Improving Outcome of Bariatric Surgery: Best Practices in an Accredited Surgical Center

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1 DOI /s y ORIGINAL CONTRIBUTIONS Improving Outcome of Bariatric Surgery: Best Practices in an Accredited Surgical Center Maher El Chaar & Leonardo Claros & George C Ezeji & Maureen Miletics & Jill Stoltzfus # Springer Science+Business Media New York 2014 Abstract The number of laparoscopic bariatric procedures being performed in the USA has increased dramatically in the past decade. Because of limited health-care resources, hospital administrators and insurance carriers are placing emphasis on length of stay and patient outcomes. The goal of this study was to evaluate the feasibility and safety of a clinical pathway in managing patients undergoing bariatric surgery in a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) accredited center. The setting was a university hospital in USA. A retrospective analysis of data collected prospectively on patients undergoing bariatric surgery at St Luke s University was performed. Patients included underwent either a laparoscopic Roux-en-Y gastric Bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG). Patients were subjected to a clinical protocol and discharged when discharge criteria were met. The primary outcomes were length of stay, 30 day readmission, complication, and reoperation rates. A cost analysis of the savings accrued was also performed. Two hundred twenty-nine patients were included in our analysis (80.4 % females and 19.6 % males). Seventy-one M. El Chaar (*): L. Claros : G. C. Ezeji : M. Miletics Department of Surgery, Division of Bariatric and Minimally Invasive Surgery, The Medical School of Temple University/St Luke s University Hospital and Health Network, 1736 Hamilton Boulevard, Allentown, PA 18104, USA Maher.ElChaar@sluhn.org L. Claros Leonardo.Claros@sluhn.org G. C. Ezeji ezejigeorge@yahoo.com M. Miletics Maureen.Miletics@sluhn.org J. Stoltzfus Research Institute, St Luke s University Hospital and Health Network, 801 Ostrum Street, Bethlehem, PA 18015, USA Jill.Stoltzfus@sluhn.org patients (31 %) underwent LSG, and 158 patients (69 %) underwent LRYGB. The average length of stay was h (range h). The 30-day readmission rate was 3.0 % (7/229 patients). The 30 day complication rate (including intervention, reintubation, and reoperation) was 2.6 % (6/229). The 30 day mortality rate was 0. The average prospective cost savings were $2,016 and $1,209 per LRYGB and LSG patient, respectively. Our bariatric surgery clinical protocol is feasible and safe with substantial prospective cost savings at St Luke s University and Health Network. Patients subjected to our protocol have low readmission and complication rates. Further studies are needed to fully elucidate the benefit of this innovative new protocol in bariatric surgery. Keywords Bariatric surgery. Laparoscopic sleeve gastrectomy. Laparoscopic gastric bypass. Obesity surgery. Clinical protocol Introduction The number of bariatric surgeries performed in the USA has increased significantly in the recent years. Traditionally, bariatric patients are hospitalized for 2 3 days following surgery [1]. In an era of increased health-care costs and limited resources, shorter hospital stays, patient safety, and high quality outcomes are of paramount importance. The concept of fasttrack surgery has been recently implemented and adopted in colorectal surgery, resulting in shorter length of stay, improved patient outcomes, and decreased health-care costs [2 5]. Given the limited health-care resources and the markedly improved outcomes with the introduction of laparoscopy to the field of bariatric surgery and in order to achieve similar results to the fast-track colorectal surgery and to improve patient satisfaction, we recently adopted a new clinical protocol at St Luke s University, with the study objective being to

