Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy

Enhanced Recovery After Surgery Guidelines and Hospital Length of Stay, Readmission, Complications, and Mortality: A Meta-Analysis of Randomized Clinical Trials

Importance

A comprehensive review of the evidence exploring the outcomes of enhanced recovery after surgery (ERAS) guidelines has not been completed.

Objective

To evaluate if ERAS guidelines are associated with improved hospital length of stay, hospital readmission, complications, and mortality compared with usual surgical care, and to understand differences in estimates based on study and patient factors.

Data Sources

MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central were searched from inception until June 2021.

Study Selection

Titles, abstracts, and full-text articles were screened by 2 independent reviewers. Eligible studies were randomized clinical trials that examined ERAS-guided surgery compared with a control group and reported on at least 1 of the outcomes.

Data Extraction and Synthesis

Data were abstracted in duplicate using a standardized data abstraction form. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Risk of bias was assessed in duplicate using the Cochrane Risk of Bias tool. Random-effects meta-analysis was used to pool estimates for each outcome, and meta-regression identified sources of heterogeneity within each outcome.

Main Outcome and Measures

The primary outcomes were hospital length of stay, hospital readmission within 30 days of index discharge, 30-day postoperative complications, and 30-day postoperative mortality.

Results

Of the 12 047 references identified, 1493 full texts were screened for eligibility, 495 were included in the systematic review, and 74 RCTs with 9076 participants were included in the meta-analysis. Included studies presented data from 21 countries and 9 ERAS-guided surgical procedures with 15 (20.3%) having a low risk of bias. The mean (SD) Reporting on ERAS Compliance, Outcomes, and Elements Research checklist score was 13.5 (2.3). Hospital length of stay decreased by 1.88 days (95% CI, 0.95-2.81 days; I2 = 86.5%; P < .001) and the risk of complications decreased (risk ratio, 0.71; 95% CI, 0.59-0.87; I2 = 78.6%; P < .001) in the ERAS group. Risk of readmission and mortality were not significant.

Conclusions and Relevance

In this meta-analysis, ERAS guidelines were associated with decreased hospital length of stay and complications. Future studies should aim to improve implementation of ERAS and increase the reach of the guidelines.

Evaluating the Impact of Enhanced Recovery After Surgery Protocols on Surgical Outcomes Following Bariatric Surgery-A Systematic Review and Meta-analysis of Randomised Clinical Trials

BACKGROUND

Enhanced recovery after surgery (ERAS) programmes are evidence-based care improvement processes for surgical patients, which are designed to decrease the impact the anticipated negative physiological cascades following surgery.

AIM

To perform a systematic review and meta-analysis of randomised clinical trials (RCTs) to evaluate the impact of ERAS protocols on outcomes following bariatric surgery compared to standard care (SC).

METHODS

A systematic review was performed in accordance with PRISMA guidelines. Meta-analysis was performed using Review Manager version 5.4 RESULTS: Six RCTs including 740 patients were included. The mean age was 40.2 years, and mean body mass index was 44.1 kg/m2. Overall, 54.1% underwent Roux-en-Y gastric bypass surgery (400/740) and 45.9% sleeve gastrectomy (340/700). Overall, patients randomised to ERAS programmes had a significant reduction in nausea and vomiting (odds ratio (OR): 0.42, 95% confidence interval (CI): 0.19-0.95, P = 0.040), intraoperative time (mean difference (MD): 5.40, 95% CI: 3.05-7.77, P < 0.001), time to mobilisation (MD: - 7.78, 95% CI: - 5.46 to - 2.10, P < 0.001), intensive care unit stay (ICUS) (MD: 0.70, 95% CI: 0.13-1.27, P = 0.020), total hospital stay (THS) (MD: - 0.42, 95% CI: - 0.69 to - 0.16, P = 0.002), and functional hospital stay (FHS) (MD: - 0.60, 95% CI: - 0.98 to - 0.22, P = 0.002) compared to those who received SC.

CONCLUSION

ERAS programmes reduce postoperative nausea and vomiting, intraoperative time, time to mobilisation, ICUS, THS, and FHS compared to those who received SC. Accordingly, ERAS should be implemented, where feasible, for patients indicated to undergo bariatric surgery. Trial registration International Prospective Register of Systematic Reviews (PROSPERO - CRD42023434492.

RESIDUAL GASTRIC VOLUME IN MORBIDLY OBESE DIABETICS AFTER AN OVERNIGHT FASTING OR 3 HOURS OF A CARBOHYDRATE-ENRICHED SUPPLEMENT: A RANDOMIZED CROSSOVER PILOT STUDY

BACKGROUND

To reduce the risk of regurgitation during anesthesia for elective procedures, residual gastric volumes (RGV) have traditionally been minimized by overnight fasting. Prolonged preoperative fasting presents some adverse consequences and has been abandoned for most surgical procedures, except for obese and/or diabetic patients.

AIMS

The aim of this study was to assess the RGV in morbidly obese diabetic patients after traditional or abbreviated fasting.

METHODS

This study was approved by the Ethics Committee for Research with Human Beings from the Federal University of Mato Grosso, under number 179.017/2012. This is a prospective, randomized, and crossover design study in eight morbidly obese type II diabetic patients. RGV was measured endoscopically after either traditional overnight fasting of at least 8 hours, or after abbreviated fasting of 6 hours for solids and 3 hours for a drink containing water plus 25 g (12.5%) of maltodextrin. Data were expressed as mean and range and differences were compared with paired t-tests at p<0.05.

RESULTS

The study population had a mean age of 41.5 years (28-53), weight of 135 kg (113-196), body mass index of 48.2 kg/m2 (40-62.4), and type II diabetes for 4.5 years (1-10). The RGV after abbreviated fasting was 21.5 ml (5-40) vs 26.3 ml (7-65) after traditional fasting. This difference was not significant (p=0.82).

CONCLUSIONS

Gastric emptying in morbidly obese diabetic patients is similar after either traditional or abbreviated fasting with a carbohydrate drink.

Shifting paradigms: protocol implementation to reduce length of stay for bariatric surgery following the pandemic at a high volume bariatric center

BACKGROUND

With the Covid-19 pandemic reducing the capacity to perform elective bariatric surgical cases, a multidisciplinary approach to reducing length of stay has been essential to continue providing this service. In conjunction with the use of our local ERAS protocols, same day discharge (SDD) and early next day discharge (NDD) for bariatric surgery is becoming more of a reality.

OBJECTIVES

To evaluate the effectiveness of our new protocols targeted at reducing length of stay (LOS) for our bariatric surgery patients during the pandemic. Secondary outcomes included comparisons of readmission and complications compared to baseline data.

METHODS

The MBSAQIP data set was analyzed identifying patients who underwent laparoscopic roux-en- Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (SG) from April to November 2021. Mean LOS and complication rates including re-admission in this baseline group were documented. This was compared to a cohort who underwent the surgeries between December 2021 and February 2022 under our new protocols for early discharge.

RESULTS

195 patients underwent bariatric surgery in the baseline group and 87 patients in the early discharge cohort were included. There was a statistically significant decrease in mean LOS comparing baseline group (34.5 h) and next day PACU discharges (25 h) with P = 0.004. No increase in complication rate from the early discharge cohort against the baseline group. (P = 0.014).

CONCLUSION

SDD and NDD in carefully selected bariatric surgery patients is feasible with good outcomes. With ERAS protocols as a foundation and a multidisciplinary approach, this can be achieved in spite of pressures placed on bariatric units by the pandemic.

Enhanced Recovery after Surgery Protocol Decreases Length of Stay and Postoperative Narcotic Use in Microvascular Breast Reconstruction

Background

Enhanced recovery after surgery (ERAS) protocols have demonstrated efficacy following microvascular breast reconstruction. This study assesses the impact of an ERAS protocol following microvascular breast reconstruction at a high-volume center.

Methods

The ERAS protocol introduced preoperative counseling, multimodal analgesia, early diet resumption, and early mobilization to our microvascular breast reconstruction procedures. Data, including length of stay, body mass index, inpatient narcotic use, outpatient narcotic prescriptions, inpatient pain scores, and complications, were prospectively collected for all patients undergoing microvascular breast reconstruction between April 2019 and July 2021. Traditional pathway patients who underwent reconstruction immediately before ERAS implementation were retrospectively reviewed as controls.

