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Lacroix C, Zamparini M, Meunier H, Fiant AL, Le Roux Y, Bion AL, Savey V, Alves A, Menahem B. Mid-term Results of an ERAS Program of Bariatric Surgery in a Tertiary Referral Center. World J Surg 2023; 47:1597-1606. [PMID: 37188970 DOI: 10.1007/s00268-023-07023-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND To identify preoperative risk factors for discharge failure beyond postoperative day two (POD-2) in bariatric surgery ERAS program in a tertiary referral center. METHODS all consecutive patients who underwent laparoscopic bariatric treated in accordance with ERAS protocol between January 2017 and December 2019 were included. Two groups were identified, failure of early discharge (> POD-2) (ERAS-F) and success of early discharge (≤ POD-2) (ERAS-S). Overall postoperative morbidity, unplanned readmission rates were analyzed at POD-30 and POD-90, respectively. Multivariate logistic regression was performed to determine the independent risk factors for LOS > 2 days (ERAS-F). RESULTS A total of 697 consecutive patients were included, 148 (21.2%) in ERAS-F group and 549 (78.8%) in ERAS-S group. All postoperative complications at POD 90, whether medical or surgical were significantly more frequent in ERAS-F group than in ERAS-S group. Neither readmission nor unplanned consultations rates at POD 90 were significantly different between both groups. History of psychiatric disorder (p = 0.01), insulin-dependent diabetes (p < 0.0001), use of anticoagulants medicine (p < 0.00001), distance to the referral center > 100 km (p = 0.006), gallbladder lithiasis (p = 0.02), and planned additional procedures (p = 0.01) were independent risk factors for delayed discharge beyond POD-2. CONCLUSIONS One in five patients with bariatric surgery failed to discharge earlier despite the ERAS program. Knowledge of these preoperative risk factors would allow us to identify patients who need more recovery time and a tailored approach to the ERAS protocol.
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Affiliation(s)
- Coralie Lacroix
- Department of Digestive Surgery, University Hospital of Caen, Avenue de La Côte de Nacre, 14033, Caen Cedex, France
| | - Marion Zamparini
- Department of Anesthesia, University Hospital of Caen, Caen, France
| | - Hugo Meunier
- Department of Digestive Surgery, University Hospital of Caen, Avenue de La Côte de Nacre, 14033, Caen Cedex, France
| | - Anne-Lise Fiant
- Department of Anesthesia, University Hospital of Caen, Caen, France
| | - Yannick Le Roux
- Department of Digestive Surgery, University Hospital of Caen, Avenue de La Côte de Nacre, 14033, Caen Cedex, France
| | - Adrien Lee Bion
- Department of Digestive Surgery, University Hospital of Caen, Avenue de La Côte de Nacre, 14033, Caen Cedex, France
| | - Véronique Savey
- Department of Nutrition, University Hospital of Caen, Caen, France
| | - Arnaud Alves
- Department of Digestive Surgery, University Hospital of Caen, Avenue de La Côte de Nacre, 14033, Caen Cedex, France
- UNICAEN, INSERM, ANTICIPE, Normandie Univ, 14000, Caen, France
| | - Benjamin Menahem
- Department of Digestive Surgery, University Hospital of Caen, Avenue de La Côte de Nacre, 14033, Caen Cedex, France.
- UNICAEN, INSERM, ANTICIPE, Normandie Univ, 14000, Caen, France.
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Motola D, Lind R, Geisel L, Aghazarian G, Ghanem M, Teixeira AF, Jawad MA. Implementing novel modalities into an institutional enhanced recovery after bariatric surgery (ERABS) protocol. Surg Endosc 2023:10.1007/s00464-023-10027-8. [PMID: 37017770 DOI: 10.1007/s00464-023-10027-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/12/2023] [Indexed: 04/06/2023]
Abstract
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.
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Affiliation(s)
- David Motola
- Department of Bariatric Surgery, Orlando Regional Medical Center, Orlando Health, 89 W Copeland Dr, 1st Floor, Orlando, FL, USA
| | - Romulo Lind
- Department of Bariatric Surgery, Orlando Regional Medical Center, Orlando Health, 89 W Copeland Dr, 1st Floor, Orlando, FL, USA.
| | - Lauren Geisel
- Department of Bariatric Surgery, Orlando Regional Medical Center, Orlando Health, 89 W Copeland Dr, 1st Floor, Orlando, FL, USA
| | - Gary Aghazarian
- Department of Bariatric Surgery, Orlando Regional Medical Center, Orlando Health, 89 W Copeland Dr, 1st Floor, Orlando, FL, USA
| | - Muhammad Ghanem
- Department of Bariatric Surgery, Orlando Regional Medical Center, Orlando Health, 89 W Copeland Dr, 1st Floor, Orlando, FL, USA
| | - Andre F Teixeira
- Department of Bariatric Surgery, Orlando Regional Medical Center, Orlando Health, 89 W Copeland Dr, 1st Floor, Orlando, FL, USA
| | - Muhammad A Jawad
- Department of Bariatric Surgery, Orlando Regional Medical Center, Orlando Health, 89 W Copeland Dr, 1st Floor, Orlando, FL, USA
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S136-operationalizing an enhanced recovery protocol after bariatric surgery: single institutional pilot experience forging data-driven standard work. Surg Endosc 2023; 37:1449-1457. [PMID: 35764842 PMCID: PMC9243783 DOI: 10.1007/s00464-022-09390-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 06/06/2022] [Indexed: 12/03/2022]
Abstract
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.
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Minimally invasive versus open duodenal switch: a nationwide retrospective analysis. Surg Endosc 2022; 36:7000-7007. [DOI: 10.1007/s00464-022-09020-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 01/03/2022] [Indexed: 11/25/2022]
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Verhoeff K, Mocanu V, Dang J, Purich K, Switzer NJ, Birch DW, Karmali S. Five Years of MBSAQIP Data: Characteristics, Outcomes, and Trends for Patients with Super-obesity. Obes Surg 2021; 32:406-415. [PMID: 34782985 DOI: 10.1007/s11695-021-05786-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/18/2021] [Accepted: 11/08/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE Incidence of super obesity (SO; BMI ≥ 50 kg/m2) is growing rapidly and confers worse metabolic complications than non-SO (BMI 30-50 kg/m2). We aim to characterize bariatric surgery patients with SO, their postoperative complications, and treatment trends over the last 5 years in hopes of informing SO-specific treatment protocols. MATERIALS AND METHODS The MBSAQIP database was analyzed, and two cohorts were compared, those with SO and non-SO. Univariate analysis was performed to determine between-group differences. Multivariable logistic regression analysis was performed to determine if SO was independently associated with serious complications or mortality. RESULTS We evaluated 751,952 patients with 173,110 (23.0%) having SO. Patients with SO were younger (42.2 ± 11.8 SO vs 45.1 ± 12.0 years non-SO, p < 0.001) and less likely to be female (74.8% vs 81.1%, p < 0.001). While comorbidities seem to be decreasing overall in bariatric surgery patients, those with SO have worse functional capacity and more endocrine, pulmonary, and vascular comorbidities. Patients with SO also have worse 30-day postoperative complications, and SO was independently associated with severe complications (OR 1.08; CI 1.05-1.11, p < 0.001) and mortality (OR 2.49; CI 2.12-2.92, p < 0.001) CONCLUSIONS: Patients with SO have significantly increased preoperative comorbidities resulting in worse postoperative outcomes. SO remains an independent risk factor for serious complications and the greatest independent risk factor for 30-day postoperative mortality. Considering the expected increase in patients with SO, substantial work is required to optimize bariatric surgery strategies specific to these patients.
