Optimizing perioperative care in bariatric surgery patients. Obes Surg. 2012;22:979-990. [PMID: 22488683 DOI: 10.1007/s11695-012-0648-6]

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

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

Economic Impact of the Implementation of an Enhanced Recovery after Surgery (ERAS) Protocol in a Bariatric Patient Undergoing a Roux-En-Y Gastric Bypass

INTRODUCTION

Enhanced Recovery After Surgery (ERAS) protocols have proven to be cost-effective in various surgical procedures, mainly in colorectal surgeries. However, there is still little scientific evidence evaluating the economic impact of their application in bariatric surgery. The present study aimed to compare the economic cost of performing a laparoscopic Roux-en-Y gastric bypass following an ERAS protocol, with the costs of following a standard-of-care protocol.

PATIENTS AND METHODS

A prospective non-randomized study of patients undergoing Roux-en-Y gastric bypass was performed. Patients were divided into two groups: patients following an ERAS protocol and patients following a standard-of-care protocol. The total costs of the procedure were subdivided into pharmacological expenditures, surgical material, and time expenses, the price of complementary tests performed during the hospital stay, and costs related to the hospital stay.

RESULTS

The 84 patients included 58 women (69%) and 26 men (31%) with a mean age of 44.3 ± 11.6 years. There were no significant differences in age, gender, and distribution of comorbidities between groups. Postoperative pain, nausea or vomiting, and hospital stay were significantly lower within the ERAS group. The pharmacological expenditures, the price of complementary tests performed during the hospital stay, and the costs related to the hospital stay, were significantly lower in the ERAS group. There were no significant differences in the surgical material and surgical time costs between groups. Globally, the total cost of the procedure was significantly lower in the ERAS group with a mean saving of 1458.62$ per patient. The implementation of an ERAS protocol implied a mean saving of 21.25% of the total cost of the procedure.

CONCLUSIONS

The implementation of an ERAS protocol significantly reduces the perioperative cost of Roux-en-Y gastric bypass.

Virtual Reality as a Surgical Care Package for Patients Undergoing Weight Loss Surgery: A Narrative Review of the Impact of an Emerging Technology

While bariatric surgery is regarded as the most effective treatment for people with severe and morbid obesity, its pathway is regarded as a complex one due to the multidisciplinary approaches required from pre-surgery education until long-term management. This is essential to maintain weight loss and improve the quality of life after bariatric surgery. Although these approaches are broadened, patient education, pre-operative preparation, behavioural therapy, rehabilitation, and dietary changes are regarded as the main domains in such complex care. With the increase in technological adaptation in medical services, virtual reality (VR) has shown many benefits that can be utilized in the care of bariatric patients undergoing surgery. However, VR has not been innovated to be a multidomain care package in which bariatric patients could benefit throughout their journey from the pre-operative optimization, recovery, and long-term follow-up. This review aims to give a brief description of some of the applications of VR technology and question whether it has the potential to be considered as a virtual ecosystem to improve the bariatric patients’ experience and pathway throughout surgery and follow-up.

Improving Bed Utilization in a Cohort of Bariatric Surgical Patients Using a Perioperative Obstructive Sleep Apnea Treatment and Bed Triage Protocol

BACKGROUND

Postoperative bariatric management often includes high-intensity monitoring for respiratory complications since > 70% of patients have obstructive sleep apnea. Given the increasing number of bariatric surgeries, there is a need to determine safe and cost-effective processes for postoperative care.The objective of this study was to determine if a novel triage and perioperative management guideline reduces postoperative monitoring and costs following bariatric surgery.

METHODS

Using a pre-post design, this is a retrospective analysis of 501 patients who had bariatric surgery. Half the patients were managed with usual care, and the other half received obstructive sleep apnea screening and treatment of moderate/severe obstructive sleep apnea with perioperative continuous positive airway pressure. The intervention group was triaged preoperatively to a postoperative nursing location based on risk factors.

RESULTS

There were no significant differences in demographics, comorbidities, frequency, or severity of OSA between groups. In the intervention group, there were fewer admissions to the intensive care unit (2.0% vs 9.1%; p < 0.01) and high acuity unit (9.6% vs 18.3%; p < 0.01). The length of stay was shorter in the intervention group (1.3 vs 2.3 days; p < 0.01) with a 50% reduction in costs. There were no statistically significant differences in the incidence of postoperative respiratory and non-respiratory complications between the two groups.