Results

The study included 200 patients, 99 in traditional versus 101 in ERAS. Groups were similar in body mass index, age (median age: traditional, 54.0 versus ERAS, 50.0) and bilateral reconstruction rates (59.6% versus 61.4%). ERAS patients had significantly shorter lengths of stay, with 96.0% being discharged by postoperative day (POD) 3, and 88.9% of the traditional cohort were discharged on POD 4 (P < 0.0001). Inpatient milligram morphine equivalents (MMEs) were smaller by 54.3% in the ERAS cohort (median MME: 154.2 versus 70.4, P < 0.0001). Additionally, ERAS patients were prescribed significantly fewer narcotics upon discharge (median MME: 337.5 versus 150.0, P < 0.0001). ERAS had a lower pain average on POD 0-3; however, this finding was not statistically significant.

Conclusion

Implementing an ERAS protocol at a high-volume microvascular breast reconstruction center reduced length of stay and postoperative narcotic usage, without increasing pain or perioperative complications.

Development and validation of a predictive model of the hospital cost associated with bariatric surgery

Hospitals are facing difficulties in predicting, evaluating, and managing cost-affecting parameters in patient treatments. Inaccurate cost prediction leads to a deficit in operational revenue. This study aims to determine the ability of Machine Learning (ML) algorithms to predict the cost of care in bariatric and metabolic surgery and develop a predictive tool for improved cost analysis. 602 patients who underwent bariatric and metabolic surgery at Wetzikon hospital from 2013 to 2019 were included in the study. Multiple variables including patient factors, surgical factors, and post-operative complications were tested using a number of predictive modeling strategies. The study was registered under Req 2022-00659 and approved by an institutional review board. The cost was defined as the sum of all costs incurred during the hospital stay, expressed in CHF (Swiss Francs). The data was preprocessed and split into a training set (80%) and a test set (20%) to build and validate models. The final model was selected based on the mean absolute percentage error (MAPE). The Random Forest model was found to be the most accurate in predicting the overall cost of bariatric surgery with a mean absolute percentage error of 12.7. The study provides evidence that the Random Forest model could be used by hospitals to help with financial calculations and cost-efficient operation. However, further research is needed to improve its accuracy. This study serves as a proof of principle for an efficient ML-based prediction tool to be tested on multi-center data in future phases of the study.

Closing the Gap: A Systematic Review and Meta-Analysis of Enhanced Recovery After Surgery Protocols in Primary Cleft Palate Repair

OBJECTIVE

Assess the evidence for Enhanced Recovery After Surgery (ERAS) protocols in the cleft palate population.

DESIGN

A systematic review of MEDLINE, Embase, Cochrane, and CINAHL databases for articles detailing the use of ERAS protocols in patients undergoing primary palatoplasty.

SETTING

New York-Presbyterian Hospital.

PATIENTS/PARTICIPANTS

Patients with cleft palate undergoing primary palatoplasty.

INTERVENTIONS

Meta-analysis of reported patient outcomes in ERAS and control cohorts.

MAIN OUTCOME MEASURE(S)

Methodological quality of included studies, opioid use, postoperative length of stay (LOS), rate of return to emergency department (ED)/readmission, and postoperative complications.

RESULTS

Following screening, 6 original articles were included; all were of Modified Downs & Black (MD&B) good or fair quality. A total of 354 and 366 were in ERAS and control cohorts, respectively. Meta-analysis of comparable ERAS studies showed a difference in LOS of 0.78 days for ERAS cohorts when compared to controls (P < .05). Additionally, ERAS patients utilized significantly less postoperative opioids than control patients (P < .05). Meta-analysis of the rate of readmission/return to ED shows no difference between ERAS and control groups (P = .59). However, the lack of standardized reporting across studies limited the power of meta-analyses.

CONCLUSIONS

ERAS protocols for cleft palate repair offer many advantages for patients, including a significant decrease in the LOS and postoperative opioid use without elevating readmission and return to ED rates. However, this analysis was limited by the paucity of literature on the topic. Better standardization of data reporting in ERAS protocols is needed to facilitate pooled meta-analysis to analyze their effectiveness.

Impact of enhanced recovery pathways on patient-reported outcomes after abdominal surgery: a systematic review

INTRODUCTION

Evidence supports that enhanced recovery pathways (ERPs) reduce length of stay and complications; however, these measures may not reflect the perspective of patients who are the main stakeholders in the recovery process. This systematic review aimed to appraise the evidence regarding the impact of ERPs on patient-reported outcomes (PROs) after abdominal surgery.

METHODS

Five databases (Medline, Embase, Biosis, Cochrane, and Web of Science) were searched for randomized controlled trials (RCTs) addressing the impact of ERPs on PROs after abdominal surgery. We focused on distinct periods of recovery: early (within 7 days postoperatively) and late (beyond 7 days). Risk of bias was assessed using Cochrane's RoB 2.0. Results were appraised descriptively as heterogeneity hindered meta-analysis. Certainty of evidence was evaluated using GRADE.

RESULTS

Fifty-six RCTs were identified [colorectal (n = 18), hepatopancreaticobiliary (HPB) (n = 11), upper gastrointestinal (UGI) (n = 10), gynecological (n = 7), urological (n = 7), general surgery (n = 3)]. Most trials had 'some concerns' (n = 30) or 'high' (n = 25) risk of bias. In the early postoperative period, ERPs improved patient-reported general health (colorectal, HPB, UGI, urological; very low to low certainty), physical health (colorectal, gynecological; very low to low certainty), mental health (colorectal, gynecological; very low certainty), pain (all specialties; very low to moderate certainty), and fatigue (colorectal; low certainty). In the late postoperative period, ERPs improved general health (HPB, UGI, urological; very low certainty), physical health (UGI, gynecological, urological; very low to low certainty), mental health (UGI, gynecological, urological; very low certainty), social health (gynecological; very low certainty), pain (gynecological, urological; very low certainty), and fatigue (gynecological; very low certainty).

CONCLUSION

This review supports that ERPs may have a positive impact on patient-reported postoperative health status (i.e., general, physical, mental, and social health) and symptom experience (i.e., pain and fatigue) after abdominal surgery; however, data were largely derived from low-quality trials. Although these findings contribute important knowledge to inform evidence-based ERP implementation, there remains a great need to improve PRO assessment in studies focused on postoperative recovery.

Development and Implementation of an Enhanced Recovery Protocol for Bariatric Patients in a Third World Environment

Introduction: An applicable and reproducible enhanced recovery protocol was developed and implemented to improve our outcomes in a third-world environment. Methods: We compared the results obtained prospectively. The group treated before the application of the enhanced recovery protocol was called usual care (UC) and included all bariatric surgeries operated on between 2014 and 2017. The new protocol was applied between 2017 and 2019 including all operated patients, and this group was called Fast Track (FT). The variables analyzed were the length of stay, readmissions, and complications recorded during the first 30 days. We also analyzed the milligrams of morphine used by each patient, and a cost analysis was performed. Results: During the study period, 816 patients were studied. Of these, 385 (47.2%) belonged to the UC group and 431 (52.8%) to the FT group. The mean hospital stay was 58.5 hours (UC) versus 40.3 hours (FT) (P = .0001). When comparing the global morbidity of both groups, we did not find significant differences (P = .47). There was also no statistically significant difference when comparing major complications (P = .79). No mortality was recorded. Morphine indication reported a statistically significant difference that favored FT. Costs were significantly higher in UC than in FT (P < .0001). Conclusions: We believe that the implementation of an enhanced recovery protocol in bariatric surgery is a reliable measure and can be implemented even in an underdevelopment environment enlarging the benefit for patients.

Decreasing length of stay in breast reconstruction patients: A national analysis of 2019-2020

BACKGROUND

The effects of COVID-19 on breast reconstruction included shifts toward alloplastic reconstruction methods to preserve hospital resources and minimize COVID exposures. We examined the effects of COVID-19 on breast reconstruction hospital length of stay (LOS) and subsequent early postoperative complication rates.

METHODS

Using the National Surgical Quality Improvement Program, we examined female patients who underwent mastectomy with immediate breast reconstruction from 2019 to 2020. We compared postoperative complications across 2019-2020 for alloplastic and autologous reconstruction patients. We further performed subanalysis of 2020 patients based on LOS.

RESULTS

Both alloplastic and autologous reconstruction patients had shorter inpatient stays. Regarding the alloplastic 2019 versus 2020 cohorts, complication rates did not differ (p > 0.05 in all cases). Alloplastic patients in 2020 with longer LOS had more unplanned reoperations (p < 0.001). Regarding autologous patients in 2019 versus 2020, the only complication increasing from 2019 to 2020 was deep surgical site infection (SSI) (2.0% vs. 3.6%, p = 0.024). Autologous patients in 2020 with longer LOS had more unplanned reoperations (p = 0.007).