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Affiliation(s)
- Kevin Verhoeff
- Department of Surgery, University of Alberta, Dvorkin Lounge Mailroom2G2 Walter C. Mackenzie Health Sciences Centre, 8440 - 112 ST NW EDMONTON AB, Edmonton, Alberta, T6G 2B7, Canada.
| | - Valentin Mocanu
- Department of Surgery, University of Alberta, Dvorkin Lounge Mailroom2G2 Walter C. Mackenzie Health Sciences Centre, 8440 - 112 ST NW EDMONTON AB, Edmonton, Alberta, T6G 2B7, Canada
| | - Jerry Dang
- Department of Surgery, University of Alberta, Dvorkin Lounge Mailroom2G2 Walter C. Mackenzie Health Sciences Centre, 8440 - 112 ST NW EDMONTON AB, Edmonton, Alberta, T6G 2B7, Canada
| | - Kieran Purich
- Department of Surgery, University of Alberta, Dvorkin Lounge Mailroom2G2 Walter C. Mackenzie Health Sciences Centre, 8440 - 112 ST NW EDMONTON AB, Edmonton, Alberta, T6G 2B7, Canada
| | - Noah J Switzer
- Department of Surgery, University of Alberta, Dvorkin Lounge Mailroom2G2 Walter C. Mackenzie Health Sciences Centre, 8440 - 112 ST NW EDMONTON AB, Edmonton, Alberta, T6G 2B7, Canada
| | - Daniel W Birch
- Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Shahzeer Karmali
- Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, Alberta, Canada
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Faessen J, Schoemakers B, VAN Veenendaal N, Visschers R, Hoofwijk A, Stoot J. Time-efficiency and hospital costs of open compared with laparoscopic groin hernia repair in a teaching hospital. Minerva Surg 2021; 76:271-280. [PMID: 34080822 DOI: 10.23736/s2724-5691.21.08589-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Time efficiency and hospital costs may influence the preferred method of groin hernia repair. Despite growing expertise in laparoscopic hernia repair, knowledge on the actual costs and the potential financial advantages over open hernia repair are limited. METHODS A single-center retrospective cohort study comparing hospital costs and time-efficiency of open-mesh (Lichtenstein) and laparoscopic groin hernia repair between 2010 and 2015, including a comparison of surgeons and residents, was conducted. Secondary outcomes were length of hospital stay, complication and recurrence rates. RESULTS Nine hundred forty-seven open and 449 laparoscopic groin hernia repairs were included. Unilateral open repair showed a shorter operation theatre occupancy (63.5 min±17.2 vs. 71.9 min±19.9, P<0.001) and lower total costs (€ 974.51±266.67 vs. € 1165.32±285.94, P<0.001) compared with laparoscopic repair. Residents had longer operative times compared with surgeons in the unilateral open procedure (43.8±13.4 min vs. 34.5±16.3 min, P<0.001), in the unilateral laparoscopic procedure (46.9±16.6 min vs. 41.7±18.7 min, P<0.001) and higher total costs in the unilateral open procedure (€ 1007.47±238.58 vs. € 909.35±305.00, P<0.001). There were no significant differences in complication and recurrence rates between residents and surgeons. CONCLUSIONS Open-mesh hernia repair appears to be superior in costs for both uni- and bilateral groin hernias when performed by surgeons as well as residents. Residents had higher total costs and longer operation times in the unilateral open groin hernia group when compared with surgeons, yet overall complications and recurrence rates were similar in all groups suggesting that residents are sometimes more expensive and slower, but just as safe.
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Affiliation(s)
- Jelle Faessen
- Department of Surgery, Zuyderland Medical Center, Sittard, the Netherlands -
| | - Bob Schoemakers
- Department of Surgery, Zuyderland Medical Center, Sittard, the Netherlands
| | | | - Ruben Visschers
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Anton Hoofwijk
- Department of Surgery, Zuyderland Medical Center, Sittard, the Netherlands
| | - Jan Stoot
- Department of Surgery, Zuyderland Medical Center, Sittard, the Netherlands
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Garcia A, Giorgi M, Parikh S, Carr AD, Ali MR. Preoperative and Intraoperative Factors That Influence Length of Stay in Patients on an Enhanced Recovery After Surgery Protocol Following Bariatric Surgery. Bariatr Surg Pract Patient Care 2021. [DOI: 10.1089/bari.2020.0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Arturo Garcia
- Department of Surgery, Davis Medical Center, University of California, Sacramento, California, USA
| | - Marcoandrea Giorgi
- Department of Surgery, Brown University, The Miriam Hospital, Providence, Rhode Island, USA
| | - Sahil Parikh
- Department of Surgery, Davis Medical Center, University of California, Sacramento, California, USA
| | - Aaron D. Carr
- Department of Surgery, Davis Medical Center, University of California, Sacramento, California, USA
| | - Mohamed R. Ali
- Department of Surgery, Davis Medical Center, University of California, Sacramento, California, USA
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Nedeljkovic-Arsenovic O, Banovic M, Radenkovic D, Rancic N, Polovina S, Micic D, Nedeljkovic I. Five-Year Outcomes in Bariatric Surgery Patients. ACTA ACUST UNITED AC 2020; 56:medicina56120669. [PMID: 33287109 PMCID: PMC7761683 DOI: 10.3390/medicina56120669] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/29/2020] [Accepted: 12/01/2020] [Indexed: 12/25/2022]
Abstract
Background and objectives: Obesity presents as a multifactorial, pandemic disease that arises as a consequence of unequal energy intake and energy consumption. Obesity adversely affects the quality of life, leading not only to disability, but also to various other disorders. Bariatric surgery is the most effective method for achieving significant and sustained weight loss in individuals with extreme obesity. The aim of this study was to examine how well surgically induced weight loss is maintained after five years of follow-up and its effects on cardiovascular risk factors and outcome. Materials and Methods: This is a retrospective cross-sectional study of 66 patients with morbid obesity, with body mass index (BMI) ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 and obesity-related health conditions, aged 20 to 61 years, mostly women (77.3%) who underwent laparoscopic Roux-en-Y gastric bypass surgery. Results: Average follow-up was 6.42 years (95% CI 6.30–6.54 years) after surgery, with survival rate of 97% in operated individuals. There was a statistically significant reduction of weight and body mass index 6 months and 5 years after surgery in comparison to the initial values (p < 0.001). Of 62 patients who presented weight loss at the end of the follow-up period, 38 were able to maintain the amount of weight loss that was attained 6 months after surgery, while 24 patients regained weight compared to their postoperative weight at 6 months. Two patients reported no weight loss after treatment. Significant weight reduction was associated with better control of diabetes and increased self-reported physical activity at 6 months and 5 years after surgery, as well as with a reduction of the use of anti-diabetic and anti-hypertensive medications. Conclusions: Our research demonstrates a positive long-term impact of bariatric surgery on patients’ health conditions, significant and sustained weight loss, and decrease in BMI, which were associated with a reduction of co-morbidities and risk factors for cardiovascular diseases.
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Affiliation(s)
- Olga Nedeljkovic-Arsenovic
- Department of Cardiology, Clinical Center of Serbia, 11000 Belgrade, Serbia;
- Correspondence: (O.N.-A.); (N.R.)
| | - Marko Banovic
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia; (M.B.); (D.R.); (D.M.)
| | - Dejan Radenkovic
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia; (M.B.); (D.R.); (D.M.)
| | - Nemanja Rancic
- Centre for Clinical Pharmacology, Military Medical Academy, 11000 Belgrade, Serbia
- Faculty of Medicine of the Military Medical Academy, University of Defense, 11000 Belgrade, Serbia
- Correspondence: (O.N.-A.); (N.R.)
| | - Snezana Polovina
- Department of Endocrinology, Clinical Center of Serbia, 11000 Belgrade, Serbia;
- Faculty of Pharmacy, University of Novi Sad, 21000 Novi Sad, Serbia
| | - Dragan Micic
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia; (M.B.); (D.R.); (D.M.)
| | - Ivana Nedeljkovic
- Department of Cardiology, Clinical Center of Serbia, 11000 Belgrade, Serbia;
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia; (M.B.); (D.R.); (D.M.)
