1, the mean temperature was
36.9 ± 0.6 °C, the mean heart rate was 78 ± 13 beats per
minute, and the mean oxygen saturation was 97 ± 1%. Ten of
the earlier mentioned patients were identified with suspected
complications due to divergent vital signs, all presenting
with tachycardia. One patient was referred to the emergency
department before the phone consultation, three during it,
and three before the physical consultation. The remaining
three presented tachycardia during the physical consultation.
There were no patients with suspected complications related
to temperature or oxygen saturation.
After analyzing the other details of the phone consulta-
tion as presented in Table3, the average pain score is found
to be NRS 4 ± 2. Nearly all patients (96.6%) reported using
acetaminophen as their primary painkiller. Additionally, 114
patients (35.5%) reported using naproxen as a secondary
pain medication, while 31 patients (9.7%) required the use of
oxynorm. Out of the 44 patients (13.9%) who reported nau-
sea during the consultation, 25 patients (7.9%) also reported
vomiting. Most cases of vomiting involved small amounts
of mucus, while two patients were referred to the ED due
to vomiting fresh blood. Regarding patient mobilization, at
the time of the phone consultation, 45.7% of patients had
already walked outside their homes.
Discussion
Our postoperative care protocol consists of several compo-
nents, including comprehensive patient education, the pres-
ence of an informal caregiver, a maximum travel time of
Fig. 1 Flowchart of postoperative events. ED, emergency department; POD, postoperative day

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45 min to the hospital, 24/7 hospital accessibility, remote
monitoring with a simple pulse oximeter and thermometer,
a phone consultation on postoperative day 1 by the surgeon,
and a physical consultation on postoperative days 2–4 with
a specialized bariatric nurse. The objective of this study was
to evaluate the efficacy of this safety net, which captured all
19 patients (5.1%) who were readmitted in the first days after
surgery. Our data indicates that the strength of the safety
net lies in the combination of all these elements. Initially,
we believed that remote monitoring was the most critical
component when implementing same-day discharge after
RYGB. However, our data reveals that only 10 out of the 19
readmitted patients had divergent vital signs, which ques-
tions the extent of the role of remote monitoring. In addition,
we did not observe any divergent signs in oxygen saturation
or temperature. Nevertheless, due to the small sample size,
it is challenging to draw definitive conclusions on the role
of remote monitoring.
Out of the 19 readmitted patients, 12 contacted the hos-
pital on their initiative. This suggests that patients were
well-informed and had a low threshold for seeking medical
attention. The present data do not provide sufficient evidence
to determine if patients with signs of complications waited
for the surgeon’s phone call or if they would have contacted
the hospital earlier if they were not expecting a call. It is
plausible that some patients may not have recognized the
symptoms, rendering the phone consultation a crucial com-
ponent for the early detection of complications. However,
the findings from this study suggest that the information
provided to patients was sufficient, as evidenced by their
ability to contact the hospital when necessary. This is in line
with the results of the study by Sada etal., which suggest
that patients are often the ones to detect complications as
they recognize abnormal recovery patterns and seek medi-
cal attention [28]. Furthermore, the study by Kummerow
Broman etal. supports this finding, as they reported no
increased rate of missed complications when telemedicine
visits were utilized [29]. Moreover, the study by Nijland
etal. did not find that home monitoring led to earlier detec-
tion of postoperative complications [20]. It is currently a
prevailing idea that responsibility in healthcare is increas-
ingly placed on patients. The present study suggests that
patients are capable of taking on this responsibility, provided
that they are adequately informed. In addition, it could be
considered that in the future, it may not be necessary for
the surgeon to make phone calls to patients. For example, a
surgical resident or nurse practitioner could perform a phone
consultation and, in case of any doubt or signs of complica-
tions, seek the advice of the surgeon. This could potentially
further increase the efficiency and cost-effectiveness of the
SDD pathway.