2 investigate the safety and efficacy of that protocol for bariatric patients in a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) accredited center. The protocol is a compilation of clinical practices in managing bariatric patients. In addition, we performed a cost analysis of that protocol to see whether the implementation of such a protocol can result in cost savings to hospitals. Our intention was to provide a clinical guide to bariatric surgeons in delivering optimal care to their patients in the setting of an MBSAQIP accredited center. Methods We conducted a retrospective analysis of data collected prospectively on consecutive patient undergoing non-revisional bariatric surgery in our institution between August 2010 and May 2011 after obtaining the approval of our institutional review board (IRB). Patients underwent either a laparoscopic Roux-en-Y gastric bypass (LRYGB) or a laparoscopic sleeve gastrectomy (LSG) and were managed following a similar clinical pathway. Adjustable gastric banding (AGB) patients were excluded from the analysis. All surgeries were performed by MC and LC, both fellowship trained bariatric surgeons. All patients underwent the same preoperative workup and followed a similar postoperative protocol. Inclusion and exclusion criteria are listed in Table 1. All patients who met the inclusion criteria between August 2010 and May 2011 and underwent primary bariatric surgery were included in our analysis and managed similarly. Revision patients were not included in our analysis. Preoperative Workup Patients completed a 3 day food log and questionnaire describing diet history and behavioral information, after which they met with the registered dietitian and filled out an evaluation questionnaire. Patients were advised to lose 5 10 % of their body weight prior to surgery with weight loss encouraged through dietary changes and increased activity. Patients who were unable to lose weight in this manner were placed on a ketogenic liquid diet 2 weeks prior to surgery that includes less than 100 g of carbohydrates, g of protein, and 64 oz of non-caloric fluid per day. In addition, patients met with our social workers for a psychological evaluation. In addition, patients underwent a preoperative cardiac evaluation, a sleep consultation to rule out sleep apnea and an upper endoscopy. In addition to the mandatory preoperative weight loss (5 % of the actual weight for patients with BMI<55 and 10 % for patients with a BMI of 55 or higher), our patients underwent a routine preoperative endoscopy and biopsy to rule out the presence of Helicobacter pylori. Patients who tested positive were treated with 2 week course of amoxicillin, clarithromycin, and lansoprazole. A cardiologist who addressed all the medical conditions and adjusted the medications appropriately also evaluated patients preoperatively. Invasive and non-invasive cardiac diagnostic studies were performed preoperatively when indicated. All patients were also referred for a consultation with a pulmonologist/sleep physician in order to screen for sleep apnea. Patients with suspected sleep apnea underwent a sleep study, and when sleep apnea was diagnosed, patients underwent a CPAP titration study preoperatively and treated with the CPAP for at least 2 weeks prior to surgery. Surgical Technique All cases were performed laparoscopically. Patients received perioperative DVT prophylaxis using subcutaneous heparin (5,000 units SQ) and a single dose of antibiotic 30 min prior to the procedure. Patients voided prior to surgery, and no Foley catheters were used intraoperatively. No postoperative Table 1 Inclusion and exclusion criteria Inclusion criteria Exclusion criteria Age 18 Attendance at an informational seminar and support group Clearance for surgery by a registered dietician and certified social worker BMI 35 with at least one comorbid condition (e.g., hypertension, diabetes mellitus, sleep apnea, hypercholesterolemia) or BMI 40 without any comorbid conditions Negative pregnancy test American Society of Anesthesiology score of 1 3 Ability to understand instructions and comply with all study requirements Preoperative percentage of excess weight loss (%EWL) of 5 10 % No contraindication for a LRYGB or LSG based on upper endoscopy findings Preoperative cardiac consultation for risk stratification Evaluation by a sleep medicine specialist to identify risk factors for sleep apnea, with treatment for at least 2 weeks prior to surgery when deemed appropriate Attendance of a team meeting 2 weeks prior to surgery to educate patients and review expectations following surgery (like ambulation and use of incentive spirometry) Revisional surgery Conversion to open procedure Laparoscopic adjustable gastric banding Presence of uncontrolled mental disorder Active eating disorder Underlying endocrine disorder Lack of the required preoperative weight loss Planned pregnancy in the next 18 months Schizophrenia or psychosis Hospital admission to the psychiatric ward in the previous 2 years