CONCLUSIONS

In 2020, hospital LOS decreased for all breast reconstruction patients with no complication differences in alloplastic patients and a slight increase in SSIs in autologous patients. Shorter LOS may lead to improved satisfaction and lower healthcare costs with low complication risk, and future research should examine the potential relationship between LOS and these outcomes.

Implementing novel modalities into an institutional enhanced recovery after bariatric surgery (ERABS) protocol

INTRODUCTION

Enhanced recovery after bariatric surgery pathways are associated with improved postoperative outcomes. This study aims to assess efficacy and safety of three novel protocol contributions (transversus abdominis plane blocks, ketamine and fosaprepitant), as well as their impact on length of stay (LOS) and on postoperative complications.

METHODS

Effectiveness and safety were retrospectively investigated in patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) over a 6-year period in a single institution. Group 1 patients were not exposed to any of our suggested interventions, whereas Group 2 were exposed to all of three.

RESULTS

Between January 2015 and August 2021, 1480 patients underwent primary SG (77.6%) or RYGB (22.4%); of those, 1132 (76.5%) and 348 (23.5%) were in Groups 1 and 2, respectively. Mean BMI and age were 45.87 versus 43.65 kg/m² and 45.53 versus 44.99 years in groups 1 and 2, respectively. Suggested interventions were associated with lower operative times (84.79 ± 24.21 vs. 80.78 ± 32.8 min, p = 0.025). In Group 2, the mean LOS decreased in 0.18 day (1.79 ± 1.04 vs. 1.60 ± 0.90; p = 0.004). Overall complication rates were 8% and 8.6% for groups 1 and 2, respectively; readmission rates were 5.7% (64 pts) vs. 7.2% (25 pts), p > 0.05. Reoperations were less prevalent in Group 2 (1.5% vs. 1.1%; p = 0.79).

CONCLUSION

Focus on optimized pain management, allied to a superior PONV control, may be relevant contributors for a lower LOS without negative impacts in complications rates.

Efficacy and safety of enhanced recovery after surgery protocol on minimally invasive bariatric surgery: a meta-analysis

BACKGROUND

Enhanced recovery after surgery (ERAS), a multidisciplinary and multimodal perioperative care protocol, has been widely used in several surgical fields. However, the effect of this care protocol on patients receiving minimally invasive bariatric surgery remains unclear. This meta-analysis compared the clinical outcomes of the ERAS protocol and standard care (SC) in patients who underwent minimally invasive bariatric surgery.

MATERIAL AND METHODS

PubMed, Web of Science, Cochrane Library, and Embase databases were systematically searched to identify literature reporting the effects of the ERAS protocol on clinical outcomes in patients undergoing minimally invasive bariatric surgery. All the articles published until 01 October 2022, were searched, followed by data extraction of the included literature and independent quality assessment. Then, pooled mean difference (MD) and odds ratio with a 95% CI were calculated by either a random-effects or fixed-effects model.

RESULTS

Overall, 21 studies involving 10 764 patients were included in the final analysis. With the ERAS protocol, the length of hospitalization (MD: -1.02, 95% CI: -1.41 to -0.64, P <0.00001), hospitalization costs (MD: -678.50, 95% CI: -1196.39 to -160.60, P =0.01), and the incidence of 30-day readmission (odds ratio =0.78, 95% CI: 0.63-0.97, P =0.02) were significantly reduced. The incidences of overall complications, major complications (Clavien-Dindo grade ≥3), postoperative nausea and vomiting, intra-abdominal bleeding, anastomotic leak, incisional infection, reoperation, and mortality did not differ significantly between the ERAS and SC groups.

CONCLUSIONS

The current meta-analysis indicated that the ERAS protocol could be safely and feasibly implemented in the perioperative management of patients receiving minimally invasive bariatric surgery. Compared with SC, this protocol leads to significantly shorter hospitalization lengths, lower 30-day readmission rate, and hospitalization costs. However, no differences were observed in postoperative complications and mortality.

A randomized controlled trial of an enhanced recovery after surgery protocol in patients undergoing laparoscopic sleeve gastrectomy

BACKGROUND

The purpose of this study was to evaluate the effect of an enhanced recovery after surgery (ERAS) protocol on opioid and anti-emetic use, length of stay and safety after laparoscopic sleeve gastrectomy (LSG).

METHODS

Patients who underwent LSG between March 2018 and January 2019 at our accredited, high-volume bariatric surgery center were randomized to either standard of care (SOC) or ERAS. ERAS included a pre- and post-surgical medication regimen designed to reduce postoperative nausea, vomiting and pain. Outcomes included post-operative symptom scores, opioid use, anti-emetic use, time to achieve readiness for discharge (RFD) and inpatient and 30-day adverse events, readmissions and emergency department visits.

RESULTS

The final analysis included 130 patients, (SOC 65; ERAS 65). Groups did not differ on demographics or comorbidities. Relative to SOC, fewer ERAS patients utilized opioids in the hospital ward (72.3% vs. 95.4%; p < .001), peak pain scores were significantly lower, and median time to achieve RFD was shorter (28.0 h vs. 44.4 h; p = 0.001). More ERAS patients were discharged on post-operative day 1 (38.5% vs. 15.4%; p < .05). The overall use of rescue anti-emetic medications was not different between groups. Rates of postoperative 30-day events, readmissions, and emergency department visits did not differ between groups.

CONCLUSION

Relative to SOC, ERAS was associated with earlier discharge, lower pain scores, less frequent use of opioids and use in lower amounts after LSG with no differences in 30 day safety outcomes.

S136-operationalizing an enhanced recovery protocol after bariatric surgery: single institutional pilot experience forging data-driven standard work

BACKGROUND

Enhanced recovery protocols (ERPs) after metabolic and bariatric surgery (MBS) may help decrease length of stay (LOS) and postoperative nausea/vomiting but implementation is often fraught with challenges. The primary aim of this pilot study was to standardize a MBS ERP with a real-time data support dashboard and checklist and assess impact on global and individual element compliance. The secondary aim was to evaluate 30 day outcomes including LOS, hospital readmissions, and re-operations.

METHODS AND PROCEDURES

An ERP, paper checklist, and virtual dashboard aligned on MBS patient care elements for pre-, intra-, and post-operative phases of care were developed and sequentially deployed. The dashboard includes surgical volumes, operative times, ERP compliance, and 30 day outcomes over a rolling 18 month period. Overall and individual element ERP compliance and outcomes were compared pre- and post-implementation via two-tailed Student's t-tests.

RESULTS

Overall, 471 patients were identified (pre-implementation: 193; post-implementation: 278). Baseline monthly average compliance rates for all patient care elements were 1.7%, 3.7%, and 6.2% for pre-, intra-, and post-operative phases, respectively. Following ERP integration with dashboard and checklist, the intra-operative phase achieved the highest overall monthly average compliance at 31.3% (P < 0.01). Following the intervention, pre-operative acetaminophen administration had the highest monthly mean compliance at ≥ 99.1%. Overall TAP block use increased 3.2-fold from a baseline mean rate of 25.4-80.8% post-implementation (P < 0.01). A significant decrease in average intra-operative monthly morphine milligram equivalents use was noted with a 56% drop pre- vs. post-implementation. Average LOS decreased from 2.0 to 1.7 days post-implementation with no impact on post-operative outcomes.

CONCLUSION

Implementation of a checklist and dashboard facilitated ERP integration and adoption of process measures with many improvements in compliance but no impact on 30 day outcomes. Further research is required to understand how clinical support tools can impact ERP adoption among MBS patients.