This study’s remarkable and encouraging finding was
the infrequent utilization of non-steroidal anti-inflamma-
tory drugs (NSAIDs) and opioids. Specifically, on the first
day following the surgery, only one-third of the patients
used naproxen, and a mere 9.7% of the patients made use
of oxynorm. Prolonged usage of NSAIDs may impede
anastomotic healing [30]; therefore, their limited usage
in this study is promising. Additionally, there is a grow-
ing trend toward minimizing the use of opioids in post-
operative pain management [8, 31]. A multimodal anal-
gesia approach has been shown to effectively reduce pain
scores without increasing the incidence of complications
[32–34]. For instance, the combination of acetaminophen
and NSAIDs is effective in postoperative pain [35]. In our
SDD protocol, we implemented strategies to reduce opioid
consumption, including perioperative wound infiltration
with bupivacaine, low-dose perioperative opioid admin-
istration, and avoidance of postoperative opioids. We also
managed patient expectations by providing preoperative
education on the expected pain level and the benefits of
Table 3 Outcomes
ED, emergency department; NRS, numeric rating scale; SD, standard
deviation
Consultation outcomes
Phone consultation (n, %) 364 (97.6)
No complaints 353 (94.6)
Suspected complication (referral to ED) 7 (1.9)
No answer 3 (0.8)
Physical consultation (n, %) 364 (97.6)
No complaints 360 (96.5)
Suspected complication (referral to ED) 4 (1.1)
No show 0
Phone consultation analysis
NRS score (mean, SD) 4 ± 2
Use of painkillers (n, %) 366 (98.1)
Acetaminophen 311 (96.6)
Naproxen 114 (35.5)
Oxynorm 31 (9.7)
Nauseous (n, %) 44 (13.9)
Vomiting (n, %) 25 (6.7)
Mucus
Fresh blood
11 (2.9)
2 (0.5)
Old blood 2 (0.5)
Oral intake 3 (0.8)
Other/not specified 7 (1.9)
Vital signs (mean, SD)
Temperature 36.9 ± 0.6
Heart rate 78 ± 13
Oxygen saturation 97 ± 1
Mobilization (n, %)
Indoor
Outdoor
165 (54.3)
139 (45.7)

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early mobilization in reducing postoperative pain associ-
ated with surgical gas. We believe this education is crucial,
as this knowledge can motivate them to actively participate
in their recovery process.
The implementation of enhanced recovery after bariat-
ric surgery is crucial before initiating same-day discharge
following RYGB. Before implementation in our hospital,
patients were already discharged in the early morning of
POD 1, resulting in a hospital stay of less than 24 h. Dur-
ing morning rounds, patients’ well-being and vital signs
were assessed. In our current practice with same-day dis-
charge, the process is quite similar, except that we conduct
the assessment and monitoring of patients’ well-being and
vital signs via phone consultation. Consequently, the tran-
sition to SDD was relatively straightforward for us. How-
ever, not all hospitals may be equipped for this change,
and successful implementation of ERABS is a critical
prerequisite.
The primary limitation of this study is the small sam-
ple size, which is a common challenge when studying the
safety of bariatric surgery, due to the low complication
rates. Therefore, while our safety net approach incor-
porating multiple elements at different time points was
effective in capturing all readmitted patients, our sample
size is too small to draw definitive conclusions about the
individual elements of the postoperative care protocol.
Another important limitation of this study is the retrospec-
tive design and the use of non-validated questionnaires.
A prospective and multicenter study with validated ques-
tionnaires would provide more robust data. Furthermore,
it should be noted that the objective of this study was not
to compare simple remote monitoring to continuous home
monitoring but rather to evaluate the effectiveness of our
same-day discharge protocol. Further studies are needed
to determine the optimal remote monitoring modality,
where patients using various types of remote monitoring
are compared, as there is currently no consensus on this
matter [12, 13, 19–22]. Finally, patient satisfaction was
not assessed in this study. This could include patients’
experience with measuring their vital signs, the perception
of the phone consultation, and how patients experienced
the burden of responsibility for monitoring themselves for
potential complications.
Conclusion
This study demonstrated that implementing a safety net,
comprising simple remote monitoring along with a phone
consultation on POD 1 and a physical checkup on POD
2 to 4, was effective in monitoring patient recovery and
detecting early complications for same-day discharge after
RYGB. The safety net successfully captured all patients
with complications. The findings of this study provide
insights that could inform healthcare providers’ decision-
making regarding same-day discharge after bariatric sur-
gery as a safe alternative to overnight hospitalization.
Data Availability The data supporting the findings of this study are
available upon request from the corresponding author.
Declarations
Ethical Approval and Informed Consent The study has been performed
in accordance with the Declaration of Helsinki, originally adopted in
1964 and its later amendments or comparable ethical standards. The
local Medical Ethics Committee waived the need to obtain informed
consent for this study.
Conflict of Interest The authors declare no competing interests.
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