Obesity prevalence among adults aged 65 and older has been rising steadily, with approximately 39% of U.S. adults in this age group classified as obese as of 2023. Metabolic and bariatric surgery (MBS), including sleeve gastrectomy (SG), has emerged as a safe and effective intervention for weight loss and improvement of obesity-related comorbidities in older adults. Although patients ≥65 years may carry a slightly increased risk of complications, age alone is not a contraindication for MBS. Advances in minimally invasive techniques and enhanced perioperative protocols have facilitated shorter hospital stays and improved recovery. Notably, same-day discharge (SDD) after MBS has become increasingly popular, especially following the COVID-19 pandemic, with rates rising from 2.4% in 2016 to 7.4% in 2021 in the general population and from 1.15% to 4.33% in patients aged 65 and older from 2015 to 2022.

Despite this growing trend, data regarding the safety and outcomes of SDD specifically in older adults remain limited. This study aimed to evaluate and compare 30-day postoperative outcomes of SDD (postoperative day 0, POD 0) versus next-day discharge (POD 1) after minimally invasive SG in adults aged 65 and older.

A retrospective analysis was conducted using the 2022 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) dataset, which encompasses prospectively collected data from over 900 accredited centers across North America. Patients aged ≥65 years who underwent primary minimally invasive SG and were discharged home on POD 0 or POD 1 were included. Exclusion criteria were revisional procedures, discharges after POD 1, non-home discharges, previous foregut surgery, and age under 65.

Demographic, clinical, and comorbidity data were evaluated, including body mass index (BMI), functional status, smoking, and histories of diabetes, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), hypertension (HTN), and cardiac interventions. Thirty-day postoperative complications and healthcare utilization metrics such as readmissions, emergency department (ED) visits, reoperations, and outpatient intravenous (IV) fluid administration were analyzed.

To address confounding factors, propensity score matching (PSM) was performed to balance demographic variables between POD 0 and POD 1 groups. Since residual imbalances persisted post-matching, a doubly robust approach combining PSM with regression adjustment was utilized to further reduce bias.

From an initial cohort of 140,630 patients undergoing SG in 2022, 4,609 met inclusion criteria—310 discharged on POD 0 and 4,299 on POD 1. Unmatched analyses revealed that POD 0 patients were younger (mean 67.8 vs 68.4 years, p=0.004), predominantly female (81.6% vs 71.7%, p=0.0002), and had lower BMI (41.4 vs 42.6 kg/m², p=0.0003) compared to POD 1 patients. They also had fewer comorbidities including HTN, OSA, and COPD.

Despite these apparently favorable factors, POD 0 patients experienced higher rates of wound disruption (0.3% vs 0%, p<0.001), acute renal failure requiring dialysis (0.3% vs 0%, p=0.015), and significantly greater need for outpatient IV fluid administration (4.8% vs 2.4%, p=0.008). Rates of surgical site infections, thromboembolic events, ICU admissions, readmissions (2.3% each), and ED visits were comparable between groups.

After 1:1 propensity matching (310 pairs), POD 0 patients remained younger (67.8 vs 70.7 years, p<0.001), with lower BMI (41.4 vs 45.8 kg/m², p<0.001), and higher female representation (81.6% vs 27.1%, p<0.001). They continued to have fewer comorbidities such as COPD, OSA, diabetes, and cardiac disease.

Importantly, perioperative outcomes showed no significant differences in reoperation rates (0.32% each), readmissions (2.3% vs 2.6%, p=0.78), or ED visits (5.2% vs 6.5%, p=0.51). However, outpatient IV fluid administration remained significantly higher in POD 0 patients (4.8% vs 0.97%, p=0.005) even after regression adjustment.

The study highlights that while SDD after SG in older adults may be feasible for selected patients, it is associated with increased complications related to dehydration and renal dysfunction despite fewer preoperative comorbidities. Dehydration is a known postoperative risk in MBS, particularly in older adults who may be on antihypertensives such as diuretics, ACE inhibitors, or ARBs, which can impair fluid balance and renal response.

Further sub-analysis identified factors significantly associated with increased outpatient IV fluid needs: immunosuppressive medication use, history of percutaneous transluminal coronary angioplasty (PTCA), and hypertension. Patients on immunosuppressants may experience gastrointestinal side effects exacerbating fluid loss, while cardiovascular disease and antihypertensive therapies contribute to fluid regulation challenges.

The increased dehydration risk in POD 0 discharged patients suggests the need for extended inpatient monitoring or enhanced outpatient support to prevent renal complications and rehospitalization. Adoption of dehydration screening tools and remote patient monitoring technologies may improve safety for older adults undergoing SDD.

Comparison with a recent study by Hamid et al. using MBSAQIP data from 2015-2022 showed no significant increase in morbidity or mortality in older adults undergoing SDD, possibly due to differences in outcome classification and inability to isolate IV fluid administration. This underscores the importance of granular postoperative hydration assessments.

The study also acknowledges the influence of selection bias, as healthier, lower-risk patients are more likely to be chosen for SDD, while those with greater comorbidities receive extended care. This creates challenges in generalizing findings and necessitates development of standardized, evidence-based criteria for SDD eligibility that consider age-specific risks and support systems.

Policy implications include concerns about Centers for Medicare and Medicaid Services proposals to remove SG from the inpatient-only list, potentially incentivizing early discharge practices that may not suit all older adults. Equitable access to MBS and safe postoperative care requires balancing cost-saving measures with patient-centered clinical judgment.

Despite rigorous PSM and regression adjustment, residual differences between POD 0 and POD 1 groups persisted, limiting full elimination of confounding. The MBSAQIP database lacks detailed clinical decision-making data, including differentiation between planned and unplanned SDD, reducing insight into provider rationale and patient selection processes. These limitations highlight the need for prospective studies incorporating qualitative data and institutional protocols to better elucidate factors influencing discharge timing and outcomes.

As MBS increasingly favors shorter hospital stays and same-day discharge protocols, particularly in the context of healthcare resource optimization, this study emphasizes caution in applying SDD uniformly to older adults undergoing SG. While generally safe, SDD in patients aged 65 and older is linked to higher dehydration-related complications and outpatient IV fluid requirements—even among those with fewer baseline comorbidities.

Future strategies should incorporate standardized risk assessments, hydration monitoring, and remote patient surveillance to enhance postoperative safety. Establishing equitable, evidence-based discharge criteria will be critical to optimizing outcomes and avoiding disparities as healthcare policies evolve.

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