Satisfaction rate of patients undergoing sleeve gastrectomy as day-case surgery compared to conventional hospitalization: a prospective non-randomized study

Abstract

Purpose:
Day-case surgery (DCS) has boomed over recent years. However, day-case bariatric surgery remains controversial due to a lack of evaluation. The objective of this study was to compare the experiences and satisfaction with general anesthesia of patients undergoing sleeve gastrectomy (SG) as DCS compared to conventional hospitalization.

Methods:
Between January 2015 and June 2016, all patients undergoing primary SG as day-case surgery or with conventional hospitalization were prospectively included in this non-randomized, non-inferiority study comparing the level of satisfaction of patients undergoing SG with conventional hospitalization (CH group, gold standard) versus SG as DCS (DCS group). The primary efficacy endpoint was comparison of the overall satisfaction rate using the EVAN-G questionnaire. The secondary endpoints were evaluation of the 6 dimensions of the EVAN-G questionnaire, discharge from hospital, adhesion with SG management and overall satisfaction with SG.

Results:
One-hundred and twenty-four patients met the inclusion criteria (62 in both groups). The DCS group was younger with fewer comorbidities (p ≤ 0.01) and had a lower BMI (p ≤ 0.01). Overall, the mean EVAN-G questionnaire score was 66.4 (63.9-68.9) for the DCS group and 68.9 (65.9-71.8) for the CH group (non-inferiority of DCS group). In the DCS group, 19% of patients would have preferred to spend the night in hospital, while 82% of patients in the CH group would have preferred DCS and a total of 75% of patients reported a high level of satisfaction.

Conclusion:
Overall satisfaction of patients undergoing SG as day-case surgery was not inferior to that of patients managed by conventional hospitalization.

Full text

Vol.:(0123456789)
1 3
Journal of Anesthesia
https://doi.org/10.1007/s00540-018-2469-9
ORIGINAL ARTICLE
Satisfaction rate ofpatients undergoing sleeve gastrectomy
asday‑case surgery compared toconventional hospitalization:
aprospective non‑randomized study
RachidBadaoui1· LionelRebibo2· KahinaKirat1· YoussefAlami1· AbdelhakimHchikat1· CyrilCosse2·
Jean‑MarcRegimbeau2,3,4,6· EmmanuelLorne1,5
Received: 17 August 2017 / Accepted: 17 February 2018
© Japanese Society of Anesthesiologists 2018
Abstract
Purpose Day-case surgery (DCS) has boomed over recent years. However, day-case bariatric surgery remains controversial
due to a lack of evaluation. The objective of this study was to compare the experiences and satisfaction with general anesthesia
of patients undergoing sleeve gastrectomy (SG) as DCS compared to conventional hospitalization.
Methods Between January 2015 and June 2016, all patients undergoing primary SG as day-case surgery or with conventional
hospitalization were prospectively included in this non-randomized, non-inferiority study comparing the level of satisfaction
of patients undergoing SG with conventional hospitalization (CH group, gold standard) versus SG as DCS (DCS group). The
primary efficacy endpoint was comparison of the overall satisfaction rate using the EVAN-G questionnaire. The secondary
endpoints were evaluation of the 6 dimensions of the EVAN-G questionnaire, discharge from hospital, adhesion with SG
management and overall satisfaction with SG.
Results One-hundred and twenty-four patients met the inclusion criteria (62 in both groups). The DCS group was younger
with fewer comorbidities (p≤0.01) and had a lower BMI (p≤0.01). Overall, the mean EVAN-G questionnaire score was
66.4 (63.9–68.9) for the DCS group and 68.9 (65.9–71.8) for the CH group (non-inferiority of DCS group). In the DCS
group, 19% of patients would have preferred to spend the night in hospital, while 82% of patients in the CH group would
have preferred DCS and a total of 75% of patients reported a high level of satisfaction.
Conclusion Overall satisfaction of patients undergoing SG as day-case surgery was not inferior to that of patients managed
by conventional hospitalization.
Keywords Bariatric surgery· Day-case surgery· Satisfaction rate· Sleeve gastrectomy
Abbreviations
SG Sleeve gastrectomy
LOS Length of hospital stay
OSA Obstructive sleep apnea syndrome
DCS Day-case surgery
CH Conventional hospitalization
POD Postoperative day
BMI Body Mass Index
Electronic supplementary material The online version of this
article (https ://doi.org/10.1007/s0054 0-018-2469-9) contains
supplementary material, which is available to authorized users.
* Jean-Marc Regimbeau
regimbeau.jean-marc@chu-amiens.fr
1 Department ofAnesthesiology, Amiens University Hospital,
Avenue René Laennec, 80054AmiensCedex01, France
2 Department ofDigestive Surgery, Amiens University
Hospital, Avenue René Laennec, 80054AmiensCedex01,
France
3 EA4294, Jules Verne University ofPicardie,
80054AmiensCedex01, France
4 Clinical Research Center, Amiens University Hospital,
Avenue René Laennec, 80054AmiensCedex01, France
5 INSERM U1088, Jules Verne University ofPicardy,
80054AvenueRenéLaennec, France
6 Service de chirurgie digestive, Hôpital Sud, CHU d’Amiens,
Avenue René Laennec, 80054AmiensCedex01, France