Enhanced Recovery After Surgery Promotes Recovery in Sleeve Gastrectomy: A Randomized Controlled Trial

Introduction: The most popular approach for treating obesity is laparoscopic sleeve gastrectomy (LSG). The enhanced recovery after surgery (ERAS) protocol aims to reduce the patient's surgical stress response, optimize their physiological function, and facilitate recovery. The purpose of this study was to investigate the efficacy and safety of the ERAS protocol in patients who have undergone LSG. Methods: Between January 2020 and March 2021, a single-center randomized controlled study with patients undergoing LSG was planned. Patient demographics, duration of surgery and anesthetic induction, postoperative nausea-vomiting (PONV) and pain scores, length of hospital stay, and emergency room readmissions within the first 30 days were also documented. Patients were divided into two groups: those who followed the ERAS protocol and those who did not. The senior surgeon was blinded for the preoperative and postoperative period, whereas the other surgeon was not. The groups were compared in terms of length of hospital stay, duration of surgery, visual analog scale (VAS) scores, PONV effect scores, and emergency service admissions within the first 30 days after surgery. Results: A total of 96 patients were included in this study. Of these, 49 were in the ERAS protocol group and 47 were in the traditional treatment group. The mean age of the patients in the ERAS and traditional treatment groups were 37.47 ± 10.11 years and 35.77 ± 9.62 years, respectively. While the ERAS group patients were hospitalized for a mean of 30.46 ± 11.26 hours, the traditional group patients were hospitalized for 52.02 ± 6.63 hours (P: .001). There was no difference between the groups in terms of the first 30-day readmission to the emergency department (P: .498). Both VAS and PONV effect scores at the 2nd and 12th hours of the ERAS group patients were lower (P: .001, .002, .001, .001, respectively). Conclusions: When compared with the conventional method, the ERAS protocol reduced patient hospitalization time, decreased postoperative nausea, vomiting, and pain scores, and did not vary in postoperative emergency department readmissions. In patients receiving LSG, the ERAS protocol can be employed safely and successfully. Clinical Trial Registration number: NCT04442568.

Enhanced recovery after surgery (ERAS) decreases complications and reduces length of stay in foregut surgery patients

INTRODUCTION

Enhanced recovery after surgery (ERAS) programs provide a framework for optimal perioperative care to improve post-operative outcomes following surgical procedures. However, there is no consensus regarding an ERAS protocol following foregut surgery. The purpose of this study was to develop an ERAS protocol for these patients and determine whether they improved outcomes.

METHODS

An IRB approved prospectively maintained database was retrospectively reviewed for all patients undergoing benign minimally invasive foregut surgery from October 2018 to January 2020. All patients were entered into the ACS risk calculator to determine their predicted rate of complications and length of stay for comparison between the ERAS and control groups. Propensity matching was used to compare post-ERAS implementation to pre-ERAS implementation patients. Firth logistic and Poisson regression analysis were used to assess the rate of complications and length of stay among the different groups of patients.

RESULTS

There were 255 patients (60 Post-ERAS, 195 Pre-ERAS) who underwent foregut operations and met inclusion criteria. ERAS was implemented, and patients were then subdivided based on those who completed ERAS (44) and those who deviated from the protocol (16). Propensity matching analysis was performed to compare the different cohorts and showed ERAS patients had 41% decreased odds of complications and 33% reduction in length of stay compared to pre-ERAS patients. Completion of the ERAS protocol resulted in even further reductions in odds of complication and length of stay compared to patients who deviated from the protocol.

CONCLUSIONS

ERAS has shown to improve perioperative outcomes, but there is limited literature supporting the use of ERAS in foregut surgery. Usage of an ERAS protocol can decrease complications and reduce the length of stay in patients.

When is it safe for the liver donor to be discharged home and prevent unnecessary re-hospitalizations? - A systematic review of the literature and expert panel recommendations

BACKGROUND

Few data are available on discharge criteria after living liver donation (LLD).

OBJECTIVES

To identify the features for fit for discharge checklist after LLD to prevent unnecessary re-hospitalizations and to provide international expert recommendations.

DATA SOURCES

Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central.

METHODS

Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. The critical outcomes included were complications rates and liver function (defined by elevated bilirubin and INR) (CRD42021260725).

RESULTS

Total 57/1710 studies were included in qualitative analysis and 28/57 on the final analysis. No randomized controlled trials were identified. The complications rate was reported in 20/28 studies and ranged from 7.8% to 71.2%. Post hepatectomy liver function was reported in 13 studies. The Quality of Evidence (QoE) was Low and Very-Low for complications rate and liver function test, respectively.

CONCLUSIONS

Monitoring and prevention of donor complications should be crucial in decision making of discharge. Pain and diet control, removal of all drains and catheters, deep venous thrombosis prophylaxis, and use routine imaging (CT scan or liver ultrasound) before discharge should be included as fit for discharge checklist (QoE; Low | GRADE of recommendation; Strong). Transient Impaired liver function (defined by elevated bilirubin and INR), a prognostic marker of outcome after liver resection, usually occurs after donor right hepatectomy and should be monitored. Improving trends for bilirubin and INR value should be observed by day 5 post hepatectomy and be included in the fit for discharge checklist. (QoE; Very-Low | GRADE; Strong).

Pharmacokinetics and local tissue response to local instillation of vocacapsaicin, a novel capsaicin prodrug, in rat and rabbit osteotomy models

Vocacapsaicin is a novel prodrug of trans-capsaicin (trans-8-methyl-N-vanillyl-6-nonenamide) being developed as a nonopioid, long-lasting, site-specific treatment for postsurgical pain management. The objective of these studies was to examine the safety and tolerability of vocacapsaicin in an osteotomy model in two animal species and to evaluate bone healing parameters. Rats undergoing unilateral femoral osteotomy received a single perioperative administration (by instillation) of vocacapsaicin (vehicle, 0.15, 0.3, and 0.6 mg/kg). Rabbits undergoing unilateral ulnar osteotomy received a single perioperative administration (by infiltration and instillation) of vocacapsaicin (vehicle, 0.256 and 0.52 mg) alone or in combination with 0.5% ropivacaine. Clinical signs, body weights, food consumption, radiography, histopathologic examinations, ex vivo bone mineral density measurements (rats only), and biomechanical testing were evaluated at 4 and 8 weeks in rats and at 2 and 10 weeks in rabbits. Plasma samples were also collected in rabbits. There were no vocacapsaicin-related effects on mortality, clinical observations, body weight, or food consumption in either species. Systemic exposure to vocacapsaicin and its metabolites, including capsaicin, was transient. In rats, vocacapsaicin was devoid of deleterious effects on bone healing parameters, and there was a trend for enhanced bone healing in rats treated with the mid-dose. In rabbits, vocacapsaicin administered alone or in combination with ropivacaine did not adversely affect bone healing parameters. In conclusion, a single perioperative administration of vocacapsaicin in unilateral osteotomy models was well tolerated, locally and systemically, supporting its continued development as a novel, nonopioid treatment for postsurgical pain management.

Effect of a single sub-dose of ketamine on postoperative fatigue syndrome in colorectal cancer patients undergoing radical laparoscopic surgery: A double-blind, pilot study

BACKGROUND

This study aimed at examining the effect of a single sub-anesthetic dose of ketamine on postoperative fatigue syndrome (POFS) in patients undergoing radical laparoscopic surgery for colorectal cancer (CRC).

METHODS

This prospective, double-blind, pilot study enrolled patients scheduled for radical laparoscopic surgery for CRC under general anesthesia. Eligible patients were randomized into the placebo and ketamine groups. The primary outcome was christensen score change at day 3. The secondary outcomes were the difference of Identity Consequence Fatigue Scale (ICFS) score between the placebo group and ketamine group at day 3 and level of serum tumor necrosis factor (TNF)-α, interleukin (IL)-6, S100β protein, and neuron-specific enolase (NSE).

RESULTS

32 participants were assigned to the ketamine group and 31 to the placebo group. Compared with placebo group, the Christensen score was lower in ketamine group at day 3 (absolute difference, -1.13; 95 % confidence interval [CI], -2.02 to -0.24; P = 0.012). Ketamine group was superior to the placebo group with regard to the ICFS scores at day 3 (absolute difference, -6.4; 95 % CI, -11.4 to -1.4; P = 0.013). The plasma TNF-α, IL-6, S100β, and NSE levels were increased after operation compared with baseline in both groups and were significantly higher in placebo group than in ketamine group within 24 h after surgery (all P < 0.05). There was no significant difference of each safety evaluation indicator between the two groups (all P > 0.05).

CONCLUSION

A single sub-anesthetic dose of ketamine may improve POFS in patients undergoing radical laparoscopic surgery for CRC, without postoperative adverse reactions.

Enhanced recovery after bariatric surgery: an Italian consensus statement

Background

Enhanced recovery after bariatric surgery (ERABS) is an approach developed to improve outcomes in obese surgical patients. Unfortunately, it is not evenly implemented in Italy. The Italian Society for the Surgery of Obesity and Metabolic Diseases and the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care joined in drafting an official statement on ERABS.

Methods

To assess the effectiveness and safety of ERABS and to develop evidence-based recommendations with regard to pre-, intra-, and post-operative care for obese patients undergoing ERABS, a 13-member expert task force of surgeons and anesthesiologists from Italian certified IFSO center of excellence in bariatric surgery was established and a review of English-language papers conducted. Oxford 2011 Levels of Evidence and U.S. Preventive Services Task Force Grade Definitions were used to grade the level of evidence and the strength of recommendations, respectively. The supporting evidence and recommendations were reviewed and discussed by the entire group at meetings to achieve a final consensus.

