Early postoperative diet after bariatric surgery: impact on length of stay and 30-day events

Oral nutritional supplements improve clinical outcomes and are cost-effective for hospitalized patients in China

OBJECTIVE

This study assessed the therapeutic benefits and modeled the cost-effectiveness of oral nutritional supplements (ONS) in China.

METHODS

Data were collected from 27 152 adult inpatients between January 1, 2018, and December 31, 2020. Propensity score matching was used for balancing the baseline characteristics between the ONS group and non-ONS group. A decision-tree model was developed to assess the cost-effectiveness of ONS for patients with nutritional risk, and the incremental cost-effectiveness ratio was the metric to determine the most cost-effective strategy. One-way sensitivity and probabilistic sensitivity analyses were conducted to assess the model's stability. In addition, subgroup analysis was conducted based on clinical characteristics. Differences in clinical outcomes between the groups were compared using Student's t test, Mann-Whitney U test, or chi-square test.

RESULTS

The ONS group displayed significantly lower levels of prealbumin, albumin, hemoglobin, and BMI than the non-ONS group at admission. The incidence of malignant tumors, intestinal obstruction, and inflammatory bowel disease was significantly higher in the ONS group than the non-ONS group. The ONS group had a significantly higher effective rate than the non-ONS group (51.7% versus 50.3%, P < 0.05). Analysis of the decision-tree model revealed that the ONS group experienced an increase in cost of 19 850.96 yuan but achieved an additional 1.3406 effectiveness rate, resulting in an incremental cost-effectiveness ratio of 14 807.51, which fell below China's 2020 per capita gross domestic product of 71 965 yuan. Sensitivity analysis further confirmed the robustness of the model.

CONCLUSIONS

ONS are demonstrated a high rate of efficacy, although patients currently using ONS are typically in a severe disease state. In addition, ONS is cost-effective. We suggest that the reimbursement coverage of ONS be expanded to include in-hospital patients who are at high nutritional risk.

Application of enhanced recovery after surgery during the perioperative period in children with Meckel's diverticulum-a single-center prospective clinical trial

Background

Enhanced recovery after surgery (ERAS) has been widely used in adult surgery. However, few studies have reported the efficacy of ERAS in paediatric patients with Meckel's diverticulum (MD), the aim of the study was to prospectively evaluate the safety and efficacy of ERAS in treating MD.

Methods

A prospective randomised controlled study of children with MD admitted to our hospital from Jan 1, 2021 to Dec 31, 2023 were conducted, we developed and implemented an ERAS program for this patients. All cases were strictly selected according to the inclusion and exclusion criteria. Among these patients, they were randomly assigned to the ERAS group or the traditional (TRAD) group with random number table row randomization. The main observational indicators were operation time, intraoperative hemorrhage, FLACC pain scale results on 2 h, 6 h, 12 h, 24 h after surgery, length of postoperative stay (LOPS), time to first defecation, time to first eating after surgery, time to discontinuation of intravenous infusion, total treatment cost, incidence of postoperative complications, 30-day readmission rate and parental satisfaction rate.

Results

A total of 50 patients underwent Meckel's diverticulectomy during this period, 7 patients were excluded, 23 patients were assigned to the ERAS group and 20 patients were assigned to the TRAD group. There were no significant differences in demographic data and operation time, intraoperative hemorrhage. The FLACC pain scale results on 2 h, 6 h, 12 h, 24 h after surgery were significantly lower in the ERAS group. The LOPS was 6.17 ± 0.89 days in the ERAS group and 8.30 ± 1.26 days in the TRAD group, resulting in a significantly shorter LOPS in ERAS group. ERAS could also reduce the first postoperative defecation time, the time to first eating after surgery and the time to discontinuation of intravenous infusion. The treatment cost was decreased in the ERAS group. The rate of complications and 30-day readmission were not significantly different between the two groups.

Conclusions

In this single-center study, the ERAS protocol for patients with MD requiring surgery was safe and effective.