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Barbat S, Thompson KJ, Mckillop IH, Kuwada TS, Gersin K, Nimeri A. Ambulatory bariatric surgery: does it really lead to higher rates of adverse events? Surg Obes Relat Dis 2020; 16:1713-1720. [PMID: 32830058 DOI: 10.1016/j.soard.2020.06.051] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 06/16/2020] [Accepted: 06/23/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Correlating patient outcomes with length of stay (LoS) is an important consideration in metabolic and bariatric surgery. At present, conflicting data exists regarding patient safety for ambulatory (AMB) metabolic and bariatric surgery. OBJECTIVE Outcomes for AMB-metabolic and bariatric surgery patients (LoS <1 d) undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) were compared with matched patients with LoS ≥1 day (non-AMB) using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry. SETTING MBSAQIP national database. METHODS The MBSAQIP registry was queried for patients undergoing SG or RYGB (2015-2017) and patients grouped as AMB/non-AMB. Exclusion criteria included LoS >4 days, age <18 or >75 years, revision surgery, gastric banding, body mass index <35 kg/m2, and day of surgery mortality. Variables were combined into major/minor complications and 30-day mortality. Analysis was performed using univariate and multivariate logistic regression and propensity matching. RESULTS After exclusions were applied 408,895 patients remained (9973 AMB). Overall, 111,279 patients underwent RYGB (1032 AMB) and 297,616 underwent SG (8941 AMB), with similar demographic characteristics and co-morbidities between groups. For AMB patients, there was no increase in 30-day mortality, reoperation, or readmission, and fewer drains were placed versus matched non-AMB patients. In AMB-SG patients more surgical site infections were reported versus non-AMB-SG, although AMB-SG patients had fewer intensive care unit admissions. For AMB-RYGB, no differences in complications were detected versus non-AMB-RYGB. CONCLUSION Based on our analysis of the MBSAQIP database, patients undergoing laparoscopic RYGB or SG procedures can be safely discharged on the day of their procedure without increased incidence of mortality, reoperation, or readmission.
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Affiliation(s)
- Selwan Barbat
- Divison of Bariatric Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina.
| | - Kyle J Thompson
- Surgical Research, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Iain H Mckillop
- Surgical Research, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Timothy S Kuwada
- Divison of Bariatric Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Keith Gersin
- Divison of Bariatric Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Abdelrahman Nimeri
- Divison of Bariatric Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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Nagliati C, Troian M, Pennisi D, Balani A. Enhanced Recovery after Bariatric Surgery: 202 Consecutive Patients in an Italian Bariatric Center. Obes Surg 2020; 29:3133-3141. [PMID: 31123991 DOI: 10.1007/s11695-019-03962-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Carlo Nagliati
- Department of Surgery, San Giovanni di Dio Hospital, Via Fatebenefratelli 34, 34170, Gorizia, Italy.
| | - Marina Troian
- Department of Surgery, Cattinara Hospital, Strada di Fiume 447, 34149, Trieste, Italy
| | - Damiano Pennisi
- Department of Surgery, San Giovanni di Dio Hospital, Via Fatebenefratelli 34, 34170, Gorizia, Italy
| | - Alessandro Balani
- Department of Surgery, San Giovanni di Dio Hospital, Via Fatebenefratelli 34, 34170, Gorizia, Italy
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Does the Implementation of Enhanced Recovery After Surgery (ERAS) Guidelines Improve Outcomes of Bariatric Surgery? A Propensity Score Analysis in 464 Patients. Obes Surg 2020; 29:2843-2853. [PMID: 31183785 DOI: 10.1007/s11695-019-03943-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Abstract
OBJECTIVES Evaluate the safety of fast track (FT) surgery program in patients undergoing primary and revisional bariatric surgery (conversion from one procedure to another); identify limiting factors for early discharge and predictive factors for readmission. METHODS This is a retrospective review of 730 consecutive morbidly obese patients who underwent bariatric surgery between January 2016 and December 2017. Fast track protocol was applied on all patients. Target discharge was after one-night stay. The primary end point is length of stay. The secondary end point is frequency of hospital contact after discharge, readmissions and reinterventions within 30 days. RESULTS Primary procedures (n = 633) were banded Roux-en-Y gastric bypass (BRYGB, 79.3%), sleeve gastrectomy (10.7%), gastric band (4.7%) and others (5.3%). Mean age (± SD) was 44.32 ± 11.26 years, and mean BMI (± SD) was 43.58 ± 6.12 kg/m2. Conversion procedures (n = 97) were gastric band to BRYGB (40.2%), or to adjustable BRYGB (39.2%), Mason to BRYGB (11.3%), sleeve to BRYGB (4.1%) and others (5.2%). Mean age (± SD) was 47.22 ± 9.1 years, and mean BMI (± SD) was 37.9 ± 7.27 kg/m2. Mean LOS in primary patients was 1.3 ± 0.99, and that in conversion patients was 1.5 ± 1.4. Successful discharge at one night or less was achieved in 650 cases (573 primary and 77 conversion). After one-night discharge, incidence of contact to the hospital, readmission and reintervention was 23.9%, 5.9% and 1.9%, in the primary group and 31.2%, 13% and 5.2% in the conversion group. CONCLUSION One-night discharge in FT managed conversion procedures is safe, compared to primary procedures. It is associated with higher readmission rates; however, the postdischarge hospital contacts and surgical complications were not statistically significant different.
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Carrano FM, Peev MP, Saunders JK, Melis M, Tognoni V, Di Lorenzo N. The Role of Minimally Invasive and Endoscopic Technologies in Morbid Obesity Treatment: Review and Critical Appraisal of the Current Clinical Practice. Obes Surg 2019; 30:736-752. [DOI: 10.1007/s11695-019-04302-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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A Single-center Experience Examining the Length of Stay and Safety of Early Discharge After Laparoscopic Roux-en-Y Gastric Bypass Surgery. Obes Surg 2019; 28:1225-1231. [PMID: 29455407 DOI: 10.1007/s11695-017-2993-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE This study's objective was to describe our experience and evaluate the safety of early discharge (ED) following laparoscopic Roux-en-Y gastric bypass (LRYGB) in a specific patient population. MATERIALS AND METHODS Patients undergoing LRYGB at Montefiore Medical Center were retrospectively reviewed. Patients readmitted in the first 30 days following surgery were compared to those patients who were not readmitted. Data analysis was used to compare groups and to determine factors associated with readmission. In addition to patient demographics, length of stay (LOS) was analyzed as an independent risk factor for readmission. RESULTS A total of 630 LRYGB were performed during this period. There were 5.1% (n = 32) of patients that required readmission within 30 days of discharge. Readmitted patients had a higher BMI (50.0 vs. 45.8; p = 0.006) and there was a trend for them to be younger (38.4 years vs. 42.0; p = 0.07). There was an increased rate of ED in 2015 (36.7%, n = 121) compared to 2014 (29.9%, n = 90). The readmission rate for ED for the study period was 4.7% (n = 10). There were no observed mortalities in our early discharge group of patients. CONCLUSIONS Discharge on post-operative day 1 following a LRYGB is safe and is not associated with an increased likelihood of being readmitted within 30 days of discharge. Our single-center experience helps to better characterize current patient profiles and length of stay trends within the field and can be used to establish a randomized controlled trial for discharging patients early after LRYGB.
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Trotta M, Ferrari C, D’Alessandro G, Sarra G, Piscitelli G, Marinari GM. Enhanced recovery after bariatric surgery (ERABS) in a high-volume bariatric center. Surg Obes Relat Dis 2019; 15:1785-1792. [DOI: 10.1016/j.soard.2019.06.038] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/16/2019] [Accepted: 06/26/2019] [Indexed: 02/08/2023]
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Hung KC, Chen YT, Chen JY, Kuo CY, Wu SC, Chiang MH, Lan KM, Wang LK, Sun CK. Clinical characteristics of arytenoid dislocation in patients undergoing bariatric/metabolic surgery: A STROBE-complaint retrospective study. Medicine (Baltimore) 2019; 98:e15318. [PMID: 31027101 PMCID: PMC6831391 DOI: 10.1097/md.0000000000015318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Tracheal intubation and the use of a large-bore calibrating orogastric (OG) tube have been reported to increase the incidence of arytenoid dislocation (AD) in patients undergoing bariatric/metabolic surgery. This study aimed at identifying the clinical characteristics of this patient subgroup.We retrospectively examined the clinical characteristics of 14 patients with AD (study group) who received tracheal intubation and OG insertion for bariatric/metabolic surgery between 2011 and 2016. For comparison, another group of 19 patients with postoperative AD collected from published literature and 3 patients from the authors' institute served as controls in whom only tracheal intubation was performed. Information on patient characteristics, anesthetic time, symptoms, time of symptom onset, intervention, and postinterventional impact on vocalization of the 2 groups were collected and compared.Patients in the study group were younger than those in the control group (38 [25-60] vs 54.5 [19-88] years, P = .03). Compared with the control group, anesthetic time (282.5 [155-360] vs 225 [25-480] minutes, P = .041) was longer and symptom onset (1.0 [0-6] vs 1.0 [0-6] days, P = .018) was more delayed in the study group. After closed reduction, the frequency of voice recovery was comparable in both groups in a time interval of 12 weeks (84.6% vs 92.9%, P = .59).Our report demonstrates that the clinical characteristics of patients with AD who received tracheal intubation and OG insertion for bariatric/metabolic surgery were different from those with postoperative AD receiving only tracheal intubation, highlighting the importance of implementing individualized strategies for AD prevention in this patient population.