Results

Compared to the conventional approach, ERABS reduces the length of hospital stay and does not heighten the risk of major post-operative complications, re-operations, and hospital re-admissions, nor does it increase the overall surgical costs. A total of 25 recommendations were proposed, covering pre-operative evaluation and care (7 items), intra-operative management (1 item, 11 sub-items), and post-operative care and discharge (6 items).

Conclusions

ERABS is an effective and safe approach. The recommendations allow the proper management of obese patients undergoing ERABS for a better outcome.

Impact of an Enhanced Recovery After Surgery Protocol on Unplanned Patient Encounters in the Early Postoperative Period After Ureteroscopy

Introduction: Ureteroscopy (URS) is associated with substantial patient-perceived morbidity. To improve the patient experience, we developed an enhanced recovery after surgery (ERAS) protocol for URS. We sought to determine if an ERAS protocol could reduce unplanned patient-initiated encounters. Materials and Methods: The ERAS protocol involves the preoperative administration of four medications to patients undergoing URS. We reviewed data on 100 consecutive patients undergoing URS with ureteral stent placement between April 2018 and August 2018. All unplanned postoperative encounters, including phone calls and electronic medical record messages, unplanned urology outpatient visits, emergency department (ED) visits, and re-admissions within 30 days of surgery, were recorded. A control group of patients undergoing URS between July 2013 and November 2014 served as a comparison group. Propensity score matching was performed. Statistical analysis included Mann-Whitney U test, Student's t-test, and Fischer's exact test. Univariable and multivariable (MVA) analyses were performed. Results: Using propensity score matching, 71 pre-ERAS (median age 57 years, interquartile range [IQR] 44-65) and 71 post-ERAS (median age 56 years, IQR 47-68) patients were compared. Although ED visits and postoperative readmissions were comparable between the two groups, significantly more unplanned phone calls/messages occurred in the pre-ERAS group than in the post-ERAS group (71 vs 27, respectively, p < 0.001). MVA regression analysis identified the ERAS protocol as a significant independent predictor of fewer patient calls (odds ratio 0.24, 95% confidence interval 0.12-0.50, p < 0.001). Conclusions: Analysis of an ERAS protocol for patients undergoing URS showed a reduction in unplanned patient-initiated communication, with implementation of the protocol. ClinicalTrials.gov: NCT04112160.

Rapid rehabilitation effect on complications, wound infection, anastomotic leak, obstruction, and hospital re-admission for gastrointestinal surgery subjects: A meta-analysis

We performed a meta‐analysis to evaluate the effect of rapid rehabilitation on the curative effect of gastrointestinal surgery subjects. A systematic literature search up to October 2021 was done and 31 studies included 4448 subjects with gastrointestinal surgery at the start of the study: 2242 of them were provided with rapid rehabilitation and 2206 were standard care. They were reporting relationships about the effect of rapid rehabilitation on the curative effect of gastrointestinal surgery subjects. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) to assess the effect of rapid rehabilitation on the curative effect of gastrointestinal surgery subjects using the dichotomous method with a random‐ or fixed‐effect model. Rapid rehabilitation had significantly lower complications (OR, 0.62; 95% CI, 0.54‐0.71, P < .001) and wound infection (OR, 0.73; 95% CI, 0.55‐0.98, P = .03) compared with standard care in subjects with gastrointestinal surgery. However, rapid rehabilitation had no significant effect on the anastomotic leak (OR, 0.90; 95% CI, 0.66‐1.22, P = .49), obstruction (OR, 0.92; 95% CI, −0.64 to 1.31, P = .65), and hospital re‐admission (OR, 0.78; 95% CI, 0.57‐1.08, P = .13) compared with standard care in subjects with gastrointestinal surgery. Rapid rehabilitation had significantly lower complications and wound infection, and had no significant effect on the anastomotic leak, obstruction, and hospital re‐admission compared with standard care in subjects with gastrointestinal surgery. Further studies are required to validate these findings.

Combined opioid free and loco-regional anaesthesia enhances the quality of recovery in sleeve gastrectomy done under ERAS protocol: a randomized controlled trial

Background

It is debatable whether opioid-free anaesthesia (OFA) is better suited than multimodal analgesia (MMA) to achieve the goals of enhanced recovery after surgery (ERAS) in patients undergoing laparoscopic sleeve gastrectomy.

Methods

In all patients, anaesthesia was conducted with an i.v. induction with propofol (2 mg. kg-1), myorelaxation with cisatracurium (0.15 mg.kg-1), in addition to an ultrasound-guided bilateral oblique subcostal transverse abdominis plane block. In addition, patients in the OFA group (n = 51) received i.v. dexmedetomidine 0.1 μg.kg-1 and ketamine (0.5 mg. kg-1) at induction, then dexmedetomidine 0.5 μg. kg-1.h-1, ketamine 0.5 mg.kg-1.h-1, and lidocaine 1 mg. kg-1.h-1 for maintenance, while patients in the MMA group (n = 52) had only i.v. fentanyl (1 μg. kg-1) at induction. The primary outcome was the quality of recovery assessed by QoR-40, at the 6th and the 24th postoperative hour. Secondary outcomes were postoperative opioid consumption, time to ambulate, time to tolerate oral fluid, and time to readiness for discharge.

Results

At the 6th hour, the QoR-40 was higher in the OFA than in the MMA group (respective median [IQR] values: 180 [173–195] vs. 185 [173–191], p < 0.0001), but no longer difference was found at the 24th hour (median values = 191 in both groups). OFA also significantly reduced postoperative pain and morphine consumption (20 mg [1–21] vs. 10 mg [1–11], p = 0.005), as well as time to oral fluid tolerance (238 [151–346] vs. 175 min [98–275], p = 0.022), and readiness for discharge (505 [439–626] vs. 444 min [356–529], p = 0.001), but did not influence time to ambulate.

Conclusion

While regional anaesthesia achieved most of the intraoperative analgesia, avoiding intraoperative opioids with the help of this OFA protocol was able to improve several sensible parameters of postoperative functional recovery, thus improving our knowledge on the OFA effects.

Clinical trial number

Registration number NCT04285255.

Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update

Background

This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol.

Methods

A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations.

Results

The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries.

Conclusion

A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.

Enhanced Recovery after Surgery in Bariatric Surgery

The enhanced recovery after surgery (ERAS) program is now widely applied in bariatric surgeries and other surgical procedures. The ERAS program in bariatric surgery consists of various components similar to that in colorectal surgery or other procedures. The major concept of the ERAS protocol relies on a multidisciplinary and multimodal approach to resolve various problems after surgical treatment. The key principles of the ERAS program in bariatric surgery include patient education, opioid-sparing multimodal pain management, prophylaxis of postoperative nausea and vomiting, goal-directed fluid therapy, and minimizing insulin resistance and catabolism. Several guidelines and studies, including randomized clinical trials and systematic reviews, have advocated for the ERAS program in bariatric surgery, which has consistently shown advantages in shortening hospital stay without increasing morbidity. The systematic application of the ERAS program in bariatric patients results in less pain and early recovery and should be routinely recommended.

ERAS reduces postoperative hospital stay and complications after bariatric surgery: A retrospective cohort study

Enhanced recovery after surgery (ERAS) is a multimodal, multidisciplinary approach for caring surgical patients. The present study aimed to compare the perioperative outcomes of laparoscopic bariatric surgery between patients with ERAS and those with conventional care.The clinical data of all patients undergoing primary laparoscopic bariatric surgery between January 2014 and June 2017 were retrospectively collected and reviewed. Patients were managed with conventional care during 2014 to 2015 (conventional care group) and with ERAS protocols during 2016 to 2017 (ERAS group). The 2 groups were compared in terms of postoperative length of hospital stay (LOS) and postoperative day 1 discharge rate.A total of 435 consecutive patients were included with 198 patients in the conventional care group and 237 patients in the ERAS group. The ERAS group had significantly shorter LOS (2.2 ± 0.9 vs 4.0 ± 2.6 days, P < .01) and significantly higher day 1 discharge rate (15.2% vs 1%, P < .01) compared with the conventional care group. During postoperative 30 days, the ERAS group had significantly less complications (2.1% vs 8.6%, P < .01) and readmissions (1.3% vs 4.5%, P = .02) compared with the conventional care group.Compared with conventional care, ERAS significantly reduces postoperative LOS, complications, and readmissions in patients undergoing laparoscopic bariatric surgery.