CONCLUSIONS

Most postoperative bariatric surgery patients can be safely managed on the surgical ward with monitoring of routine vitals alone if patients with moderate/severe obstructive sleep apnea receive perioperative continuous positive airway pressure.

Higher Adherence to ERAS Society® Recommendations is Associated with Shorter Hospital Stay Without an Increase in Postoperative Complications or Readmissions in Bariatric Surgery: the Association Between Use of Enhanced Recovery After Surgery Protocols and Postoperative Complications after Bariatric Surgery (POWER 3) Multicenter Observational Study

PURPOSE

The effectiveness of enhanced recovery after surgery (ERAS) pathways in patients undergoing bariatric surgery remains unclear. Our objective was to determine the effect of the ERAS elements on patient outcomes following elective bariatric surgery.

MATERIALS AND METHODS

Prospective cohort study in adult patients undergoing elective bariatric surgery. Each participating center selected a single 3-month data collection period between October 2019 and September 2020. We assessed the 24 individual components of the ERAS pathways in all patients. We used a multivariable and multilevel logistic regression model to adjust for baseline risk factors, ERAS elements, and center differences RESULTS: We included 1419 patients. One hundred and fourteen patients (8%) developed postoperative complications. There were no differences in the incidence of overall postoperative complications between the self-designated ERAS and non-ERAS groups (54 (8.7%) vs. 60 (7.6%); OR, 1.14; 95% CI, 0.73-1.79; P = .56), neither for moderate-to-severe complications, readmissions, re-interventions, mortality, or hospital stay (2 [IQR 2-3] vs. 3 [IQR 2-4] days, 0.85; 95% CI, 0.62-1.17; P = .33) Adherence to the ERAS elements in the highest adherence quartile (Q1) was greater than 72.2%, while in the lowest adherence quartile (Q4) it was less than 55%. Patients with the highest adherence rates had shorter hospital stay (2 [IQR 2-3] vs. 3 [IQR 2-4] days, 1.54; 95% CI, 1.09-2.17; P = .015), while there were no differences in the other outcomes CONCLUSIONS: Higher adherence to ERAS Society® recommendations was associated with a shorter hospital stay without an increase in postoperative complications or readmissions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03864861.

Effectiveness of a Low-Calorie Diet for Liver Volume Reduction Prior to Bariatric Surgery: a Systematic Review

An energy-restricted diet is often prescribed before bariatric surgery to reduce weight and liver volume. While very-low-calorie diets (VLCDs, 450–800 kcal per day) have shown to be effective, the effectiveness of low-calorie diets (LCDs, 800–1500 kcal per day) is less obvious. The objective of this systematic review was to elucidate the effectiveness of LCD on liver volume reduction in patients awaiting bariatric surgery. Eight studies (n = 251) were included describing nine different diets (800–1200 kcal, 2–8 weeks). An LCD was effective in liver volume reduction (12–27%) and weight loss (4–17%), particularly during the first weeks. The LCD showed an acceptable patients’ compliance. Based on these findings, an LCD (800–1200 kcal), instead of a VLCD, for 2 to 4 weeks should be preferred.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of implementation of an enhanced recovery after surgery (ERAS) program in laparoscopic Roux-en-Y gastric bypass: a prospective randomized clinical trial

BACKGROUND

The essence of enhanced recovery after surgery (ERAS) program is the multimodal approach, and many authors have demonstrated safety and feasibility in fast-track bariatric surgery.

OBJECTIVES

The aim of this study was to evaluate the postoperative pain after the implementation of an ERAS protocol in Roux-en-Y gastric bypass and to compare it with the application of a standard care protocol.

SETTING

University Hospital Rey Juan Carlos, Madrid, Spain.

METHODS

A prospective randomized clinical trial of all the patients undergoing Roux-en-Y gastric bypass was performed. Patients were randomized into the following 2 groups: those patients after an ERAS program and those patients after a standard care protocol. Postoperative pain, nausea or vomiting, morbidity, mortality, hospital stay, and analytic acute phase reactants 24 hours after surgery were evaluated.

RESULTS

One hundred eighty patients were included in the study, 90 in each group. Postoperative pain (16 versus 37 mm; P < .001), nausea or vomiting (8.9% versus 2.2%; P = .0498), and hospital stay (1.7 versus 2.8 d; P < .001) were significantly lower in the ERAS group. There were no significant differences in complications, mortality, and readmission rates. White blood cell count, serum fibrinogen, and C reactive protein levels were significantly lower in the ERAS group 24 hours after surgery.