Journal of Anesthesia
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Introduction
Several studies have reported an increasing incidence of
obesity, which now constitutes a global public health prob-
lem that affects all ages, all socioeconomic classes and
all parts of the world [1–3]. Bariatric surgery has yielded
good results in terms of weight loss, correction of cardio-
vascular risk factors and change in lifestyle [4]. Laparo-
scopic sleeve gastrectomy (SG) has become increasingly
popular because of the apparent ease of this technique and
its good results (in terms of weight loss and improvement
of comorbidities) [5]. Low postoperative complication
rates have been reported compared to duodenal switch
[6] or Roux-en-Y gastric bypass [7] due to the absence of
anastomosis.
Day-case surgery is becoming increasingly popular for
three main reasons. Firstly, avoidance of overnight hospi-
talization reduces the risk of hospital-acquired infections.
Secondly, day-case management can improve the quality
of care and raise the levels of patient satisfaction without
adding any additional risk. Lastly, the cost of admission to
a DCS unit is undoubtedly lower than that of conventional
hospitalization.
Day-case surgery remains the subject of a number of
criticisms and few studies have compared the satisfaction
rate of patients undergoing day-case surgery (DCS) versus
conventional hospitalization (CH). Patient satisfaction is a
key indicator of quality to be considered when evaluating
clinical practices [8, 9], which must be compatible with
the patient’s expectations. Only limited data have been
published in the literature on patients undergoing day-case
bariatric surgery, and the satisfaction of patients undergo-
ing day-case bariatric surgery has never been studied.
The objective of this study was to compare the experi-
ences and satisfaction with general anesthesia of patients
undergoing SG as day-case surgery compared to patients
undergoing SG with conventional hospitalization.
Materials andmethods
This was a prospective, observational, non-randomized
study of a group of patients undergoing day-case or con-
ventional SG between January 2015 and June 2016. This
non-inferiority study compared the level of satisfaction of
patients undergoing SG with conventional hospitalization
(forming the CH group, considered to be the gold stand-
ard) to that of patients undergoing DCS SG (forming the
DCS group).
This study was approved by the Amiens University
Hospital non-interventional research ethics committee
(CEERNI). All patients were provided with a patient
information sheet during a preoperative consultation and
all patients provided their written informed consent to
participate. Day-case SG was previously validated in our
institution based on a local research protocol entitled “Fea-
sibility of Laparoscopic Sleeve Gastrectomy in Day-Case
Surgery (GASTRAMBU)” (ClinicalTrials.gov Identifier
NCT01513005).
In our institution, it is usual to allocate all patients who
are planned for SG into the CH or DCS according to the
criteria descripted in ‘Specific indication for SG as day-case
surgery’ section. It is usual to perform EVAN-G question-
naire for all postoperative patients who undergo SG in our
institution. Our institutional review board concluded that
the registration was not required for this study (including
performing additional questionnaire).
Indication forbariatric surgery
The indication for bariatric surgery was validated in accord-
ance with French national guidelines and a multidisciplinary
obesity staff meeting [10].
Specic indication forSG asday‑case surgery
The inclusion criteria for SG as day-case surgery have been
previously described [11]. Briefly, inclusion criteria were
Body Mass Index (BMI) between 35 and 60kg/m2, absence
of significant medical history (cardiovascular and/or pul-
monary diseases, no history of major abdominal surgery),
treatment-compliant patients aged between 18 and 60years,
living within an hour’s drive of a hospital and with an on-site
support person available for the night after surgery, access to
a telephone and an American Society of Anesthesiologists
score of I, II or controlled III [12]. Patients were excluded
from day-case surgery in the presence of heart disease (his-
tory of myocardial infarction, cardiac arrhythmia, antico-
agulation or antiplatelet therapy) or OSA, poorly controlled
diabetes, or when they were a prisoner or were thought to
be poorly compliant.
Description ofthevarious care pathways
Conventional hospitalization
A preoperative anesthetic consultation was performed at
least 2weeks before SG by an anesthetist with an extensive
experience of anesthesia of obese patients undergoing bari-
atric surgery. Patients were admitted the day before surgery
(Fig.1).