Enhanced Recovery Pathways for Flap-Based Reconstruction: Systematic Review and Meta-Analysis

BACKGROUND

Enhanced Recovery After Surgery (ERAS) pathways are known to improve patient outcomes after surgery. In recent years, there have been growing interest in ERAS for reconstructive surgery.

OBJECTIVES

To systematically review and summarise literature on the key components and outcomes of ERAS pathways for autologous flap-based reconstruction.

DATA SOURCES

Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Current Controlled Trials, World Health Organization International Clinical Trials Registry Platform and reference lists of relevant studies.

INCLUSION CRITERIA

All primary studies of ERAS pathways for free and pedicled flap-based reconstructions reported in the English language.

OUTCOME MEASURES

The primary outcome measure was length of stay. Secondary outcomes were complication rates including total flap loss, partial flap loss, unplanned reoperation within 30 days, readmission to hospital within 30 days, surgical site infections and medical complications.

RESULTS

Sixteen studies were included. Eleven studies describe ERAS pathways for autologous breast reconstructions and five for autologous head and neck reconstructions. Length of stay was lower in ERAS groups compared to control groups (mean reduction, 1.57 days; 95% CI, - 2.15 to - 0.99). Total flap loss, partial flap loss, unplanned reoperations, readmissions, surgical site infections and medical complication rates were similar between both groups. Compliance rates were poorly reported.

CONCLUSION

ERAS pathways for flap-based reconstruction reduce length of stay without increasing complication rates. ERAS pathways should be adapted to each institution according to their needs, resources and caseload. There is potential for the development of ERAS pathways for chest wall, perineum and lower limb reconstruction.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Outcomes of Enhanced Recovery After Surgery Protocols Versus Conventional Management in Patients Undergoing Bariatric Surgery

Background: Enhanced recovery after surgery (ERAS) pathways focus on decreasing surgical stress and promoting return to normal function for patients undergoing surgical procedures. The aim of our study was to evaluate the impact of an ERAS protocol on outcomes of patients undergoing primary sleeve gastrectomy and Roux-en-Y gastric bypass. Outcomes included hospital length of stay (LOS), and management of postoperative pain and postoperative nausea and vomiting (PONV) measured by pain medications and antiemetic use, respectively. Incidence of 90-day emergency department (ED) visits, readmissions, and complications were also analyzed. Methods: A retrospective review was performed from October 1, 2016 to October 31, 2018 of patients enrolled in the ERAS versus the conventional pathway. Patient baseline characteristics, pain and nausea scores, LOS, and postoperative outcome variables were collected. Results: Non-ERAS (n = 193) and ERAS (n = 173) groups had similar patient characteristics. Fewer ERAS patients required postoperative opioids and antiemetics (P < .01), with a significant difference in postoperative nausea control in favor of ERAS patients (P < .05). There was a decreasing trend in median LOS (2 versus 1, P = .28), 90-day postoperative readmissions (10.4% versus 8.1%, P = .47), and major adverse events (5.2% versus 1.7%, P = .07) after ERAS implementation. The ED visits and postoperative need for intravenous fluid for dehydration were significantly lower in the ERAS group (P = .01). Conclusion: Implementation of ERAS pathway for bariatric surgery was associated with less opioid usage, PONV, ED visits, and postoperative need for intravenous fluids, without increasing LOS, 90-day readmission or rates of adverse effects.

The influence of preoperative carbohydrate loading on postoperative outcomes in bariatric surgery patients: a randomized, controlled trial

BACKGROUND

Preoperative carbohydrate loading is a component of Enhanced Recovery After Surgery (ERAS) protocols, but there is limited literature in bariatric surgery patients.

OBJECTIVES

The objective of this study was to characterize the impact of preoperative carbohydrate loading on postoperative bariatric surgery outcomes.

SETTING

University Hospital.

METHODS

Patients undergoing a primary minimally invasive Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between 2018 and 2020 were randomized to standard management or intervention. Standard management patients were nothing by mouth (NPO) after midnight prior to surgery. Intervention patients consumed 2 carbohydrate drinks: 1 the night before and another 3 hours prior to surgery. Primary outcomes analyzed included postoperative nausea and vomiting (PONV), length of stay, and overall complications.

RESULTS

In total, 134 patients were analyzed: 64 intervention (47.8%) and 70 (52.2%) standard. In the end, 7% and 15% of patients were lost to follow-up at 6-weeks and 3-months, respectively. There was no statistically significant difference in length of stay (2.0 ± 1.2 vs 2.1 ± .9 d; P = .65) or postoperative outcomes between the 2 groups. There were no episodes of aspiration among the intervention group. Among RYGB patients, intervention patients had a shorter duration of nausea compared with standard patients. There was no significant difference in glycemic control among patients with and without diabetes.

CONCLUSIONS

Preoperative carbohydrate drinks can be administered to bariatric surgery patients without significant risks. Carbohydrate loading preoperatively can decrease the duration of PONV in RYGB patients. Carbohydrate drinks can be safely included in bariatric ERAS protocols for patients with and without diabetes, although the benefits remain unknown.

Analysis of the 'Evaluation Indicators' of an Enhanced Recovery After Bariatric Surgery Pathway in the First Six Months After Implementation

The implementation of a clinical pathway in bariatric surgery (BS) might facilitate systemic care. Focusing on enhanced recovery after surgery (ERAS) programs may also improve surgical outcomes depending on the degree of adherence achieved. We hypothesized that the implementation of an ERAS clinical pathway in BS (ERABS) improves clinical outcomes compared to traditional treatment in a tertiary care hospital. The main objective was to assess the degree of adherence to the ERABS program. Secondary objectives were to evaluate compliance with the quality indicators of the Spanish Society for Obesity Surgery (SECO) and overall patients' satisfaction. A retrospective observational study was designed. Data from patients who underwent BS into an ERABS context were reviewed and compared with traditionally treated patients. Process and outcomes indicators adapted from RICA (Recuperación Intensificada en Cirugía Abdominal) pathway, degree of compliance with SECO quality indicators and patients' satisfaction were analyzed. Forty-three patients were included per group. Indicators' compliance rate per patient was 83.23%. Differences were found in postoperative bleeding, immediate morbidity and overall morbidity, but not in severity of complications. No patient felt dissatisfied or unsatisfied. Average compliance with indicators of process and outcome was 90.45%. Overall morbidity in ERABS group did not differ from that recommended by SECO, but traditional group did show significant increase. Adherence was 83.63% and overall incidence of complications was 7%. Our study shows improved clinical outcomes in ERABS group with a high degree of adherence. Quality indicators were met, improving overall morbidity with no difference in the severity of complications.

Impact of Enhanced Recovery After Bariatric Surgery (ERABS) Protocol in Reducing Length of Stay and Hospitalization Costs: the Experience of a Philanthropic Hospital in Brazil

OVERVIEW

The global prevalence of obesity and increase in bariatric surgeries are burdening the healthcare system. Enhanced recovery postoperative protocols are associated with a reduction in hospitalization costs and length of stay (LOS) and may be an alternative to reduce public health expenses.

OBJECTIVE

To assess the impact of implementing a customized Enhanced Recovery After Bariatric Surgery (ERABS) protocol on hospitalization costs (HC), LOS, and complication rates.

SETTING

Santa Marcelina Hospital, São Paulo, Brazil.

METHODS

A retrospective electronic health record analysis of patients who underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy and who were cared for within a clinical pathway (CP) protocol (Jan. 2016-Aug. 2018) or after implementation of an ERABS protocol (Aug. 2018-Jun. 2019). The LOS, HC, and complication, readmission, and reoperation rates were compared between the two groups.

RESULTS

Eighty-two patients were included in the study (CP, 56, 87.5% women; ERABS, 26, 92.3% women). Hospital LOS and total HC decreased significantly by 32.5% and 15.2%, respectively (both, p < 0.05), after implementation of ERABS. There were no significant differences in 30-day readmission, complication, or reoperation rates.

CONCLUSION

The implementation of a standardized enhanced recovery program resulted in reduced LOS and HC without an increase in perioperative morbidity. The ERABS protocol is cost-effective and can help ease the healthcare burden.