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Affiliation(s)
- Kuo-Chuan Hung
- Department of Anaesthesiology, Chi Mei Medical Center, Tainan
| | - Yi-Ting Chen
- Department of Anaesthesiology, Chang Gung Memorial Hospital, Chia-Yi
| | - Jen-Yin Chen
- Department of Anaesthesiology, Chi Mei Medical Center, Tainan
- Department of the Senior Citizen Service Management, Chia Nan University of Pharmacy and Science, Tainan
| | - Chuan-Yi Kuo
- Department of Anaesthesiology, E-Da Hospital, I-Shou University
| | - Shao-Chun Wu
- Department of Anaesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine
| | - Min-Hsien Chiang
- Department of Anaesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine
| | - Kuo-Mao Lan
- Department of Anaesthesiology, Chi Mei Medical Center, Tainan
| | - Li-Kai Wang
- Department of Anaesthesiology, Chi Mei Medical Center, Tainan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan
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Kizilcik N, Koner O. Magnesium Sulfate Reduced Opioid Consumption in Obese Patients Undergoing Sleeve Gastrectomy: a Prospective, Randomized Clinical Trial. Obes Surg 2018; 28:2783-2788. [DOI: 10.1007/s11695-018-3243-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Ruiz-Tovar J, Muñoz JL, Royo P, Duran M, Redondo E, Ramirez JM. Implementation of the Spanish ERAS program in bariatric surgery. MINIM INVASIV THER 2018. [PMID: 29519184 DOI: 10.1080/13645706.2018.1446988] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Introduction: The essence of Enhanced Recovery After Surgery (ERAS) programs is the multimodal approach, and many authors have demonstrated safety and feasibility in fast track bariatric surgery. According to this concept, a multidisciplinary ERAS program for bariatric surgery has been developed by the Spanish Fast Track Group (ERAS Spain). The aim of this study was to analyze the initial implementation of this Spanish National ERAS protocol in bariatric surgery, comparing it with a historical cohort receiving standard care. Material and methods: A multi-centric prospective study was performed, including 233 consecutive patients undergoing bariatric surgery during 2015 and following ERAS protocol. It was compared with a historical cohort of 286 patients, who underwent bariatric surgery at the same institutions between 2013 and 2014 and following standard care. Compliance with the protocol, morbidity, mortality, hospital stay and readmission were evaluated. Results: Bariatric techniques performed were Roux-en-Y gastric bypass and sleeve gastrectomy. There were no significant differences in complications, mortality and readmission. Postoperative pain and hospital stay were significantly lower in the ERAS group. The total compliance to protocol was 80%. Conclusion: The Spanish National ERAS protocol is a safe issue, obtaining similar results to standard care in terms of complications, reoperations, mortality and readmissions. It is associated with less postoperative pain and earlier hospital discharge.
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Affiliation(s)
- Jaime Ruiz-Tovar
- a Department of Surgery, Bariatric Surgery Unit , University Hospital Rey Juan Carlos , Madrid , Spain
| | - José Luis Muñoz
- b Department of Anaesthesiology , General University Hospital Elche , Alicante , Spain
| | - Pablo Royo
- c Department of Surgery, Bariatric Surgery Unit , Clinical University Hospital Lozano Blesa , Zaragoza , Spain
| | - Manuel Duran
- a Department of Surgery, Bariatric Surgery Unit , University Hospital Rey Juan Carlos , Madrid , Spain
| | - Elisabeth Redondo
- c Department of Surgery, Bariatric Surgery Unit , Clinical University Hospital Lozano Blesa , Zaragoza , Spain
| | - Jose Manuel Ramirez
- c Department of Surgery, Bariatric Surgery Unit , Clinical University Hospital Lozano Blesa , Zaragoza , Spain
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Inaba CS, Koh CY, Sujatha-Bhaskar S, Zhang L, Nguyen NT. Same-Day Discharge after Laparoscopic Roux-en-Y Gastric Bypass: An Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Database. J Am Coll Surg 2018; 226:868-873. [PMID: 29428234 DOI: 10.1016/j.jamcollsurg.2018.01.049] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 01/29/2018] [Accepted: 01/29/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been performed with successful discharge on postoperative day 1 (POD1). There are limited studies on same-day discharge after LRYGB. The objective of this study was to examine the frequency and outcomes of same-day discharge after LRYGB. STUDY DESIGN The 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was analyzed for adult patients who underwent elective LRYGB cases with same-day vs POD1 discharge. Open and revisional cases were excluded. Multivariate analysis was performed to compare risk-adjusted 30-day mortality, overall morbidity, readmission, and reoperation. RESULTS There were 354 (0.9%) patients who were discharged on the same day as surgery after LRYGB. After exclusion criteria, 319 patients with same-day discharge and 9,402 patients with POD1 discharge were examined. For same-day vs POD1 discharge groups, mean ages were 45.0 and 44.5 years, respectively, and mean BMIs were 47.3 kg/m2 and 45.9 kg/m2, respectively. The unadjusted mortality rate was significantly higher for same-day compared with POD1 discharge (0.94% vs. 0.05%, respectively; p = 0.0017). Compared with POD1 discharge, same-day discharge had higher overall morbidity (3.76% vs 1.54%; adjusted odds ratio [AOR] 2.41; p = 0.0216), but no statistically significant differences for readmissions (3.45% vs. 3.66%; AOR 0.85; p = 0.9999) or reoperations (1.88% vs. 0.89%; AOR 2.33; p = 0.2428). CONCLUSIONS Same-day discharge after LRYGB is associated with increased morbidity and mortality compared with POD1 discharge. The practice of same-day discharge after LRYGB should be considered experimental until further studies confirm which patient characteristics will ensure safe same-day discharge.
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Affiliation(s)
- Colette S Inaba
- Department of Surgery, University of California Irvine Medical Center, Orange, CA
| | - Christina Y Koh
- Department of Surgery, University of California Irvine Medical Center, Orange, CA
| | | | - Lishi Zhang
- Institute for Clinical and Translational Science, University of California Irvine, Irvine, CA
| | - Ninh T Nguyen
- Department of Surgery, University of California Irvine Medical Center, Orange, CA.
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Mahmood F, Sharples AJ, Rotundo A, Balaji N, Rao VSR. Factors Predicting Length of Stay Following Bariatric Surgery: Retrospective Review of a Single UK Tertiary Centre Experience. Obes Surg 2018; 28:1924-1930. [DOI: 10.1007/s11695-017-3105-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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22
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Siotos C, Stergios K, Naska A, Frountzas M, Pergialiotis V, Perrea DN, Nikiteas N. The impact of fast track protocols in upper gastrointestinal surgery: A meta-analysis of observational studies. Surgeon 2018; 16:183-192. [PMID: 29337046 DOI: 10.1016/j.surge.2017.12.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 10/01/2017] [Accepted: 12/01/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Fast track surgery has been implemented in colorectal procedures during the last decade and is accompanied by significant improvement in patient outcomes during the early postoperative period. However, to date, its adoption in upper gastrointestinal surgery remains a matter of debate. In this context, we aimed to summarize the existing evidence in the international literature. MATERIALS AND METHODS We searched Medline, Scopus, ClinicalTrials.gov and Cochrane Central Register databases for published randomized controlled trials. The meta-analysis was performed with the RevMan 5.3.5 software. MAIN FINDINGS Thirty studies were finally included in the present meta-analysis. The post-operative morbidity was not influenced by the implementation of fast track surgery (FTS) (OR 0.84, 95% CI 0.64-1.09). However, in cases treated with laparoscopic surgery fast track surgery seemed to reduce morbidity by 50% (p = .006). The overall mortality of patients was low in the majority of included studies and was not influenced by fast track surgery (OR 1.12, 95% CI 0.50-2.52). The duration of postoperative hospitalization was significantly reduced with the adoption of FTS (MD -2.24, 95% CI -2.63 to -1.85 days). Concurrently, the overall cost was significantly reduced in cases treated with FTS (MD -982.30, 95% CI -1367.68 to -596.91 U.S dollars). CONCLUSION According to the findings of our meta-analysis suggest that FTS seems to be safe in patients undergoing upper gastrointestinal surgery and reduce both the days of postoperative hospitalization and the overall cost. This observation should be taken into account in future recommendations to enhance the implementation of FTS protocols in current clinical practice.