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Day‑case management
A preoperative anesthetic consultation was performed at
least 2weeks before day-case SG by an anesthetist with an
extensive experience of day-case surgery, but without an
extensive experience of anesthesia and postoperative man-
agement of obese patients undergoing bariatric surgery.
Patients were admitted on the day of surgery (Fig.1).
Anesthetic procedure
The anesthetic protocol was specifically developed for day-
case SG [13] and was then extended to SG performed with
conventional hospitalization during the study period. All
patients received treatment with cimetidine (400mg) and
premedication with hydroxyzine (1.5mg/kg) was admin-
istered 30min before anesthesia for anxious patients.
Patients wore compression stockings since the night
before surgery. In the operating room, pressure points
were checked and secured during patient positioning, and
antibiotic prophylaxis with cefazolin (4g) was adminis-
tered, followed by 5min of preoxygenation with 100%
oxygen in a beach chair position. General anesthesia was
induced with propofol (2.5mg/kg), sufentanil (0.5µg/kg),
and rocuronium (1mg/kg of real body weight) to facili-
tate tracheal intubation. Anesthesia was maintained with
4–6% desflurane and 0.1–0.25µg/kg/min remifentanil.
The objective of mechanical ventilation was to maintain
arterial oxygen saturation above 95% and CO2 between
30 and 35mmHg with a 50% inhaled oxygen concentra-
tion. Standard monitoring included the use of a cardiac
monitor and pulse oximeter (SpO2) and measurements of
heart rate (HR), end-tidal CO2 (EtCO2), and noninvasive
blood pressure monitoring. Muscle relaxation was moni-
tored with a TOF Watch (TOF Watch®, Alsevia Pharma,
75016 Paris, FRANCE). The depth of anesthesia was
Fig. 1 Organizational design of
day-case surgery and conven-
tional hospitalization. SG sleeve
gastrectomy