The Application of Enhanced Recovery After Surgery (ERAS) for Patients Undergoing Bariatric Surgery: a Systematic Review and Meta-analysis

To systematically evaluate the effectiveness and safety of the enhanced recovery after surgery (ERAS) pathway in bariatric surgery. A literature search was conducted using PubMed, Medline, EMBASE, OVID, World Health Organization International Trial Register, and Cochrane Library identifying all eligible studies comparing ERAS protocols with standard care (SC) in bariatric surgery through May 2020. Relevant perioperative parameters were extracted from the resulting studies for meta-analysis. The primary outcome was the length of hospital stay, and secondary outcomes included operation time, postoperative nausea, and vomiting (PONV), postoperative complications, readmission, reoperation, and subsequent emergency room visits. Postoperative complications were categorized according to the Clavien-Dindo classification. Final analysis included five randomized controlled trials (RCTs) and twelve observational studies which included 4964 patients in the ERAS group and 3218 patients in the SC group. The length of the hospital stay was significantly decreased (p < 0.01) after ERAS protocol management, as did the incidence of POVN (p < 0.01). No significant differences were observed between the ERAS group and SC group in terms of operation time (p = 0.37), postoperative complications (p = 0.18), readmission (p = 0.17), reoperation (p = 0.34), or emergency room visits (p = 0.65). The application of ERAS protocols in bariatric surgery is safe and feasible, effectively shortening the length of a hospital stay without compromising morbidity, and accelerating patient recovery.

Enhanced Recovery after Surgery (ERAS): a Systematic Review of Randomised Controlled Trials (RCTs) in Bariatric Surgery

OBJECTIVE

Our aim was to conduct an up-to-date systematic review of randomised controlled trials (RCTs) to determine the benefits and harms of enhanced recovery after surgery (ERAS) programme in bariatric surgery.

METHODS

MEDLINE, Embase, PubMed, CINAHL and the Cochrane Library were searched for RCTs on ERAS versus standard care (SC) until April 2020. The primary endpoint was the length of hospital stay (LOS).

RESULTS

Five RCTs included a total of 610 procedures. ERAS adoption is capable of significantly reducing LOS (MD of - 0.51; 95% CI - 0.92 to - 0.10; P = 0.01) and postoperative nausea and vomiting (PONV) (OR 0.42; 95% CI 0.19 to 0.95; P = 0.04). No significant differences in terms of adverse events and readmissions.

CONCLUSIONS

The implementation of ERAS in bariatric surgery produces a significant reduction in LOS and PONV.

From the Knife to the Endoscope-a History of Bariatric Surgery

PURPOSE OF REVIEW

This review was conducted to gain insight into the history, present and future of bariatric and/or metabolic surgery and endoscopic treatments of obesity. The challenges that have been overcome, the challenges we still face and our recommendations for the future are discussed.

RECENT FINDINGS

Over the last few decades, a number of treatment strategies have emerged for the treatment of obesity. Both endoscopic and surgical options are available and they lead to significant weight loss and comorbidity reduction. However, to remain a credible treatment alternative to the obesity pandemic, we need to perform these procedures in much larger numbers than we currently do. Even though significant gains have been made in reducing the morbidity and mortality of surgical interventions, there is further room for improvement, especially when it comes to long-term issues. Due to its impact on almost every single organ system in the human body, bariatric surgery has attracted the attention of academics from a variety of medical disciplines. This has led to a rapidly enlarging body of high-quality scientific literature, supporting its wider use and cost-effectiveness.

CONCLUSION

Despite the advances made in bariatric surgery, the criteria determining suitability of patients for bariatric surgery in most parts of the world are still based on a consensus agreed upon in the USA in 1991. There is a need to formulate some new consensus and guidelines that would allow for a significant expansion of the pool of patients that can be offered these procedures.

How can lean thinking improve ERAS program in bariatric surgery?

INTRODUCTION

Enhanced recovery after bariatric surgery protocol (ERABS) decreased length of hospital stay (LOS) without influencing clinical outcomes. ERABS improved logistics aspects in operating room (OR) with OR time savings. Lean management was used to reorganize OR logistics and to improve its efficiency. This study analyzed clinical and OR logistic aspects in ERABS protocols.

METHODS

Retrospective analysis of prospectively maintained database of obese patients undergoing bariatric surgery from 2017 to 2019 was performed. Since September 2018, patients were treated with ERABS protocol (ERABS group). All patients treated with a standard protocol between January 2017 and September 2018 (control group) were compared to ERABS group. Preoperative (anthropometric data, surgical and medical history) and intraoperative (type of procedure) were analyzed in two groups. LOS was the primary outcomes parameter analyzed; complications, readmissions and reoperations within 30 days were the secondary outcomes. Logistic endpoints were evaluated in time saving and efficiency: surgical time, team work time and total anesthesia time.

RESULTS

471 patients underwent bariatric surgery: 239 patients (control group) compared to 232 patients (ERABS group). ERABS presented more previous surgical history rate (p = 0.04) compared to control group with difference of type of procedure performed (p < 0.001). Roux-en-Y gastric bypass was mainly procedure in both groups (61.1% in control group compared to 52.6% in ERABS groups). Mean LOS was shorter in ERABS (3.16 days) compared to control group (4.81 days) with no difference in clinical outcomes rate. All logistics endpoints showed a time savings in ERABS group compared to control group (surgical procedure, total anesthesia and team work time, p < 0.001). In multivariate analysis, LOS was associated to ERAS status (IRR 0.722; p < 0.0001), team work time (IRR 1.002; p = 0.002), surgical procedure time (IRR 1.002; p < 0.0001). ERAS status was not associated with complication neither readmission, but surgical procedure time was a factor associated with complication (IRR 1.011; p = 0.0008).

CONCLUSION

This study confirmed that ERABS protocol is safe and a feasible alternative with improved LOS. OR reorganization and logistic efficiency achieved using lean management helped reduce all OR times and these are likely related to the improvement in LOS and complication.

A Nurse-Led Evidence-Based Practice Protocol to Reduce Postoperative Nausea and Vomiting in the Bariatric Surgery Patient

PURPOSE

To create and implement a standard care bundle to reduce postoperative nausea and vomiting (PONV) in the bariatric surgery patient.

DESIGN

Evidence-based quality improvement project.

METHODS

A pre- and postintervention chart review identified high-risk indicators for PONV in patients with longer lengths of stay (LOS), which led to the development of targeted care bundle components.

FINDINGS

A clinically significant difference was observed in predicted PONV for Apfel scores 3 and 4 in patients receiving the full bundle compared with those receiving a partial bundle. Decreased LOS after implementation of the antiemetic care bundle was found. Health care provider compliance with bundle administration was low (57%).

CONCLUSIONS

Clinically significant PONV scores were low after implementation of the antiemetic bundle for high-risk patients. The nurse-led creation and implementation of an antiemetic care bundle may have contributed to decreased LOS, reduced PONV, and reduced provider variability in care management.

Enhanced recovery after bariatric surgery (ERABS) protocol implementation in a laparoscopic center

INTRODUCTION

Enhanced recovery after bariatric surgery (ERABS) protocols consist of a combination of several preoperative, intraoperative and postoperative methods for the management of the surgical patient. The aim of this study was to evaluate the impact of the ERABS protocol on length of hospital stay (LOS) and postoperative complications.

MATERIAL AND METHODS

Retrospective study of patients who underwent elective Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) between 2015 and 2018. From 2015 to 2017, patients received traditional management (pre-ERABS group). Those who underwent surgery during 2018 were managed with our ERABS protocol (ERABS group). The primary outcome was LOS. Secondary outcomes were readmission rate and 30-day postoperative complications.

RESULTS

A total of 200 patients who received RYGB and SG between 2015 and 2018 were retrospectively analyzed; we included 120 patients in the pre-ERABS group and 80 in the ERABS group. The median LOS was four days [2-49] in the pre-ERABS group, as compared with two days [1-26] in the ERABS group (p < .0001). No significant differences were found in postoperative complication rates, readmissions, and mortality.

CONCLUSION

Implementation of the ERABS protocol is related to a better postoperative recovery and allows an early discharge without increasing postoperative complications, readmissions or mortality.

Postoperative Remote Monitoring with a Transcutaneous Biosensing Patch: Preliminary Evaluation of Data Collection

Introduction. Connected systems transmitting vital parameters could well represent a tool to shorten postoperative hospital stay while providing continuous remote patient monitoring and potentially detect the onset of complications. Our aim was to analyze the functionality of a transcutaneous biosensing data collection patch in morbidly obese patients. Materials and Methods. An adhesive patch (The HealthPatch MD™) was applied to patients' chests postoperatively. The patch was connected to a tablet via a bluetooth network to collect the heart rate, respiratory rate, skin temperature, and posture recognition data. The tablet conveyed data to a secure health data central server by means of a WiFi or 3G/4G transmission. Data were stored in a digital health platform to which health care professionals could connect. The evaluation focused on the volume, quality, and security of data transmission. A pilot phase involved 10 patients. Thirty-three additional patients undergoing bariatric surgery were included in the experimental phase. Results. The mean length of stay was 2.28 days (range: 2-5 days). The mean time of patch application was 51 ± 25.2 hours per patient (range: 19-139 hours), totalizing 1,683 hours of recording for the 33 patients included. During this time, a total of 7.562.531 data measurement points were collected and transmitted to the e-health platform via the patch. Two total disconnections and two partial disconnections were observed. The acquisition of patient postural data was unreliable. Conclusions. Connected telemetry for remote postoperative monitoring is promising. However, it is still limited by data transmission problems.