3 nasogastric tubes were used. LRYGB and LSG were performed using a standardized five-trocar technique. An upper endoscopy was performed intraoperatively at the end of all bariatric procedures to check for bleeding and leak. No routine surgical drains were used. LRYGB The biliopancreatic limb measured around 60 cm, the Roux limb measured cm. The jejunojejunostomy was created using a linear stapling device. The gastric pouch measured ml. The gastrojejunostomy was created using a 25 mm circular stapler with the anvil introduced transorally. LSG The gastrocolic ligament was transected starting 6 cm from the pylorus. A 36 Fr bougie was used for calibration. All staple lines were reinforced with a reabsorbable buttressing material. No routine reinforcement or imbrication of the staple lines was performed unless there was a clinical concern about the formation of the staple lines. Postoperative Protocol Patients were started on a liquid diet 6 h following surgery. All patients were admitted to a telemetry floor to continuously monitor heart rate and oxygen saturation. Patients with sleep apnea were encouraged to use their positive airway devices when necessary. No routine radiographic studies were performed. On postoperative day 1 (POD1) discharge criteria included tolerance of liquid diet (defined as the ability to tolerate at least 1 oz of liquid diet every 15 min), absence of nausea and vomiting, stable hemoglobin and hematocrit, lack of tachycardia at rest, frequent ambulation without assistance, and oxygen saturation of at least 93 % of oxygen. Patients are not discharged home unless all the above criteria are met. After a careful examination by the surgeon and when all the discharge criteria are met, patients are discharged home to follow-up in the office in 2 weeks. When discharge criteria are not met, patients are kept in the hospital and treated appropriately until all discharge criteria are met. Patients discharged on POD1 are entered in our database as 24 h stay, patients discharged on POD2 are entered as 48 h stay, etc. Patients were seen by a clinical pharmacist, the hospitalist, and the bariatric coordinator prior to discharge to review medications and discharge planning. The clinical pharmacist educates patients on medications and adjusts long-acting medications to short-acting ones. The hospitalist adjusts the dosages of the medications based on the patient clinical condition. The coordinator reviews the discharge planning and the support tools available to the patient postoperatively. On postoperative day 1, every patient receives a phone call to review discharge instruction, to address any question or concern, and to make sure patient is compliant with the discharge instruction. During that phone call, we also review with the patient fluid intake, vitamin supplementation, and the support tools available like emergency services, dietary support, and the availability of a surgeon on call 24 h a day in case of an emergency. Data Analysis Primary study outcomes were length of hospital stay (LOS) and rates of complications, mortality, readmission, and reoperation at 30 days. Complications included all events in the following categories: thromboembolic events, reintervention (like endoscopy or percutaneous drainage), reoperation, reintubation, leak, gastrointestinal bleeding, and cardiovascular and cerebrovascular events. Readmissions included all patients admitted to our hospital including patients who were admitted for observation and stayed less than 24 h. Emergency room visits and admissions to other hospitals were not included in the definition of our readmission rate. Secondary outcomes were operative time, intraoperative blood loss, and preoperative excess weight loss (%EWL). Demographics included age, gender, race, preoperative BMI, and frequency of comorbidities. LRYGB and LSG were analyzed together and separately. Univariate p values were calculated based on separate chi-square or Fisher s exact tests for categorical variables, independent sample t tests for normally distributed continuous variables, and Mann-Whitney tests for skewed continuous variables. To determine the predictive impact of age, gender, race, surgical group, and number of comorbidities on LOS, we also performed standard multivariate linear regression analysis. For all comparisons, p 0.05 denotes a statistical