Journal of Anesthesia
1 3
monitored by bispectral index (BIS) (BIS™ Quatro (4
Electrode) Sensor & BIS™ Complete 2-Channel Moni-
tor, Medtronic, 92100 Boulogne Billancourt, FRANCE)
and was maintained at BIS values between 40 and 60.
Intraoperative hypothermia was prevented by a warming
system (3M™ Bair Hugger™, 3M, 95006 Cergy-Pontoise
Cedex, France). Neuromuscular blockade was systemati-
cally reversed using sugammadex (4mg/kg) when TOF
was equal to or greater than 2 and the patient was extu-
bated in the operating room. Multimodal postoperative
analgesia included nefopam (20mg), tramadol (100mg),
and paracetamol (1g), started 30min before the end of
surgery, and completed by intravenous morphine titra-
tion in the recovery room when the visual analog scale
was greater than 30mm. To prevent postoperative nausea
and vomiting (PONV), patients routinely received dexa-
methasone (8mg) and droperidol (1.25mg) at the time of
induction of anesthesia, and ondansetron (4mg) during
the postoperative period. All drug doses were calculated
based on ideal body weight.
Postoperative management
Conventional hospitalization
After SG, patients were admitted to the conventional recov-
ery room and were then transferred to the digestive surgery
ward. Oral refeeding was authorized in the evening after
SG. The patient was deemed suitable for discharge on the
day following SG in the absence of any particular symptoms
after food intake. A surgical follow-up visit was planned on
POD 30 (Fig.1).
Day‑case surgery
Day-case management has been described previously
[11,14]. Briefly, after surgery, patients were first admitted
to the day-case surgery recovery room and were then trans-
ferred to the day-case surgery unit for assessment of vital
signs (temperature, heart rate, blood pressure and oxygen
saturation), any postoperative nausea and pain and collec-
tion of a blood sample for determination of the hemoglobin
level. The patient was deemed suitable for discharge on the
same day in the absence of any particular symptoms after
food intake during recovery and after examination by both
the surgeon and the anesthetist. When these conditions were
not met, the patient was hospitalized overnight. Patients
were always contacted by the day-case surgery unit nurse
on postoperative day (POD) one and were always reviewed
in the clinic on POD4 (specific scheduled consultation for
day-case SG) including complete physical examination and
blood biochemistry. Patients were then reviewed on POD
30 (Fig.1).
Evaluation ofpatient satisfaction
EVAN‑G questionnaire
Satisfaction with day-case surgery and conventional hospi-
talization management was evaluated using the EVAN-G
questionnaire. The EVAN-G questionnaire is a questionnaire
evaluating the experiences of general anesthesia and is vali-
dated for both day-case surgery and conventional hospitali-
zation [15].
The EVAN-G questionnaire comprises 6 dimensions
assessing satisfaction in relation to 26 items: attention,
information, privacy, management of pain, discomfort and
waiting times (Supplementary Figure). Each dimension was
evaluated using a five-point verbal scale. The EVAN-G score
is expressed as a global score out of 100, and the score of
each of the 6 dimensions expressed as a percentage.
Other questionnaires
Other questionnaires were specifically designed for this
study:
• Evaluation of discharge from hospital, including prepara-
tion for discharge from hospital and experience at home,
expressed as a score out of 100, as for the EVAN-G ques-
tionnaire:
– Preparation for discharge (four items): information
on monitoring, warning signs, resumption of activity
and the feeling of being discharged too quickly.
– Experience at home (three items): pain, discomfort,
and functional discomfort at home.
• Adhesion to the procedure was evaluated by additional
binary questions concerning adhesion to the procedure
and overall satisfaction with the type of management.
The patient was asked whether they:
– Would have preferred to spend the night in hospital
(in the case of day-case SG), or be discharged home
on the day of surgery (in the case of conventional
hospitalization),
– Would make the same choice if they had to undergo
the procedure again,
– Would recommend this type of management to a
loved one.
• Overall satisfaction with SG using a 5-point verbal scale.
The level of satisfaction was considered to be high when
the answer was “very satisfied” or “completely satisfied”.

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Methodology ofevaluation ofpatient satisfaction
Patients included in this study were informed about partici-
pation in this study and its modalities during the preopera-
tive anesthetic consultation. Each patient was contacted by
telephone on postoperative day (POD) by an independent
anesthetist who did not participate in their management, to
fill in the questionnaire.
Study endpoints
The primary endpoint was comparison of the satisfaction
rate of patients undergoing SG as day-case surgery and with
conventional hospitalization according to the score of the
EVAN-G questionnaire [15]. The secondary endpoints were
evaluation of the 6 dimensions of the EVAN-G question-
naire, evaluation of discharge from hospital, evaluation of
adhesion and satisfaction with SG management and overall
satisfaction with the SG procedure.
Inclusion andexclusion criteria
Inclusion criteria were patients undergoing SG as day-case
surgery or with conventional hospitalization on the same day
and scheduled at the beginning of the operating list (about
9:00 a.m.). To avoid bias when evaluating satisfaction rates,
patients undergoing SG with conventional hospitalization at
the beginning of the operating list were included, as SG as
day-case surgery was always performed at the beginning of
the day-case surgery operating list. Exclusion criteria were
patients refusing to participate in the study or failing to
answer the postoperative phone call, unscheduled overnight
admission after day-case SG and postoperative complica-
tions following SG.
Sample size calculation andstatistical analysis
It was assumed that day-case surgery management would
not be inferior to conventional hospitalization in terms of the
satisfaction rate after SG. The sample size was calculated on
the basis of published data reported by Auquier etal. [15]
and an expected mean and standard deviation of 75±14.
With a non-inferiority margin of 7% of the mean and a two-
sided α risk of 5% and a β risk of 20%, a sample size of 62
patients per group was required. Non-inferiority would be
established if the upper limit of the two-sided 95% confi-
dence interval of the difference of satisfaction rates between
the 2 groups was lower than the non-inferiority margin.
Patients in the two groups were divided into pairs (based
on date and position on the operating list). When a patient
in one group had to be excluded from the study, the paired
patient in the other group was also excluded. Patients under-
going SG on the same day were included in order to reduce
the risk of bias related to external events and all SG proce-
dures were performed at the beginning of the operating list
to avoid any bias related to the time to oral feeding after SG.
Quantitative variables with a non-normal distribution
were expressed as median (IQR) for the variables and vari-
ables with a normal distribution were expressed as mean
(95% confidence interval). Normal distribution was assessed
by the d’Agostino-Pearson test. Qualitative variables were
expressed as a percentage with 95% confidence interval and
were compared by a Chi square test. A non-inferiority test
(Welch’s t test) was performed for the global score (primary
endpoint) and the scores for each dimension. The limit for
statistical significance was p≤0.05. All statistical analyses
were performed with SAS software (version 9.2, SAS Insti-
tute, Cary, NC, USA). The study was conducted according
to STROBE guidelines.
Results
Study population
Of the 140 patients initially selected, 124 patients met the
inclusion criteria (62 in the SG day-case surgery group
and 62 in the conventional hospitalization group) (Fig.2).
Reasons for exclusion were: no response in two patients,
unplanned overnight admission in three patients, major post-
operative complications in three patients (one gastric leak in
the SG day-case surgery group, one hematoma and one case
of postoperative bleeding in the conventional hospitalization
group).
Patient characteristics are summarized in Table1. Glob-
ally, the day-case SG group was younger with fewer comor-
bidities and a lower BMI. The majority of patients undergo-
ing SG as day-case surgery were females (92%) (Table1).
Surgical procedure andpostoperative data
All procedures were performed laparoscopically. The mean
operating time (±SD (range) was 57±11min (35–65) for
day-case SG and 66±14min (35–85) for SG with conven-
tional hospitalization. Abdominal drainage was not required
in either of the two groups.
By comparing pain scores at admission and discharge
from the post-anesthesia care unit (PACU) (Table2), when
leaving the operating room, 83.8% of patients in the DCS
group and 80.6% of patients in the CH group experienced no
pain or only mild pain (p=0.43). When leaving the PACU,
93.5 and 92% of patients experienced no pain or only mild
pain, respectively (p=0.62). Data on PACU are summarized
in Table2.

