SSAT - a Simplified Protocol for the Perioperative Management of Morbidly Obese End Stage Renal Disease Patients

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a Simplified Protocol for the Perioperative Management of Morbidly Obese End Stage Renal Disease Patients
Christopher M. Freeman^*¹, Junzi Shi², Steve Woodle¹, Jonathan Thompson¹, Stephen C. Benoit³, Daniel Schauer⁴, Rita R. Alloway⁴, Tayyab Diwan¹

¹Surgery, University of Cincinnati College of Medicine, Cincinnati, OH; ²College of Medicine, University of Cincinnati, Cincinnati, OH; ³Psychology, University of Cincinnati, Cincinnati, OH; ⁴Medicine, University of Cincinnati Medical Center, Cincinnati, OH

PURPOSE: Sleeve gastrectomy (SG) has overtaken gastric bypass as the most common metabolic surgery procedure. Given the relative ease, efficacy, and proven safety of SG, the procedure has been offered to patient populations that may not have been considered for the procedure due to medical comorbidities. One such group that has benefited from the expanded role of SG is the end stage renal disease (ESRD) patient population that is ineligible for definitive therapy—renal transplantation—due to morbid obesity. In the largest series to date (60 patients), our group has demonstrated safety, efficacy, and increased access to transplantation. This population poses unique perioperative management challenges—need for and timing of hemodialysis (HD), management of medications, electrolytes, gastric dysmotility, hypertension—that may deter the non-transplant surgeon from offering SG to the ESRD patient. The aim of this study was to determine if the initiation of a simplified ESRD-specific perioperative protocol would decrease hospital length of stay (LOS) without altering readmission rate. By initiating a simplified ESRD patient-specific protocol, the general or metabolic surgeon may consider offering SG to this unique population.
METHODS: Data were collected from the SG experience of a single bariatric and transplant trained surgeon (TSD). The first consecutive 60 renal transplant candidates to undergo SG from December 2011 to April 2014 were analyzed. The experience with the first 30 patients was used to develop a subsequent protocol which included timing of perioperative dialysis, nutrition initiation, management of anti-hypertensive medications and insulin, and focused short-term follow up. The first 30 patients (pre-protocol) were compared to the second 30 patients (post-protocol). Groups were compared using Mann-Whitney Rank Sum test (hospital LOS) and Fisher's exact test (readmission). Data are presented as median with interquartile ranges.
RESULTS: Following initiation of the protocol, hospital LOS was significantly reduced from 3 days (3-3 days) to 2 days (2-2.25 days) (p < 0.001). This reduction in hospital LOS was not accompanied by an increased hospital readmission rate: three patients were readmitted within 90 days for each group.
CONCLUSION: Through initiating an ESRD patient-specific protocol for perioperative management of SG patients we were able to decrease hospital length of stay without increasing 90-day readmission rate. By implementing a similar protocol, general or metabolic surgeons without a background in transplant surgery will be able to confidently manage this unique patient population.

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