significance with no adjustment for the multiple comparisons. To assess the estimated cost savings associated with our clinical protocol, we compared our mean LOS with mean outcomes reported for aggregated 2011 Bariatric Outcome Longitudinal Database (BOLD) data and used our hospital network s cost per adjusted patient day of $2,016 as the general metric for our comparison, with separate assessments for LRYGB and sleeve gastrectomy (SG). Results We included 229 patients in our analysis; 158 patients underwent a LRYGB (69 %), and 71 underwent a LSG (31 %). Average age and BMI of all patients were and 46.33, respectively. Average BMI on the day of surgery was (Table 2). Preoperative %EWL for all patients was 4.8 % (4.3 % for LRYGB and 5 % for LSG; p>0.05) (Table 3). We found no significant differences in age, gender, race, preoperative %EWL, initial BMI, or DOS BMI between LRYGB and LSG patients (p>0.05). Frequency of major comorbidities is shown in Table 4; nearly 25 % of our patients

4 Table 2 Demographics Age Gender Race Initial BMI DOS BMI Females (%) Males (%) White (%) Non-white (%) LRYGB (n=158) 44.15± ± ±8.41 LSG (n=71) 46.99± ± ±6.29 p value LRYGB+LSG (N=229) 45.05± ± ±7.91 p 0.05 denotes a statistical significance with no adjustment for multiple comparisons BMI body mass index, EWL excess weight loss, DOS day of surgery had diabetes mellitus type 2, and almost 34 % of them were diagnosed with sleep apnea prior to surgery. The average number of associated comorbidities per patient was 3.27 (3.34 for LRYGB and 3.27 for LSG; p=0.81). Overall mean intraoperative blood loss was ml (20.73 ml for LRYGB and ml for LSG; p=0.44). Overall mean operative time was min (105 min for LRYGB and 85 min for LSG; p<0.0001). On average, LRYGB took about 20 min longer to complete than LSG (Table 3). Overall mean length of stay was h (1.35 days) (32.51 for LRYGB and for LSG; p=0.79). One patient in the LSG group stayed for 72 h (discharged on POD3) because of continuous nausea and dry heaving after surgery. Those symptoms were managed with antiemetics, and patient was discharged on postoperative day 3. In the LRYGB group, one patient was consistently tachycardiac and was found to have a trocar site hernia on computed tomography (CT) scan and was taken back to the operating room for repair of the trocar site hernia. The hospital length of stay of that patient was 96 h. We had no 30 day mortality in our study group. The overall 30 day complication rate was 2.6 %, but none of the LSG patients experienced complications (Table 5). There were six complications among LRYGB patients (Table 6); in this group, three patients developed postoperative complications requiring reoperation (overall 30 day reoperation rate=1.3 %). Two patients had trocar surgical site infections that required incision and drainage in the operating room, and one patient had a reexploration for trocar site hernia. Table 3 Secondary outcome measures Preoperative %EWL Operative time (min) Intraoperative blood loss (ml) LRYGB (n=158) ± ±28.68 LSG (n=71) ± ±40.20 p value 0.66 < LRYGB+LSG (N=229) ± ±32.77 p 0.05 denotes a statistical significance with no adjustment for multiple comparisons EWL excess weight loss In addition, one patient was readmitted for dehydration within the first 30 days following surgery (overall 30 day readmission rate=3.0 %). There was no significant difference between the LRYGB and LSG groups regarding 30 day complications, readmissions, or reoperation rates. Based on multivariate linear regression, none of the included independent variables (age, gender, race, surgical group, number of comorbidities, and %EWL) significantly predicted length of stay (adjusted R 2 =0.02; β coefficients= 0.11 to 0.13; p values=0.08 to 0.88). However, the number of comorbidities trended toward significant prediction (p=0.08). Based on the BOLD mean LOS for LRYGB of 2.4 days, with an associated cost of $4,838.40, compared to our mean LOS for LRYGB of 1.4 days at $2,822.40, the difference of $2, represents projected savings for our network per RYGB patient. Similarly, based on the BOLD mean LOS for SG of 1.9 days, with an associated cost of $3,830.40, compared to our mean LOS for SG of 1.3 days at $2,620.80, the difference of $1, represents projected savings for our network per LSG case (Table 7). Discussion The number of bariatric procedures being performed in the USA has risen dramatically in recent years, with a