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Affiliation(s)
- Charalampos Siotos
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Stergios
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece; Department of General Surgery, Watford General Hospital - West Hertfordshire Hospitals NHS Trust, UK.
| | - Androniki Naska
- Department of Hygiene, Epidemiology and Medical Statistics, WHO Collaborating Center for Food and Nutrition Policies, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Maximos Frountzas
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasilios Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Despina N Perrea
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Nikiteas
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Implementation of enhanced recovery programs for bariatric surgery. Results from the Francophone large-scale database. Surg Obes Relat Dis 2018; 14:99-105. [DOI: 10.1016/j.soard.2017.09.535] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 09/13/2017] [Accepted: 09/28/2017] [Indexed: 02/06/2023]
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Bamgbade OA, Oluwole O, Khaw RR. Perioperative Antiemetic Therapy for Fast-Track Laparoscopic Bariatric Surgery. Obes Surg 2017; 28:1296-1301. [DOI: 10.1007/s11695-017-3009-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Simonelli V, Goergen M, Orlando GG, Arru L, Zolotas CA, Geeroms M, Poulain V, Azagra JS. Fast-Track in Bariatric and Metabolic Surgery: Feasibility and Cost Analysis Through a Matched-Cohort Study in a Single Centre. Obes Surg 2017; 26:1970-7. [PMID: 27272321 DOI: 10.1007/s11695-016-2255-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Due to the rise in severe obesity in Western countries and the increase in bariatric surgery, enhanced recovery (ER) pathways should be developed and promoted. METHODS A monocentric prospective series of 103 bariatric surgery patients managed with the ER pathway (group ER) was compared with a retrospective and immediately previous series of 103 patients managed with standard care (group CS). The aim of the present study was to assess and compare the differences in terms of mean postoperative length of stay (LOS), costs for surgery and recovery, and the differences in terms of complications, readmission, and reoperation rate in the short term between the ER and CS groups. RESULTS The mean LOS was 4.18 days in group CS and 1.79 days in group ER (p < 0.0001). The mean operative time (OT) per patient was 190.20 min in the group CS and 133.54 min in the group ER, resulting in an average cost of 7272.57€ per patient in group CS and 5424.09€ per patient in group ER. The average recovery cost was 1809.94€ for the group CS series and 775.07 for the group ER one. Overall complications (Clavien-Dindo up to II) occurred in 6 patients (5.8 %) in group CS and in 2 patients (1.9 %) in group ER (p = 0.149) and specific complications (Clavien-Dindo IIIb) occurred for 9 patients (8.7 %) in Group CS and for 14 patients (13.5 %) in group ER (p = 0.268) after hospital discharge within 1-month of follow-up. Twelve patients (11.5 %) in group CS and 13 (12.5 %) in group ER were readmitted after discharge (p = 0.831) within 1-month of follow-up; 8 patients (7.7 %) in group CS versus 9 patients (8.8 %) in group ER needed to be reoperated (p = 0.800) within 1-month follow-up. CONCLUSIONS Enhanced recovery pathway reduces significantly LOS in bariatric surgical patients and shortens the mean OT of the procedure, with no significant differences in terms of surgical outcomes. Furthermore, recovery charges were lower and operative time was shorter allowing for procedural cost reduction.
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Affiliation(s)
- Vincenzo Simonelli
- Centre Hospitalier de Luxembourg, 4 Rue Barblé, L-1210, Luxembourg City, Grand Duchy of Luxembourg.
| | - Martine Goergen
- Centre Hospitalier de Luxembourg, 4 Rue Barblé, L-1210, Luxembourg City, Grand Duchy of Luxembourg
| | - Gennaro G Orlando
- Centre Hospitalier de Luxembourg, 4 Rue Barblé, L-1210, Luxembourg City, Grand Duchy of Luxembourg
| | - Luca Arru
- Centre Hospitalier de Luxembourg, 4 Rue Barblé, L-1210, Luxembourg City, Grand Duchy of Luxembourg
| | - Charalampos A Zolotas
- Centre Hospitalier de Luxembourg, 4 Rue Barblé, L-1210, Luxembourg City, Grand Duchy of Luxembourg
| | - Maxim Geeroms
- Centre Hospitalier de Luxembourg, 4 Rue Barblé, L-1210, Luxembourg City, Grand Duchy of Luxembourg
| | - Virginie Poulain
- Centre Hospitalier de Luxembourg, 4 Rue Barblé, L-1210, Luxembourg City, Grand Duchy of Luxembourg
| | - Juan S Azagra
- Centre Hospitalier de Luxembourg, 4 Rue Barblé, L-1210, Luxembourg City, Grand Duchy of Luxembourg.
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van Mil SR, Duinhouwer LE, Mannaerts GHH, Biter LU, Dunkelgrun M, Apers JA. The Standardized Postoperative Checklist for Bariatric Surgery; a Tool for Safe Early Discharge? Obes Surg 2017. [DOI: 10.1007/s11695-017-2746-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Bamgbade OA, Oluwole O, Khaw RR. Perioperative Analgesia for Fast-Track Laparoscopic Bariatric Surgery. Obes Surg 2017; 27:1828-1834. [DOI: 10.1007/s11695-017-2562-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Implementation of the Spanish National Enhanced Recovery Program (ERAS) in Bariatric Surgery: A Pilot Study. Surg Laparosc Endosc Percutan Tech 2016; 26:439-443. [DOI: 10.1097/sle.0000000000000323] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Warnakulasuriya SR, Yates DR, Wilson JT, Stone M, Redman J, Davies S. Cardiopulmonary Exercise Testing Has no Additive Incremental Value to Standard Scoring Systems when Risk Stratifying for Bariatric Surgery. Obes Surg 2016; 27:187-193. [PMID: 27638412 DOI: 10.1007/s11695-016-2351-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Cardiopulmonary exercise testing (CPET) can identify patients at risk of adverse post-operative outcomes following major abdominal surgery including bariatric surgery. Scoring systems that also aim to predict post-operative outcome in this group include the validated obesity surgery mortality risk score (OSMRS). This study aims to investigate if CPET has additive value to other scoring systems in predicting post-operative outcomes following bariatric surgery. METHODS Data was collected retrospectively on 398 patients who underwent CPET between October 2008 and April 2013. CPET data, medical history, complication rates and length of stay (LOS) were obtained from patient records. Data was analysed to investigate the relationship between CPET and other scoring systems with post-operative outcome. RESULTS Two hundred and fifty patients underwent Roux-en-Y gastric bypass or sleeve gastrectomy. Median LOS was 4 days (IQR 4-6 days) and 41 patients (16.4 %) developed a complication. Adjusted data showed a risk difference for complications of 17 % (95 % CI 9-25 %) between high- and low-risk patients stratified by OSMRS alongside a 27 % (95 % CI 12-45 %) longer LOS. Variation in AT or peak VO2 showed no significant relationship with complications or LOS. Amongst high OSMRS risk patients, there was no significant difference in complications or LOS when CPET data was added to this analysis. CONCLUSIONS Cardiopulmonary exercise testing adds no incremental value in predicting post-operative outcomes in the bariatric population compared to the OSMRS, which is strongly predictive of length of stay and complication following bariatric surgery.
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Affiliation(s)
| | - David R Yates
- York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE, UK
| | - Jonathan T Wilson
- York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE, UK
| | - Michael Stone
- York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE, UK
| | - Jonathan Redman
- York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE, UK
| | - Simon Davies
- York Teaching Hospital NHS Foundation Trust, Wiggington Road, York, YO31 8HE, UK.