Enhanced Recovery after Bariatric Surgery: 202 Consecutive Patients in an Italian Bariatric Center

BACKGROUND

Enhanced Recovery After Surgery (ERAS) pathways have been shown to improve postoperative outcomes. However, its application in bariatric surgery is still limited. The aim of the study was to define the safety of ERAS in bariatric patients with regard to postoperative complications, length of hospital stay (LOS), and readmission rates within 30 days from surgery.

METHODS

The effectiveness and safety of an ERAS protocol was prospectively investigated in morbidly obese patients who underwent bariatric surgery in a single-institute experience over a 2-year period.

RESULTS

Between June 2016 and September 2018, a total of 89 laparoscopic sleeve gastrectomy (SG), 105 Roux-en-Y gastric bypass (RYGB), and 8 one-anastomosis gastric bypass (OAGB) were performed. Twenty patients (9.9%) were revisional cases. Mean (standard deviation, SD) BMI and age at time of surgery were 43.2 (± 6.2) kg/m² and 46 (± 11.3) years, respectively. Median (range) surgical time was 118 (45-255) minutes. Overall postoperative complication rate was 7.4%, with 6 (3.0%) patients developing grade III-IV complications according to the Clavien-Dindo classification. Median (range) LOS was 2 (1-50) days, with mean (SD) LOS of 2.3 (± 3.6) days. Overall, 36.6% of patients were discharged by first postoperative day and 77.7% by second postoperative day. Readmission rate was 4.5%. No mortality was observed during the study period.

CONCLUSIONS

According to the results of the present study, ERAS in primary and revisional bariatric surgery is safe and feasible, with short LOS, low morbidity and readmission rates, and no mortality. A significant reduction of mean LOS was progressively noted over the study period.

Does the Implementation of Enhanced Recovery After Surgery (ERAS) Guidelines Improve Outcomes of Bariatric Surgery? A Propensity Score Analysis in 464 Patients

BACKGROUND

The aim of this study was to investigate whether the implementation of enhanced recovery after surgery (ERAS) guidelines according to Thorell and co. in our tertiary referral bariatric center might improve post-operative outcomes.

METHODS

ERAS program was introduced in our center since January 1, 2017. Retrospective review of a prospectively collected database identified patients who underwent laparoscopic primary and revisional bariatric surgeries from October 2005 to January 2018. Patients exposed to ERAS program ("ERAS group") were matched in a 1:1 ratio with patients exposed to conventional care (control group) using a propensity score based on age, gender, preoperative body mass index (BMI), diabetes mellitus, and the type of procedures. The primary outcome was total hospital length of stay (LOS) and the secondary outcomes included the post-operative complications and readmission rates.

RESULTS

During the study period, 464 patients were included, 232 in each group. Implementation of the ERAS protocol was significantly associated with a reduction of LOS (2.47 ± 1.7 vs 5.39 ± 1.9 days, p < 0.00001). One-third of patients was discharged (77/232, 33%) on the first postoperative day (POD) and more than three quarter of patients on POD 2 (182/232, 77%). At the opposite, no patients of the control group were discharged on POD 2. Overall 30-day and 90-day morbidity and readmission rates were the same in both groups. There was no death in each group.

CONCLUSIONS

This large case-matched study using a propensity score analysis suggests that implementation of ERAS program significantly reduced length of hospital stay without significant increases on overall morbidity, and readmission rates.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

Reducing complication rates and hospital readmissions while revising the enhanced recovery after bariatric surgery (ERABS) protocol

BACKGROUND

To optimize the postoperative phase following bariatric surgery, the enhanced recovery after bariatric surgery pathway (ERABS) has been developed. The aim of ERABS is to create a care path that is as safe, efficient and patient-friendly as possible. Continuous evaluation and optimization of ERABS are important to ensure a safe treatment path and may result in better outcomes. The objective of this study was to compare the clinical outcomes of patients undergoing bariatric surgery over 2014-2017, during which the ERABS protocol was continuously evaluated and optimized.

METHODS

This is a retrospective cohort study. Data were collected from patients undergoing a primary Roux-en-Y gastric bypass or sleeve gastrectomy between January 2014 and December 2017. Outcomes were early complications, unplanned hospital revisits, readmissions, duration of surgery and length of hospital stay.

RESULTS

2889 patients underwent a primary bariatric procedure in a single center. There was a significant decrease in minor complications over the years from 7.0 to 1.9% (p < 0.001). Hospital revisit rates decreased after 2015 (p < 0.001). Readmission rates decreased over time (p < 0.001). The mean duration of surgery decreased from 52 (in 2014) to 41 (in 2017) minutes (p < 0.001). Median length of hospital stay decreased from 1.8 to 1.5 days in 2015 (p = 0.002) and remained stable since.

CONCLUSION

An improvement of the ERABS protocol was associated with a decrease in minor complication rates, number of unplanned hospital revisits and readmission rates after primary bariatric procedures.

Safety and efficacy of laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass: A systematic review and meta-analysis

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are widely performed to cure obesity and obesity-related diseases. Our aim was to compare these two procedures.

MATERIALS AND METHODS

An electronic literature search was performed from inception to December 2018. The clinical outcomes between LSG and LRYGB were pooled using software RevMan5.3.

RESULTS

A total of 1076 patients from 11 studies were analysed. LSG had shorter operation time (mean difference [MD] = -33.81; 95% confidence interval [CI], -46.04 to -21.57; P < .00001) and less early complications rate (risk ratio [RR] = 0.55; 95% CI, 0.36-0.84; P = .005) compared with LRYGB. There were no significant difference about the readmission rate (RR = 0.57; 95% CI, 0.21-1.54; P = .27) and re-operation rate (RR = 0.43; 95% CI, 0.14-1.27; P = .13) between LSG and LRYGB. The conversion to open rate and mortality rate within 30 days was low in both LSG and LRYGB. Mean hospital stay in LSG group (0.3-5.2 d) seems shorter than that in the LRYGB group (2.3-6.6 d). As to the effect of LSG and LRYGB on the percentage of excess weight loss (EWL), there was no significant difference between these two surgeries in EWL (MD = -4.05; 95% CI, -8.89 to 0.80; P = .10). LSG was equal to LRYGB on remission of T2DM (RR = 0.94; 95% CI, 0.84-1.06; P = .31).

CONCLUSIONS

Both LSG and LRYGB can be performed with very low conversion to open rate and mortality rate. The readmission rate and re-operation rate are comparable between these two surgeries. The efficacy of these two surgeries on EWL and T2DM is equivalent, but LSG has an advantage over LRYGB in operation time and early complications rate.

Combination of Epidural Blockade and Parecoxib in Enhanced Recovery After Gastrointestinal Surgery

OBJECTIVE

To investigation effects of the combination use of epidural blockade and parecoxib in postoperative recovery of colorectal cancer (CRC) patients.

METHODS

The present prospective single-blinded study included 186 CRC patients who received radical resection during April 2016 to December 2017. All patients were randomized into 3 different groups, the epidural blockade group, the combined-group with both epidural blockade and pre-intravenous injection of parecoxib, and the control group. The mean operative time, bleeding volume, the first out of bed activity time and hospital stay time were recorded. The mini-mental state examination (MMSE) score and Ramsay score were measured for cognitive function and the Visual Analog Score (VAS) was determined for the pain condition.

RESULTS

The surgery time for the control group was significantly shorter than the other 2 groups (P < 0.05). The VAS scores were significantly lower in both the combined group and the epidural blockade group when compared with the control group and were dramatically lower in the combined group than the others 2 groups (all P < 0.05). The first out of bed activity time and hospital stay time were the shortest in the combined group, and the control group had the longest time (all P < 0.05). Both the Ramsay and MMSE scores were the highest in the combination group than other groups (all P < 0.05) and no significant difference was observed between the epidural blockade group and the control.

CONCLUSION

The combination of epidural blockade and parecoxib could enhance the recovery process, as well as reduce the pain for the CRC patients.