previous study showing that between 1998 and 2002, there was a 450 % increase. During this period, the growth of laparoscopic surgery greatly exceeded that of open bariatric surgery [1], with a dramatic increase in the number of obese patients seeking bariatric surgery because of improved outcomes, decreased postoperative pain, and shorter hospital stay associated with the laparoscopic approach [6]. In addition, a recent prospective, multicenter, observational study of 30 day outcomes in patients undergoing bariatric surgery showed that bariatric surgery is safe, with 30 day morbidity and mortality rates for bariatric procedures performed at ten clinical sites in the USA equaling 4.3 and 0.3 %, respectively [7]. While acknowledging these significant improvements in the overall safety and quality of bariatric surgery outcomes over

5 Table 4 Incidence of comorbidities p 0.05 denotes a statistical significance with no adjustment for multiple comparisons Diabetes mellitus type 2 Hypertension Hypercholesterolemia Sleep apnea LRYGB (n=158) (%) LSG (n=71) (%) p value LRYGB+LSG (N=229) (%) time, surgeons find themselves under constant pressure from insurance carriers and hospital administrators to discharge patients in a timely fashion without compromising patient satisfaction, safety, and outcome. With the implementation of the Affordable Health Care Act, surgeons will find themselves under scrutiny and will have to work closely with hospital administrators to address cost savings and patient outcomes. This sense of pressure is due in part to limited resources and increasing health-care costs, which makes a new surgery protocol particularly appealing. However, implementing such a protocol requires a cultural change at the discharge planning level and the involvement of a multidisciplinary team involving dieticians, social workers, pharmacists, nurses, the bariatric coordinator, hospitalists, and surgeons in addition to hospital administrative support. It is also important to set goals and expectations for patients prior to surgery and to ensure that patients are actively involved in the discharge planning which is what we usually do during the preoperative team meeting. This change in the organizational structuring of hospitals was previously adopted with the implementation of fast-track colorectal surgery and resulted in improved outcomes, lower complication rates, and shorter hospital stays [2 4, 8 10], even in patients with severe comorbidities [11]. As a result, fast-track colorectal surgery is now widely practiced, which led us to investigate the feasibility of a similar approach that incorporates best clinical practices with bariatric patients. The implementation of this protocol in our center resulted in a shorter length of stay (1.3 days on average) and a 30 day readmission rate of 3.0 %, which is comparable to or better than the readmission rates reported in other studies. In a study by Burns et al., the median length of stay following bariatric surgery including gastric banding was 3 days, and readmission rate within the first 28 days following surgery was 8 % [12]. In another study examining the patterns of readmission within 90 days after RYGB, a total of 1,222 patients who underwent either an open RYGB or a LRYGB were retrospectively reviewed. The 30 day readmission rate was 83/1,222 (6.7 %) [13]. In addition, a recent prospective randomized trial by Nguyen et al., gastric bypass patients had an average LOS of 3.1daysanda30dayreadmissionrateof5.4%[14]. When we analyzed our primary outcomes based on demographics, we found that our results differed from other published studies. In a large retrospective analysis of 37,765 patients who underwent laparoscopic gastric bypass, the 30 day readmission rate was % with an average LOS of 2.62 days. In this study, black patients had a longer LOS and higher 30 day readmission rates compared to white patients (2.79 vs 2.60 days, p<0.001, and 3.00 vs 2.32 %, p<0.01, respectively). Older patients (>65 years old) also had significantly longer LOS compared to younger patients (<30 years old) (3.47 vs 2.37 days, p<0.001). Additionally, older patients had a higher (though non-significantly different) 30 day readmission rate [15]. In contrast, our study showed no significant differences in LOS or readmission rates based on age or race (white vs non-white). These differences are likely due to the fact that our study population was