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1 3
Three patients undergoing day-case SG required over-
night admission and were all discharged at POD 1. The mean
LOS for conventional SG was 1.9days (1–3).
EVAN‑G questionnaire
The mean global score for the EVAN-G questionnaire was
66.4±9.9 (63.9–68.9) and 68.9±11.8 (65.9–71.8) for SG
as day-case surgery and SG with conventional hospitaliza-
tion, respectively. The non-inferiority of day-case surgery vs
conventional hospitalization was demonstrated, as the differ-
ence was less than 5 points (p≤0.001—non-inferiority test).
Globally, no significant difference was observed between
the DCS and CH groups except for “waiting times”
(Table3).
Other questionnaires
The scores on the discharge questionnaire were similar
between SG as day-case surgery and SG with conventional
Fig. 2 Study flow chart. SG
sleeve gastrectomy. Aster-
isk: patients with unplanned
overnight admission. Double
asterisks: patients with major
postoperative complications
Table 1 Preoperative data of patients undergoing SG as day-case sur-
gery or with conventional hospitalization
BMI Body Mass Index, OSA obstructive sleep apnoea, GERD gastro-
oesophageal reflux disease, DCS day-case surgery, CH conventional
hospitalisation
DCS group
(n=62)
CH group
(n=62)
p
Age in years
(range)
34±9 (19–52) 42±11 (21–62) ≤0.0001
Male gender (%) 5 (8) 16 (26) ≤0.01
BMI (kg/m2) 41.8±3.5
(35–51)
44.2±6.1
(35–60)
≤0.01
Hypertension (%) 9 (15) 21 (34) 0.01
Type 2 diabetes
(%)
2 (3) 15 (24) ≤0.001
OSA (%) 0 (0) 20 (32) ≤0.0001
Dyslipidaemia (%) 6 (10) 13 (21) ≤0.001
GERD (%) 7 (11) 7 (11) 1
Asthma (%) 1 (2) 7 (11) 0.07
Depression (%) 1 (1.6) 3 (5) 0.61