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Enhanced Recovery after Bariatric Surgery in the Severely Obese, Morbidly Obese, Super-Morbidly Obese and Super-Super Morbidly Obese Using Evidence-Based Clinical Pathways: a Comparative Study. Obes Surg 2016; 27:560-568. [DOI: 10.1007/s11695-016-2366-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Pike TW, Lodge JPA. Fast-Track Management after Laparoscopic Roux-en-Y Gastric Bypass. J Am Coll Surg 2016; 223:203. [PMID: 27345917 DOI: 10.1016/j.jamcollsurg.2016.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 04/18/2016] [Indexed: 11/16/2022]
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Raftopoulos I, Giannakou A, Davidson E. Prospective 30-Day Outcome Evaluation of a Fast-Track Protocol for 23-Hour Ambulatory Primary and Revisional Laparoscopic Roux-en-Y Gastric Bypass in 820 Consecutive Unselected Patients. J Am Coll Surg 2016; 222:1189-200. [DOI: 10.1016/j.jamcollsurg.2016.03.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 03/02/2016] [Accepted: 03/03/2016] [Indexed: 01/07/2023]
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Javanainen MH, Scheinin T, Mustonen H, Leivonen M. Do Changes in Perioperative and Postoperative Treatment Protocol Influence the Frequency of Pulmonary Complications? A Retrospective Analysis of Four Different Bariatric Groups. Obes Surg 2016; 27:64-69. [PMID: 27220851 DOI: 10.1007/s11695-016-2236-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The current understanding of prophylaxis of pulmonary complications in bariatric surgery is weak. PURPOSE The aim of this study was to observe how changes in perioperative and postoperative treatments affect the incidence of pulmonary complications in bariatric patients. MATERIALS This is a retrospective clinical study of 400 consecutive bariatric patients. The patients, who either underwent a sleeve gastrectomy or a Roux-en-Y gastric bypass, were divided consecutively into four subgroups with different approaches to perioperative treatment. METHODS The first group (patients 0-100) was recovered in the intensive care unit with minimal mobilization (ICU). They had a urinary catheter and a drain. The second group (patients 101-200) was similar to the first group, but the patients used a continuous positive airway pressure (CPAP) device intermittently (ICU-CPAP). The third group (patients 201-300) was recovered on a normal ward without a urinary catheter or a drain and used a CPAP device (ward-slow). The fourth group (patients 301-400) walked to the operating theater and was mobilized in the recovery room during the first 2 h after the operation (ward-fast). CPAP was also used. Primary endpoints were pulmonary complications, pneumonia, and infection, non-ultra descriptus (NUD). RESULTS The number of pulmonary complications among the groups was significantly different. A long operation time increased the risk for infection (p < 0.001 95 % CI from 2.02 to 6.59 %). CONCLUSIONS Operation time increases the risk for pulmonary complications. Changes in perioperative care toward the ERAS protocol may have a positive effect on the number of pulmonary complications.
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Laparoscopic Roux en-Y Gastric Bypass Using a Modified Retrocolic–Supracolic Approach: Outcomes from 300 Patients. World J Surg 2016; 40:1918-24. [DOI: 10.1007/s00268-016-3478-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Proczko M, Kaska L, Twardowski P, Stepaniak P. Implementing enhanced recovery after bariatric surgery protocol: a retrospective study. J Anesth 2016; 30:170-3. [PMID: 26499320 PMCID: PMC4744256 DOI: 10.1007/s00540-015-2089-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 10/06/2015] [Indexed: 12/13/2022]
Abstract
While the demand for bariatric surgery is increasing, hospital capacity remains limited. The ERABS (Enhanced Recovery After Bariatric Surgery) protocol has been implemented in a number of bariatric centers. We retrospectively compared the operating room logistics and postoperative complications between pre-ERABS and ERABS periods in an academic hospital. The primary endpoint was the length of stay in hospital. The secondary endpoints were turnover times-the time required for preparing the operating room for the next case, induction time (from induction of anesthesia until a patient is ready for surgery), surgical time (duration of surgery), procedure time (duration of stay in the operating room), and the incidence of re-admissions, re-operations and complications during admission and within 30 days after surgery. Of a total of 374 patients, 228 and 146 received surgery following the pre-ERABS and ERABS protocols, respectively. The length of hospital stay was significantly shortened from 3.7 (95 % confidence interval [CI] 3.1-4.7) days to 2.1 (95 % CI 1.6-2.6) days (P < 0.001). Procedure (surgical) times were shortened by 15 (7) min and 12 (5) min for gastric bypass and gastric sleeve surgery, respectively (P < 0.001 for both), by introducing the ERABS protocol. Induction times were reduced from 15.2 (95 % CI 14.3-16.1) min to 12.5 (95 % CI 11.7-13.3) min (P < 0.001).Turnover times were shortened significantly from 38 (95 % CI 44-32) min to 11 (95 % CI 8-14) min. The incidence of re-operations, re-admissions and complications did not change.
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Affiliation(s)
- Monika Proczko
- General Surgical Clinical Hospital for Endocrinology and Transplantology at the Gdansk University of Medicine in Poland, Gdansk, Poland
| | - Lukasz Kaska
- General Surgical Clinical Hospital for Endocrinology and Transplantology at the Gdansk University of Medicine in Poland, Gdansk, Poland
| | - Pawel Twardowski
- Department of Clinical Anesthesiology and Intensive Therapy at the Gdansk University of Medicine in Poland, Gdansk, Poland
| | - Pieter Stepaniak
- General Surgical Clinical Hospital for Endocrinology and Transplantology at the Gdansk University of Medicine in Poland, Gdansk, Poland.
- Department of Operating Rooms, Catharina Hospital, P.O. Box 1350, 5602 ZA, Eindhoven, The Netherlands.
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Dogan K, Kraaij L, Aarts EO, Koehestanie P, Hammink E, van Laarhoven CJHM, Aufenacker TJ, Janssen IMC, Berends FJ. Fast-track bariatric surgery improves perioperative care and logistics compared to conventional care. Obes Surg 2015; 25:28-35. [PMID: 24993524 DOI: 10.1007/s11695-014-1355-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Due to the increased incidence of morbid obesity, the demand for bariatric surgery is increasing. Therefore, the methods for optimising perioperative care for the improvement of surgical outcome and to increase efficacy are necessary. The aim of this prospective matched cohort study is to objectify the effect of the fast-track surgery (FTS) programme in patients undergoing primary Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) surgery compared to conventional perioperative care (CPC). METHODS This study compared the perioperative outcome data of two groups of 75 consecutive morbid obese patients who underwent a primary LRYGB according to international guidelines in the periods January 2011-April 2011 (CPC group) and April 2012-June 2012 (FTS group). The two groups were matched for age and sex. Primary endpoints were surgery and hospitalisation time, while secondary endpoints were intraoperative medication use and complication rates. RESULTS Baseline patient characteristics for age, sex, weight and ASA classification were similar (p > 0.05) for CPC and FTS patients. BMI and waist circumference were significantly lower (p < 0.05) in the FTS compared to CPC. The total time from arrival at the operating room to the arrival at the recovery was reduced from 119 to 82 min (p < 0.001). Surgery time was reduced from 80 to 56 min (p < 0.001); mean hospital stay was reduced from 65 to 43 h (p < 0.001). Major complications occurred in 3 versus 4 % in the FTS and CPC, respectively. CONCLUSIONS The introduction of a fast-track programme after primary LRYGB improves short-term recovery and may reduces direct hospital-related resources.
