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Clinical pathways are promoted for standardizing patient care and decreasing resource use without compromising outcome. Once established, we hypothesized that clinical pathways can then be used to modify patient care to achieve specific goals. Our aim was to evaluate a clinical pathway for the bariatric surgical patient that was initially designed to standardize care and later altered to modify the postoperative course. We retrospectively reviewed 150 consecutive patients undergoing open gastric bypass by a single surgeon. The first 50 patients were managed without a formal pathway, (group I). The next 50 were managed with a pathway that standardized care in order to reduce length of stay (LOS), (group II). For the final 50 patients, the pathway was modified to shorten nasogastric decompression time (group III). Patient information, blood loss (EBL), operative time, length of stay (LOS), nasogastric decompression, 30-day complication rates, and early readmissions were reviewed. The groups were similar with respect to gender, age, body mass index, American Society of Anesthesiologists (ASA) classification, and EBL. Operative time was significantly less in groups II and III compared to group I (82% and 68% vs. 38% <180 minutes, P < 0.05). LOS was shorter in groups II and III compared to group I (62% and 42% vs. 20% with a 4-day LOS, P < 0.05). Duration of nasogastric tube decompression was successfully decreased in group III when compared to groups I and II (76% vs. 14% and 6% 1 day or less, P < 0.05). Complication rates were significantly lower in group III as well (14% vs. 36% and 28%, P < 0.05). Standardizing patient care with a clinical pathway decreases LOS after bariatric surgery. An established clinical pathway can then be used to further modify patient care in order to achieve specific goals, such as shortened time of nasogastric decompression. This goal was accomplished without compromising patient outcome.

Open gastric bypass has been demonstrated to provide durable weight loss in morbidly obese patients. As laparoscopic techniques have evolved surgeons are offering patients such an approach for performance of gastric bypass. The purpose of this study was to evaluate the relationship between increasing experience and outcome for this technically challenging operation. A retrospective analysis was performed on the initial 160 consecutive patients undergoing laparoscopic gastric bypass by a single surgeon over a 24-month period. Patients were divided into quartiles for data analysis. Duration of surgery decreased significantly between quartiles: 324 +/- 124, 225 +/- 70, 190 +/- 47, and 168 +/- 40 minutes, respectively (P < 0.01). However, the conversion rate (3.1%) and mean hospital length of stay (2.1 +/- 2.4 days) were unaffected by surgeon experience. The early and late postoperative complication rates were 9.4 and 3.1 per cent, respectively. Early complications included: leak (1.3%), bleeding (3.8%), obstruction (1.9%), acute gastric distention (0.6%), subphrenic abscess (0.6%), and wound infection (0.6%). Late complications include: obstruction (1.3%), anastomotic stricture (1.3%), and marginal ulcer (0.6%). The complication rates did not change statistically between quartiles. The excess weight loss at one year was 77.4 +/- 16.7 per cent. These data suggest that throughout the learning curve laparoscopic gastric bypass can be accomplished with acceptable complication rates, conversion rates, and hospital length of stay. Duration of surgery improves with experience. Early weight loss results compare favorably with those of open gastric bypass.

Bariatric surgery is being performed in increasing numbers in an era when reimbursements are being reduced. Academic health centers bear the responsibility for training surgeons to perform these operations yet must keep costs to a minimum and retain high quality. The UCLA Bariatric Surgery Program developed a clinical pathway for the pre- and postoperative management for gastric bypass patients to achieve these goals. Medical records for 182 consecutive gastric bypass patients were retrospectively reviewed before implementation of the pathway (Group I) during the fiscal year of 1998/1999. Data on average length of stay, average intensive care unit length of stay, average standard variable cost, percentage readmission rate, and percentage return to the operating room were collected. This information was compared with the data collected prospectively from 182 patients after implementation of the pathway in July of 1999 (Group II) during the fiscal year of 1999/2000. Hospital cost per admission was reduced by 40 per cent in Group II compared with Group I (P < 0.02). The average length of stay was reduced from 4.05 days in Group I to 3.17 days in Group II (P < 0.033). Overall readmission rate was decreased from 4.2 per cent in Group I to 3.2 per cent in Group II (P < 0.05). There were no differences in morbidities between both groups. The pathway reduced costs by reducing the hospital length of stay, intensive care unit utilization, and readmission rates. Quality was maintained as evidenced by a similar pattern of postoperative morbidities yet readmission rates were reduced. Our results indicate that implementation of a clinical pathway for bariatric surgery reduces cost and improves quality of care in an academic institution.