relatively homogenous with all patients undergoing a standardized surgical technique with similar preoperative and postoperative protocols. In addition, the number of comorbidities did not correlate with the LOS. Our study also reported overall 30 day complication and mortality rates that are lower than those recently reported by the Longitudinal Assessment of Bariatric Surgery (LABS) Consortium (2.6 and 0 % vs 4.3 and 0.3 %, respectively), despite not including any adjustable gastric band patients in our study, since Table 5 Primary outcome measures LOS 30 day complication rate 30 day mortality rate 30 day readmission rate 30 day reoperation rate LRYGB (n=158) 32.51±15.81 (median=24; 6/158 (3.8 %) 0/158 7/158 (4.5 %) 3/158 (1.9 %) raw range=24 96) LSG (n=71) 32.33±14.05 (median=24; 0/71 0/71 0/71 0/71 raw range=24 72) p value LRYGB+LSG (N=229) 32.45±15.25 (median=24; raw range=24 96) p<0.05 denotes a statistical significance with no adjustment for the multiple comparisons LOS length of stay 6/229 (2.6 %) 0/229 (0 %) 7/229 (3.0 %) 3/229 (1.3 %)

6 Table 6 Adverse outcomes within 30 days after surgery Outcome Total (N=227) LSG (n=71) LRYGB (n=158) Death DVT/PE Marginal ulcer Surgical site infection Trocar site hernia Total this type of procedure is performed on an outpatient basis in most certain centers and was therefore excluded from our analysis [7]. Compared to the most recent BOLD data reported in November 2011 based on 295,304 patient data entered between June 1, 2007 and December 31, 2010, our results are also very favorable. Our overall 30 day complication and readmission rates were 2.6 and 3.0 % compared to and 4.8 % for the LRYGB and 8.52 and 3.65 % for LSG. Despite a shorter hospital stay and substantial cost savings, our 30 day complication and readmission rates were lower than the reported 2011 BOLD data rates, and therefore, we believe that this protocol can be safely implemented without compromising safety and outcome of our patients which remain our number one priority irrespective of the cost savings achieved with this protocol. Furthermore, our study found no significant association between the number of comorbidities and length of stay, suggesting that this protocol can be successfully adopted in morbidly obese patients suffering of multiple comorbid conditions as long as they undergo an extensive and comprehensive preoperative workup to effectively manage and address these conditions as described in our Methods section. Unfortunately, we do not have any data on the severity of these comorbidities to include in our analysis. In addition, Medicare/Medicaid vs private insurance status was not included in our analysis. However, elderly patients (65 years and older, Medicare status) in our series had a similar LOS compared to non-elderly patients (abstract Obesity Week, Atlanta, 2013). This study has few limitations. One of the limitations is the lack of a comparative group. Even though we acknowledge that the addition of a comparative group to the study can help illustrate the benefits of this protocol, unfortunately, such a group is not available to us. Prior the arrival of both surgeons involved in this study (MEC and LC) to St Luke s University Hospital and the establishment of this protocol, all bariatric surgeries were performed by another surgeon in an open fashion exclusively and not laparoscopically, and therefore, we were not able to use those patients to compare them to our new protocol patient population. In addition, our readmission rate did not include patients who were readmitted to other hospitals. Also, our sample size is relatively small, and our follow-up period is limited to the perioperative period. Currently, we continue to implement this protocol, and we will be reporting our results with a larger sample size and a longer follow-up period. We believe that our initial results are very encouraging. Therefore, this protocol should be investigated on a larger scale, preferably through a multicenter trial, in order to fully elucidate its safety and effectiveness for bariatric surgery patients. Individual bariatric centers interested in implementing a similar protocol need to approach the issue very carefully and understand the cultural change needed at the institutional level to make sure all the necessary components are in place to be able to implement it safely. In addition to experienced bariatric surgeons, experienced support staff