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Affiliation(s)
- Kemal Dogan
- Department of Surgery, Rijnstate Hospital Arnhem, Intern post number 1190, Post Box 9555, 6800 TA, Arnhem, The Netherlands,
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Outcome of Laparoscopic Gastric Bypass (LRYGB) with a Program for Enhanced Recovery After Surgery (ERAS). Obes Surg 2015. [DOI: 10.1007/s11695-015-1799-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Bindal V, John S, Dudeja U. Enhanced recovery protocols--time to trim and adopt a lean bariatric practice. Surg Obes Relat Dis 2015; 11:819-20. [PMID: 26117167 DOI: 10.1016/j.soard.2015.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 04/29/2015] [Accepted: 04/29/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Vivek Bindal
- Institute of Minimal Access, Metabolic and Bariatric Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Suviraj John
- Institute of Minimal Access, Metabolic and Bariatric Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Usha Dudeja
- School of Medical Science and Research, Sharda University, Greater Noida, India
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Mannaerts GHH, van Mil SR, Stepaniak PS, Dunkelgrün M, de Quelerij M, Verbrugge SJ, Zengerink HF, Biter LU. Results of Implementing an Enhanced Recovery After Bariatric Surgery (ERABS) Protocol. Obes Surg 2015; 26:303-12. [DOI: 10.1007/s11695-015-1742-3] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Is there a role for enhanced recovery after laparoscopic bariatric surgery? Preliminary results from a specialist obesity treatment center. Surg Obes Relat Dis 2015; 12:119-26. [PMID: 25892343 DOI: 10.1016/j.soard.2015.03.008] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 03/12/2015] [Accepted: 03/15/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND There has been a relative lack of research on the effect of enhanced recovery in the context of morbid obesity surgery. OBJECTIVES To determine if the application of enhanced recovery after surgery (ERAS) principles can contribute to reduce postoperative hospital length of stay after bariatric surgery, controlling for other factors that may influence safe discharge on the first postoperative day. SETTING University teaching hospital, United Kingdom. METHODS Between February 2011 and December 2014, prospectively collected data on all patients undergoing laparoscopic bariatric surgery under the care of a single surgeon were reviewed. From January 2012, all patients were enrolled in an ERAS protocol and were assessed for fitness for early discharge (within 24 hr from the operation). Baseline patient characteristics and additional concomitant procedures data were compared for patients treated before and after implementation of the ERAS protocol; 30-day readmission data were analyzed for patients discharged on the first postoperative day and those discharged later. The effect of the implementation of the ERAS protocol on discharge on the first postoperative day was analyzed using multivariate analysis, while taking into account the effects of potential confounders (e.g., age, gender, American Society of Anesthesiologists [ASA] grade, concomitant surgical procedures, etc.). RESULTS Two-hundred and eighty-eight consecutive patients underwent bariatric surgery. Of these, 278 (96.5%) were potentially suitable for early discharge, while 10 (3.5%) patients developed an acute postoperative complication that delayed discharge irrespective of the effect of ERAS. All these patients required a reoperation within 48 hours and therefore were not considered suitable for early discharge and were not included in the statistical analysis. During the entire study period, 100 of 278 (36%) patients were discharged on the first postoperative day, 28.5% after laparoscopic Roux-en-Y gastric bypass (LRYGB) and 60.9% after laparoscopic sleeve gastrectomy (LSG); 178 of 278 (64%) patients were discharged after ≥ 2 days (mean: 2.58, range: 2-5). After implementation of the ERAS protocol in January 2012, the rate of patients discharged on the first postoperative day increased significantly from 1.6% to 39.7% after LRYGB (P<.01). Early discharge increased from 50% to 67.5% after LSG; although this change did not reach statistical significance (P = .294), it nevertheless represents a clinically relevant result. Four (4%) patients were readmitted after having been discharged on the first postoperative day, 10 (5.3%) patients after having been discharged ≥ 2 postoperative days. This difference was not statistically significant (P = .620). CONCLUSIONS The implementation of an enhanced recovery program after bariatric surgery is feasible, well tolerated, and can significantly reduce the length of hospital stay without increasing readmission rates. Controlling for several possible confounders, implementation of the ERAS protocol remained the strongest predictor of discharge on the first postoperative day after laparoscopic bariatric surgery.
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Matłok M, Pędziwiatr M, Major P, Kłęk S, Budzyński P, Małczak P. One hundred seventy-nine consecutive bariatric operations after introduction of protocol inspired by the principles of enhanced recovery after surgery (ERAS®) in bariatric surgery. Med Sci Monit 2015; 21:791-7. [PMID: 25779669 PMCID: PMC4373155 DOI: 10.12659/msm.893297] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background Obese patients are a very large high-risk group for complications after surgical procedures. In this group, optimized perioperative care and a faster recovery to full activity can contribute to a decreased rate of postoperative complications. The introduction of ERAS®-based protocol is now even more important in bariatric surgery centers. The results of our study support the idea of implementation of ERAS®-based protocol in this special group of patients. Material/Methods This analysis included 170 patients (62 male/108 female, mean BMI 46.7 kg/m2) who had undergone laparoscopic bariatric surgery, and whose perioperative care was conducted according to a protocol inspired by ERAS® principles. Examined factors included oral nutrition tolerance, time until mobilization after surgery, requirements for opioids, duration of hospitalization, and readmission rate. Results During the first 24 postoperative hours, oral administration of liquid nutrition was tolerated by 162 (95.3%) patients and 163 (95.8%) were fully mobile. In 44 (25.8%) patients it was necessary to administer opioids to relieve pain. Intravenous liquid supply was discontinued within 24 hours in 145 (85.3%) patients. The complication rate was 10.5% (mainly rhabdomyolysis and impaired passage of gastric contents). The average time of hospitalization was 2.9 days and the readmission rate was 1.7%. Conclusions The introduction of an ERAS® principles-inspired protocol in our center proved technically possible and safe for our patients, and allowed for reduced hospitalization times without increased rate of complications or readmissions.
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Affiliation(s)
- Maciej Matłok
- 2nd Department of General Surgery, Jagiellonian University - Medical College, Cracow, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University - Medical College, Cracow, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University - Medical College, Cracow, Poland
| | - Stanisław Kłęk
- 2nd Department of General Surgery, Jagiellonian University - Medical College, Cracow, Poland
| | - Piotr Budzyński
- 2nd Department of General Surgery, Jagiellonian University - Medical College, Cracow, Poland
| | - Piotr Małczak
- 2nd Department of General Surgery - Students' Society of Science, Jagiellonian University - Medical College, Cracow, Poland
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Awad S, Carter S, Purkayastha S, Hakky S, Moorthy K, Cousins J, Ahmed AR. Enhanced recovery after bariatric surgery (ERABS): clinical outcomes from a tertiary referral bariatric centre. Obes Surg 2015; 24:753-8. [PMID: 24357126 PMCID: PMC3972428 DOI: 10.1007/s11695-013-1151-4] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
There is paucity of data on Enhanced Recovery After Bariatric Surgery (ERABS) protocols. This feasibility study reports outcomes of this protocol utilized within a tertiary-referral bariatric centre. Data on consecutive primary procedures (laparoscopic gastric bypasses, sleeve gastrectomies and gastric bands) performed over 9 months within an ERABS protocol were prospectively recorded. Interventions utilized included shortened preoperative fasts, intra-operative humidification, early mobilization and feeding, avoidance of fluid overload, incentive spirometry, use of prokinetics and laxatives. Data collected included demographics, co-morbidities, morbidity, mortality, length of stay (LOS) and re-admissions. A total of 226 procedures (age [mean ± SD], 45 ± 11 years, median [interquartile range] BMI 44.9 [41.0–49.0] kg/m2) were undertaken: 150 (66 %) bypasses, 47 (21 %) sleeves and 29 (13 %) bands. Hypertension, diabetes mellitus, sleep apnea and limited mobility were present in 40 %, 34 %, 24 % and 9 % of patients, respectively. No anastomotic or staple line leaks/bleeds were encountered. Ten (4.4 %) patients developed postoperative morbidity (mainly respiratory complications). One death occurred from massive pulmonary embolus in a high-risk patient (despite insertion of preoperative-IVC filter). Respective mean ± SD LOS for bypasses, sleeves and bands were 1.88 ± 1.12, 2.30 ± 1.69 and 0.69 ± 0.81 days. Successful discharge on the first postoperative day was achieved in 37 % and 28 % of bypasses and sleeves, respectively. Day-case gastric bands were performed in 48 %. Thirty-day hospital re-admission occurred in six (2.7 %) patients. Applying an ERABS protocol was feasible, safe, associated with low morbidity, acceptable LOS and low 30-day re-admission rates. The presence of multiple medical co-morbidities should not preclude use of an ERABS protocol within bariatric patients.
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Affiliation(s)
- Sherif Awad
- Imperial Weight Centre, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK,
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Sood J. Advancing frontiers in anaesthesiology with laparoscopy. World J Gastroenterol 2014; 20:14308-14. [PMID: 25339818 PMCID: PMC4202360 DOI: 10.3748/wjg.v20.i39.14308] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 03/12/2014] [Accepted: 06/14/2014] [Indexed: 02/07/2023] Open
Abstract
The introduction of laparoscopy in the surgeon's armamentarium was in fact a "revolution in the history of surgery". Since this technique involves insufflation of carbon dioxide it produces several pathophysiological changes which have to be understood by the anaesthesiologist who can modify the anaesthesia technique accordingly. Advantages of laparoscopy include reduced pain, small scars and early return to work. Certain complications specific to laparoscopic surgery are due to carboperitoneum and increased intra-abdominal pressure. Venous air embolism, although very rare, can be lethal if not managed promptly. Other complications include subcutaneous emphysema, haemodynamic compromise and arrhythmias. Although associated with minimal postoperative morbidity, postoperative pain, nausea and vomiting can be quite problematic. The limitations of laparoscopy have been overcome by the introduction of robotic surgery. There are important implications for the anaesthesiologist during robotic surgeries which have to be practiced accordingly. Robotic surgery has a learning curve for both the surgeon and the anaesthesiologist. The robot is bulky, and cannot be disengaged after docking. Therefore it is important that the anaesthetized patient remains immobile throughout surgery and anaesthesia is reversed only after the robot has been disengaged at the end of surgery. Advances in laparoscopy and robotic surgery have modified anaesthetic techniques too.