Journal of Anesthesia
1 3
hospitalization (71 (65.8–77.2) vs 71 (65.9–75.7), respec-
tively; p=0.7). Similar scores were also reported for the
experience at home: 85 (73–94) for SG as day-case surgery
vs 83 (72–93) for SG with conventional hospitalization
(p=0.56).
On the additional binary questionnaire, 19% of patients
in the DCS group would have preferred to spend the night in
hospital, while 82% of patients in the CH group would have
preferred to have been discharged on the same day as sur-
gery. Surprisingly, 98% of patients in the DCS group would
recommend this type of management. The results for the
binary questionnaire are summarized in Table4 and showed
statistically significant differences for all variables. Seventy-
five per cent of patients reported a high level of satisfaction
with the global management of SG. No significant differ-
ences were observed between DCS and CH group (Table5).
Table 2 PACU data on
SG performed as day-case
surgery or as conventional
hospitalization
DCS day-case surgery, CH conventional hospitalisation, PACU postoperative care unit, PONV postopera-
tive nausea and vomiting
DCS group (n=62) CH group (n=62) p
Absent or mild pain at PACU admission (%) 52 (83.8) 50 (80.6) 0.43
Absent or mild pain at PACU discharge (%) 58 (93.5) 57 (92) 0.62
Use of morphine medication (%) 7 (11.3) 7 (11.3) 0.65
Use of ondansetron (%) 4 (6.4) 6 (9.6) 0.21
No PONV at PACU discharge (%) 52 (83.8) 49 (79) 0.38
Mean stay at PACU in minutes (range) 80 (35–140) 100 (45–155) ≤0.05
Table 3 Results of EVAN-G
items according to the type of
management
DCS day-case surgery, CH conventional hospitalisation
DCS group (n=62) CH group (n=62) p
Global index (95% CI) 66.4±9.9 (63.9–68.9) 68.9±11.8 (65.9–71.8) ≤0.001
Attention (95% CI) 53.1±14.7 (51.4–58.8) 56.5±18.2 (51.4–58.8) 0.06
Information (95% CI) 58.7±18.8 (53.9–63.5) 67.8±22.9 (62.1–73.4) 0.76
Privacy (95% CI) 55.5±9.9 (52.9–57.9) 59.2±15.4 (55.4–63.1) 0.11
Pain (95% CI) 67.2±22.7 (59.5–70.9) 61.2±23.9 (55.2–67.1) 0.09
Discomfort (95% CI) 78.8±18.2 (74.1–83.4) 83.2±16.8 (79.1–87.4) 0.09
Waiting (95% CI) 85.3±20.8 (79.9–90.6) 85.6±22.5 (80.0–91.1) 0.04
Table 4 Results of additional binary questionnaire
SG: sleeve gastrectomy, DCS: day-case surgery, CH: conventional
hospitalisation
Yes No No response p value
Would you have preferred
to spend the night in
hospital (for DCS group)
(%)
12 (19) 48 (78) 2 (3) <0.001
Would you have preferred
to have been discharge
the same day as SG (for
CH group) (%)
51 (82) 11 (18) 0 (0) <0.001
Would you choose the same option if you had to do it again (%)
DCS group 60 (97) 2 (3) 0 (0) <0.001
CH group 59 (95) 3 (5) 0 (0) <0.001
Would you recommend this type of management to a friend (%)
DCS group 61 (98) 1 (2) 0 (0) <0.001
CH group 56 (90) 6 (10) 0 (0) <0.001
Table 5 Overall evaluation of satisfaction to perform SG depending type of management
SG sleeve gastrectomy, DCS day-case surgery, CH conventional hospitalisation
Not at all satisfied Poorly satisfied Satisfied Very satisfied Completely satisfied p value
DCS group (%) 2 (3) 6 (9.5) 6 (9.5) 18 (29) 30 (49) 0.77
CH group (%) 1 (1.5) 8 (13) 8 (13) 20 (32) 25 (40.5)
Total (%) 3 (2.4) 14 (11.3) 14 (11.3) 38 (30.6) 55 (44.4)