Clinical practice guidelines for prevention and treatment of postoperative gastrointestinal disorder with Integrated Traditional Chinese and Western Medicine (2023)

Postoperative gastrointestinal disorder (POGD) was a common complication after surgery under anesthesia. Strategies in combination with Traditional Chinese Medicine and Western medicine showed some distinct effects but standardized clinical practice guidelines were not available. Thus, a multidisciplinary expert team from various professional bodies including the Perioperative and Anesthesia Professional Committees of the Chinese Association of Integrative Medicine (CAIM), jointly with Gansu Province Clinical Research Center of Integrative Anesthesiology/Anesthesia and Pain Medical Center of Gansu Provincial Hospital of Traditional Chinese Medicine and WHO Collaborating Center for Guideline Implementation and Knowledge Translation/Chinese Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Center/Gansu Provincial Center for Medical Guideline Industry Technology/Evidence-based Medicine Center of Lanzhou University, was established to develop evidence-based guidelines. Clinical questions (7 background and 12 clinical questions) were identified through literature reviews and expert consensus meetings. Based on systematic reviews/meta-analyses, evidence quality was analyzed and the advantages and disadvantages of interventional measures were weighed with input from patients' preferences. Finally, 20 recommendations were developed through the Delphi-based consensus meetings. These recommendations included disease definitions, etiologies, pathogenesis, syndrome differentiation, diagnosis, and perioperative prevention and treatment.

Perioperative Nutritional Management in Enhanced Recovery after Bariatric Surgery

Obesity is a crucial health problem because it leads to several chronic diseases with an increased risk of mortality and it is very hard to reverse with conventional treatment including changes in lifestyle and pharmacotherapy. Bariatric surgery (BS), comprising a range of various surgical procedures that modify the digestive tract favouring weight loss, is considered the most effective medical intervention to counteract severe obesity, especially in the presence of metabolic comorbidities. The Enhanced Recovery After Bariatric Surgery (ERABS) protocols include a set of recommendations that can be applied before and after BS. The primary aim of ERABS protocols is to facilitate and expedite the recovery process while enhancing the overall effectiveness of bariatric procedures. ERABS protocols include indications about preoperative fasting as well as on how to feed the patient on the day of the intervention, and how to nourish and hydrate in the days after BS. This narrative review examines the application, the feasibility and the efficacy of ERABS protocols applied to the field of nutrition. We found that ERABS protocols, in particular not fasting the patient before the surgery, are often not correctly applied for reasons that are not evidence-based. Furthermore, we identified some gaps in the research about some practises that could be implemented in the presence of additional evidence.

Severe Cannabis use is Associated with Complications and Prolonged Length of Stay in Bariatric Surgery

PURPOSE

In the United States, recreational and medicinal cannabis use has continually increased in recent years, including in patients undergoing bariatric surgery. However, the effects of cannabis use on morbidity and mortality after bariatric surgery are uncertain, and the literature is limited by a paucity of studies. This study intends to evaluate the effects of cannabis use disorder on outcomes in patients undergoing bariatric surgery.

MATERIALS AND METHODS

The National Inpatient Sample 2016-2019 was queried for patients ≥ 18 years who underwent roux-en-y gastric bypass (RYGB), vertical sleeve gastrectomy (VSG), or adjustable gastric band (AGB) surgery. Cannabis use disorder was identified using ICD-10 coding. Three outcomes were evaluated: medical complications, in-hospital mortality, and length of stay. Logistic regression was used to evaluate effects of cannabis use disorder on medical complications and in-hospital mortality, and linear regression for length of stay. All models controlled for race, age, sex, income, procedure type, and various medical comorbidities.

RESULTS

A total of 713,290 patients were included in this study, with 1,870 (0.26%) having cannabis use disorder. Cannabis use disorder was associated with medical complications (OR: 2.24; 95% CI: 1.31-3.82; P = 0.003) and longer lengths of stay (β: 1.3; SE: 0.297; P < 0.001), but not in-hospital mortality (OR: 3.29; CI: 0.94-11.5); P = 0.062).

CONCLUSIONS

Severe cannabis use was associated with higher risk for complications and extended length of stay. Future investigations are needed to better elucidate the relationship between cannabis use and bariatric surgery, including effects of dosage, chronicity, and method of ingestion.

Is an Early Resumption of a Regular Diet After Laparoscopic Roux-en-Y Gastric Bypass Safe?