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Pike TW, White AD, Snook NJ, Dean SG, Lodge JPA. Simplified Fast-Track Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg 2014; 25:413-7. [DOI: 10.1007/s11695-014-1408-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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de la Matta-Martín M, Acosta-Martínez J, Sánchez-Carrillo F. Anesthesia for bariatric surgery: 8-year retrospective study: are our patients now easier to manage? ACTA ACUST UNITED AC 2014; 61:422-8. [PMID: 24666510 DOI: 10.1016/j.redar.2014.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 11/27/2013] [Accepted: 01/20/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To review the perioperative management of patients who had undergone bariatric surgery in our institution during an 8-year period, with the aim of identifying variables that correlated with improved clinical outcomes and changes in perioperative practice. METHODS This was a retrospective observational study of 437 patients who had undergone bariatric surgery from January 2005 to June 2013. Of these patients, 163 had undergone open or laparoscopic biliopancreatic diversion (Group 1), and 274 had been managed according to a Tailored Laparoscopic Approach Program (TLAP) (Group 2). We analyzed major cardiocirculatory, pulmonary, and surgery-related complications, mortality rate, intensive care unit (ICU) admissions, post-anesthetic care unit (PACU) length of stay, and perioperative management standards, throughout the study period. RESULTS Changes were observed in anesthetic patterns and perioperative care standards during the study period: 25% of patients had combined epidural anesthesia in 2005, compared with none at present; ICU admissions decreased from 28.6% in 2005 to 3.1% at present; and time in PACU declined from a median of 23 h in 2005 to 5.12h at present. Duration of postoperative opioid therapy was also significantly reduced (from 48 h to 6h). Group 2 had a significantly lower mortality rate than Group 1 (0.37% versus 4.3%, respectively, P=0.004). CONCLUSIONS In our institution, adoption of a TLAP for bariatric surgery has led to changes in perioperative care standards that have been followed by clear improvements according to morbidity, mortality and management indicators.
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Affiliation(s)
- M de la Matta-Martín
- Unidad de Gestión Clínica del Bloque Quirúrgico, Hospital General, Hospital Universitario, Virgen del Rocío, Sevilla, Spain.
| | - J Acosta-Martínez
- Unidad de Gestión Clínica del Bloque Quirúrgico, Hospital General, Hospital Universitario, Virgen del Rocío, Sevilla, Spain
| | - F Sánchez-Carrillo
- Unidad de Gestión Clínica del Bloque Quirúrgico, Hospital General, Hospital Universitario, Virgen del Rocío, Sevilla, Spain
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Fast Track Care for Gastric Bypass Patients Decreases Length of Stay Without Increasing Complications in an UnselectedPatient Cohort. Obes Surg 2013; 24:390-6. [DOI: 10.1007/s11695-013-1133-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Perioperative pain. Int Anesthesiol Clin 2013; 51:67-79. [PMID: 23797646 DOI: 10.1097/aia.0b013e31829b8d62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Elliott JA, Patel VM, Kirresh A, Ashrafian H, Le Roux CW, Olbers T, Athanasiou T, Zacharakis E. Fast-track laparoscopic bariatric surgery: a systematic review. Updates Surg 2013; 65:85-94. [PMID: 23371325 DOI: 10.1007/s13304-012-0195-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 12/18/2012] [Indexed: 02/06/2023]
Abstract
This study aimed to systematically evaluate the evidence-based literature on fast-track laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) to determine the feasibility and safety of fast-track laparoscopic bariatric surgery. A literature search of PubMed, EMBASE and Cochrane Library using the MeSH terms "bariatric surgery", "ambulatory surgical procedures" and related terms as keywords was performed. The study included articles that reported on intended next-day discharge for LRYGB and same-day discharge for LAGB. Data were extracted on study design and size, patient demographics, patient-selection criteria, patient preparation, perioperative management, operative details, clinical outcomes, and follow-up. The review included 13 studies classified as level 3b or 4 evidence. There were seven studies that investigated LAGB, five studies investigated LRYGB and one study detailed outcomes from both LRYGB and LAGB. Next-day discharge rate ranged from 81 to 100 % for LRYGB. Same-day discharge rate ranged from 76 to 98 % for LAGB. In LRYGB and LAGB complication, re-admission and mortality rates (≤10.5, ≤7.5, ≤0.1 %, respectively) were comparable with the conventional perioperative care. From our results, the fast-track management of patients undergoing LRYGB and LAGB is feasible. With careful patient selection and preparation within high-volume centres, and application of care pathways including close outpatient follow-up, outcomes for fast-track bariatric procedures can compare favourably with those reported in the literature for standard management, but with decreased cost. However, further studies from independent researchers are required to determine the safety of a generalised adoption of this approach outside of dedicated bariatric units, and to formally demonstrate the cost-benefit of fast-track bariatric surgery.
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Lemanu DP, Singh PP, Berridge K, Burr M, Birch C, Babor R, MacCormick AD, Arroll B, Hill AG. Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy. Br J Surg 2013; 100:482-9. [PMID: 23339040 DOI: 10.1002/bjs.9026] [Citation(s) in RCA: 160] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND Optimized perioperative care within an enhanced recovery after surgery (ERAS) protocol is designed to reduce morbidity after surgery, resulting in a shorter hospital stay. The present study evaluated this approach in the context of sleeve gastrectomy for patients with morbid obesity. METHODS Patients were allocated to perioperative care according to a bariatric ERAS protocol or a control group that received standard care. These groups were also compared with a historical group of patients who underwent laparoscopic sleeve gastrectomy at the same institution between 2006 and 2010, selected using matched propensity scores. The primary outcome was median length of hospital stay. Secondary outcomes included readmission rates, postoperative morbidity, postoperative fatigue and mean cost per patient. RESULTS Of 116 patients included in the analysis, 78 were allocated to the ERAS (40) or control (38) group and there were 38 in the historical group. There were no differences in baseline characteristics between groups. Median hospital stay was significantly shorter in the ERAS group (1 day) than in the control (2 days; P < 0·001) and historical (3 days; P < 0·001) groups. It was also shorter in the control group than in the historical group (P = 0·010). There was no difference in readmission rates, postoperative complications or postoperative fatigue. The mean cost per patient was significantly higher in the historical group than in the ERAS (P = 0·010) and control (P = 0·018) groups. CONCLUSION The ERAS protocol in the setting of bariatric surgery shortened hospital stay and was cost-effective. There was no increase in perioperative morbidity. REGISTRATION NUMBER NCT01303809 (http://www.clinicaltrials.gov).
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Affiliation(s)
- D P Lemanu
- Department of Surgery, South Auckland Clinical School, Auckland, New Zealand.
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Abstract
PURPOSE OF REVIEW The aim of this review is to summarize important publications in enhanced recovery during 2010-2011 and to highlight key themes. Specifically, we focus on updated systematic reviews of high-quality clinical trials of enhanced recovery in colorectal surgery, exemplar studies of enhanced recovery in other specialties, and exploration of which elements of the enhanced recovery package might be associated with improved patient outcome. RECENT FINDINGS An expanding evidence base of clinical trials and implementation evaluations supports the effectiveness of enhanced recovery programmes in improving outcome following major elective surgery. The majority of this literature derives from the study of patients undergoing colorectal surgery, but increasingly enhanced recovery is spreading to other surgical specialties. The combination of reduced length of hospital stay (a surrogate for morbidity) with no increase in readmissions to hospital suggests that morbidity is reduced with enhanced recovery. Inconsistency in morbidity reporting limits the value of pooling data between studies, but within study comparisons in general support this conclusion. Patients adhering to an enhanced recovery programme return to normal function faster than those following traditional care pathways. SUMMARY Enhanced recovery adoption is likely to continue to grow (range of specialties and penetration within specialties). This progression is supported by the available published data.
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