is also needed for the implementation of such a protocol. Also, bariatric centers are encouraged to perform a retrospective analysis of their outcome measures to decide whether routine practices can be modified to improve patient satisfaction, shorten hospital stay, avoid complications, and improve outcome. For example, if a bariatric procedure routinely takes less than 2 h, the insertion of a Foley catheter can be omitted to avoid postoperative UTI, urinary retention, etc., which can increase the complication rate and lengthen the hospital stay. In addition, one needs to reevaluate the practice of performing routine radiographic studies following bariatric surgery in routine cases. If the institution leak rate is low as is the case in most MBSAQIP centers, routine studies Table 7 Cost analysis SLUHN 2011 BOLD National Data LRYGB (n=158) LSG (n=71) LRYGB (n=149,8477) LSG (n=16,885) Length of stay (LOS) (days) Estimated cost (assuming $2,016 as the cost per adjusted patient day for SLUHN) Cost savings achieved by SLUHN versus BOLD outcomes Mean=1.4 (converted from mean of h) $2, days=$2, $4, $2, =$2,016.00/LRYGB patient Mean=1.3 (converted from mean of h) $2, days=$2, $3, $2, =$1,209.60/LSG patient Mean=2.4 $2, days=$4, N/A Mean=1.9 $2, days=$3, N/A SLUHN St Luke s University Health Network, BOLD Bariatric Outcome Longitudinal Database

7 will only cause patient discomfort, add to the hospital cost of bariatric surgery, and lengthen hospital stay. The implementation of a similar protocol should only be performed in comprehensive bariatric surgery centers with all the necessary support staff and key personnel. Conclusion The adoption of a new and innovative bariatric surgery protocol can result in significant savings to the health-care system and improved patient outcomes. When performed in an accredited center, this protocol appears to be both safe and effective, resulting in shorter hospital stay as well as lower complication, readmission, and reoperation rates. Large multicenter trials are needed to further quantify the benefits of a similar protocol in bariatric surgery. Conflict of Interest Dr. Maher El Chaar, Dr. Ezeji G.C., Dr. Leonardo Claros, Dr. Jill Stoltzfus, and Ms. Maureen Miletics have no conflict of interest to disclose/declare. References 1. Nguyen NT, Root J, Zainabadi K, et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg. 2005;140(12): discussion Feo CV, Lanzara S, Sortini D, et al. Fast track postoperative management after elective colorectal surgery: a controlled trail. Am Surg. 2009;75(12): Gouvas N, Tan E, Windsor A, et al. Fast-track vs standard care in colorectal surgery: a meta-analysis update. Int J Colorectal Di. 2009;24(10): Counihan TC, Favuzza J. Fast track colorectal surgery. Clin Colon Rectal Surg. 2009;22(1): Carli F, Charlebois P, Baldini G, et al. An integrated multidisciplinary approach to implementation of a fast-track program for laparoscopic colorectal surgery. Can J Anaesth. 2009;56(11): Nguyen NT, Goldman C, Rosenquist CJ, et al. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg. 2001;234(3): discussion Flum DR, Belle SH, King WC, et al. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;361(5): Baird G, Maxson P, Wrobleski D, Luna BS. Fast-track colorectal surgery program reduces hospital length of stay. Clin Nurse Spec; 24(4): Ionescu D, Iancu C, Ion D, et al. Implementing fast-track protocol for colorectal surgery: a prospective randomized clinical trial. World J Surg. 2009;33(11): Holak J. Fast track concept in colorectal surgery in a regional hospital setting. Rozhl Chir. 2009;88(9): Rix T, Jourdan L. Fast track postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery (Br J Surg 2001;88:1533-8). Br J Surg 2002; 89(5):625; author reply Burns EM, Naseem H, Bottle A, et al. Introduction of laparoscopic bariatric surgery in England: observational population cohort study. BMJ; 341:c Kellogg TA, Swan T, Leslie DA, et al. Patterns of readmission and reoperation within 90 days after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2009;5(4): Nguyen NT, Slone JA, Nguyen XM, et al. A prospective randomized trial of laparoscopic gastric bypass versus laparoscopic adjustable gastric banding for the treatment of morbid obesity: outcomes, quality of life, and costs. Ann Surg. 2009;250(4): Tiwari MM, Goede MR, Reynoso JF, et al. Differences in outcomes of laparoscopic gastric bypass. Surg Obes Relat Dis. 2011;7(3):