Background

Return to a normal diet is a crucial step after bariatric surgery. Proximal anastomosis is a source of concern for early feeding as the passage of solid food through a recent anastomosis could well increase pressure and the risk of leakage. This study aims to assess the safety of an early normal diet after a laparoscopic Roux-en-Y gastric bypass (LRYGB).

Materials and Methods

All consecutive patients undergoing primary LRYGB between January 2015 and December 2020 were included prospectively. Three postoperative pureed diets were compared at 4 weeks, 2 weeks, and 1 week. All-cause morbidity at 90 days was the main outcome. Overall complications, severe complications (Clavien-Dindo ≥ grade 3a), length of hospital stay, number of emergency, and unplanned consultations during the 3 postoperative months were recorded for each group.

Results

Three hundred and sixty-seven patients with a mean BMI of 42.10 kg/m² (± SD: 4.78) were included. All-cause morbidity at 90 days was 11.7% (43/367) and no significant difference was observed between the 3 groups. Adjustment for patients and operative cofounders did not demonstrate any increased risk of postoperative complications between the 3 groups, with an odds ratio of 1, 1.23(95% CI [0. 55–2.75]), and 1.14 (95% CI [0.49, 2.67]) for groups 1, 2, and 3 respectively. Severe complications (Clavien-Dindo ≥ grade 3a) and emergency or unplanned consultations were also similar in the 3 groups.

Conclusion

Return to a normal diet 1 week after LRYGB did not increase short-term morbidity and unplanned consultations. It may be safe and contribute to patient comfort.

Graphical abstract

Enhanced Recovery After Surgery (ERAS) protocol in bariatric and metabolic surgery (BMS)-analysis of practices in nutritional aspects from five continents

This study aims to understand the prevalent practices on the nutritional aspects of the enhanced recovery after surgery (ERAS) protocol based on the knowledge and practice of surgeons, nutritionists, and anesthesiologists who work in the bariatric and metabolic surgery (BMS) units worldwide. This cross-sectional study enrolled BMS unit professionals from five continents-Africa, America, Asia, Europe, and Oceania. An electronic questionnaire developed by the researchers was provided to evaluate practices about the three nutritional aspects of ERAS protocol in BMS (Thorel et al. 2016): preoperative fasting, carbohydrate loading, and early postoperative nutrition. Only surgeons, nutritionists, and anesthesiologists were invited to participate. One hundred twenty-five professionals answered the questionnaires: 50.4% from America and 39.2% from Europe. The profile of participating professionals was bariatric surgeons 70.2%, nutritionists 26.4%, and anesthesiologists 3.3%. Approximately 47.9% of professionals work in private services, for about 11 to 20 years (48.7%). In all continents, a large majority were aware of the protocol. Professionals from the African continent reported having implemented the ERAS bariatric protocol 4.0 ± 0 years ago. It is worth mentioning that professionals from the five continents implemented the ERAS protocol based on the published literature (p = 0.012). About preoperative fasting abbreviation protocol, a significant difference was found between continents and consequently between services (p = 0.000). There is no uniformity in the conduct of shortening of fasting in the preoperative period and the immediate postoperative period. Early postoperative (PO) period protein supplementation is not performed in a standard fashion in all units globally. ERAS principles and practices are partial and insufficiently implemented on the five continents despite the prevalent knowledge of professionals based on evidence. Moreover, there is no uniformity in fasting, immediate postoperative diet, and early protein supplementation practices globally.

Nutrition in surgical patients: how soon is too soon?

PURPOSE OF REVIEW

Preoperative nutrition support has been extensively studied; however, data on the timing of postoperative nutrition initiation are scarce. The current review focuses on the importance of early nutritional support in surgical patients and their impact on outcomes.

RECENT FINDINGS

Early nutrition support during the postoperative course may be the most important step that can be taken toward preventing subsequent malnutrition-related complications. European Society for Parenteral and Enteral Nutrition guidelines recommends early nutrition to improve outcomes after surgery and accelerates the recovery. Moreover, nutritional support should be personalized, and disease process-based.

SUMMARY

Existing studies appear to focus mostly on abdominal and gastrointestinal surgery. Further prospective observational and randomized clinical trials across different surgical populations will aid surgeons to better understand how early feeds in either form can reduce morbidity, quality of life, and increase recovery rates.