Journal of Anesthesia
1 3
Discussion
In the series by Auquier etal. [15], the mean score of
the cohort allowing validation of the EVAN-G score was
75±14. The series by Franck etal. [16], which validated
evaluation of satisfaction with emergency day-case sur-
gery, reported a high satisfaction rate of 82 (79–84). The
lower satisfaction rates observed in this study compared
to the literature may be due to the lower mean age and
BMI of the study population. Auquier etal. [15] reported
that higher scores were observed in older patients, while
the population in the present study was younger than in
the majority of studies using EVAN-G score and this
younger sample was, therefore, probably more demand-
ing. Several previous studies have described the negative
impact of obesity on the doctor–patient relationship [17,
18]. Wee etal. showed that the level of satisfaction was
inversely proportional to BMI [19]. The patient’s weight
is also related to care-related patient satisfaction and
obese patients reported lower levels of satisfaction for
most aspects of care compared to normal-weight patients
[19]. The difference between our results and those of other
series can, therefore, be explained by the fact that the
EVAN-G questionnaire has been validated for general sur-
gery populations, while the present study was conducted
in a specific population and the EVAN-G questionnaire
may not be sensitive to the quality of care related to the
patient’s weight. This point constitutes one of the limita-
tions of this study, as patients were not explicitly asked
whether they thought that their weight affected the way in
which they were treated by caregivers, or whether patients
thought that the teams had negative opinions concerning
them because of their weight, resulting in poorer quality
of care.
The lowest scores of the EVAN-G questionnaire were
observed for the information dimension in all studies using
this questionnaire [15, 16]. Comparison of the two types
of management showed even poorer results for this dimen-
sion in the DCS group (58.7 for day-case SG vs. 67.8 for
SG with conventional hospitalization) (Table3). These
results are fairly surprising, but can be explained by the
fact that the preoperative anesthetic consultation prior to
day-case SG was conducted by anesthetist with extensive
experience in day-case surgery, but no experience in bari-
atric surgery and who therefore probably provided poorer
quality information about the specific aspects of bariatric
surgery during the preoperative consultation.
The day-case SG group reported better pain control,
which corroborates the fact that day-case SG can be per-
formed as a primary procedure, as it is painless and the
ambulatory setting places the patient at the center of his/
her management, making the patient less dependent on
the nursing team. In day-case surgery, analgesics are only
administered in the presence of symptoms and not sys-
tematically. In conventional hospitalization, patients do
not always receive all prescribed does of analgesics, and
analgesic administration may sometimes be delayed. It has
been estimated that only 50% of patients experiencing pain
actually receive analgesics [20].
Eighty per cent of patients undergoing SG with conven-
tional hospitalization indicated that they would accept day-
case surgery if it were proposed (Table4). One explana-
tion for these results could be the short length of hospital
stay, similar to that of day-case surgery. In contrast, 19%
of patients in the day-case SG group would have preferred
to spend the night in hospital, as they would have felt reas-
sured by spending the first night in hospital. Many patients
in the DCS group reported anxiety during the first night at
home and said that they would have been psychologically
reassured by spending the first night in hospital, without
affecting their overall satisfaction with day-case surgery. A
non-medicalized structure close to the hospital could pos-
sibly constitute a good alternative in these patients [21].
The scores for the “preparation for discharge from
hospital” and “experience at home” dimensions of the
additional questionnaire were higher than the EVAN-G
score, although they assessed the same items (Table4).
This difference between the two questionnaires highlights
the problems of understanding of some of the items of the
EVAN-G questionnaire. A similar discrepancy was also
observed when analyzing the responses to the additional
binary questionnaire, as the majority of patients were
satisfied with the proposed procedure and would recom-
mend it. A higher level of satisfaction (with 75% of very
and completely satisfied patients) was also observed on
the additional questionnaire compared to the EVAN-G
questionnaire, raising the question of the validity of the
EVAN-G score in obese patients, who constitute a specific
population. Specific questionnaires evaluating quality of
life after bariatric surgery have been proposed, but appear
to be over-simplified [22].
The major limitation of this study was that it was not
a randomized study and comprised two fairly different
populations with a higher BMI, a higher proportion of
males and more comorbidities in the CH group, which
could induce a bias in this study. A randomized design
could have increased the impact of this study, but only
three series on day-case SG have been published to date
[11, 23, 24] and data on the feasibility and safety of day-
case SG are currently lacking. A randomized study in our
center would have required the inclusion of only those
patients presenting the criteria for day-case surgery and
would, therefore, have decreased the day-case SG rate.

Journal of Anesthesia
1 3
Conclusion
Overall satisfaction of patients undergoing SG as day-case
surgery was not inferior to patients managed with conven-
tional hospitalization. A specialist anesthetist consultation
should be preferred prior to day-case bariatric surgery, due
to the specific characteristics of patients undergoing bariatric
surgery. The satisfaction scores observed in this study were
lower than those reported in the literature. Moreover, dis-
crepancies were observed between the results of the EVAN-
G questionnaire and the additional questionnaires, probably
mainly related to the characteristics of our bariatric surgery
population.
Funding Support was provided solely from institutional source.
Compliance with ethical standards
Conflict of interest None of the authors have any conflicts of interest
to declare.
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