CONCLUSION

The implementation of an ERAS protocol was associated with lower postoperative pain, reduced incidence of postoperative nausea or vomiting, lower levels of acute phase reactants, and earlier hospital discharge. Complications, reinterventions, mortality, and readmission rates were similar to that obtained after a standard care protocol.

Enhanced recovery after surgery (ERAS) in one-anastomosis gastric bypass surgery: a matched-cohort study

BACKGROUND

One-anastomosis gastric bypass (OAGB) is considered new from the bariatric standpoint.

OBJECTIVES

To assess the effectiveness and safety of the enhanced recovery after surgery protocol compared with the conventional approach in perioperative care of OAGB patients.

SETTING

Turkey.

METHODS

The prospectively collected data of 92 patients managed with standard care (group 1) were compared with 216 patients managed by the enhanced recovery after surgery pathway (group 2). All patients underwent OAGB by the same surgeon. The groups were compared in terms of mean postoperative length of stay; costs for surgery and recovery; and rates of complications, emergency room visits, and readmissions.

RESULTS

Length of stay was always 5 days in group 1 and had a mean of 1.2 ± 1.3 days in group 2 (P < .001). The mean total cost for surgery and recovery was 858.6 ± 33.1 USD in group 1 and 625.2 ± 289.1 USD in group 2 (P < .001). Specific complications (Clavien-Dindo IIIa) occurred in 1 patient (1.1%) in group 1 and in 3 patients (1.4 %) in group 2 (P = 1.000). Fifty-seven patients (61.9%) in group 1 and 45 (20.9%) in group 2 visited the emergency room within 1 month of being discharged (P < .001). Two patients (.9%) in group 2 needed hospital readmission; there was no need for rehospitalization in group 1 (P < .001).

CONCLUSION

The enhanced recovery after surgery pathway significantly reduces length of stay and cost after OAGB, with no significant difference in terms of surgical outcomes. It also reduces postdischarge resource utilization.

Text messaging improves preoperative exercise in patients undergoing bariatric surgery

BACKGROUND

To investigate whether a text message intervention improves adherence to preoperative exercise advice prior to laparoscopic sleeve gastrectomy (LSG).

METHODS

A single-blinded parallel design 1:1 ratio randomized controlled trial was performed in patients undergoing LSG as a single-stage bariatric procedure for morbid obesity. The intervention group received preoperative daily text messages. The primary outcome was adherence to preoperative exercise advice as assessed by the number of participants partaking in ≥450 metabolic equivalent minutes (METmin-1 ) exercise activity per week preoperatively.

RESULTS

Eighty-eight patients were included in the analysis with 44 allocated to each arm. Adherence and exercise activity increased significantly from baseline in the exposure group (EG) but not in the control group (CG). Adherence was significantly higher in the EG at the end of the intervention period compared to the CG. Despite increased exercise activity, there was no improvement in 6-min walk test or surgical recovery.

CONCLUSION

A daily text message intervention improved adherence to preoperative exercise advice, but this did not correlate with improved surgical recovery.

Implementation of the Spanish ERAS program in bariatric surgery

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.

The safety and efficiency of a fast-track protocol for sleeve gastrectomy: a team approach

BACKGROUND

Increasing numbers of morbid obese patients has led to increased numbers of bariatric procedures. Fast-track protocols are being developed to enhance the available resources, while maintaining a safe procedure. Reported results on safety merely apply to a mixed bariatric population. The objective was to evaluate safety and efficiency of the fast-track principles in patients undergoing sleeve gastrectomy.

METHODS

Retrospective observational study including patients undergoing primary sleeve gastrectomy at the Obesity Centre of the Catharina Hospital Eindhoven, the Netherlands. Conventional perioperative care (CC) (2008-2011) versus a fast-track protocol (FT) (2011-2013), using short-acting anesthetic agents, a multi-modal pain protocol to reduce opioids, and early mobilization. The main parameters for safety were intraoperative, early and late postoperative complications. Procedure time and hospital stay were used to evaluate efficiency.

RESULTS

This study included 805 patients, 494 patients were subjected to the conventional care and 318 patients to fast-track protocol. A reduction of median operation time from 60 (CC) to 40 minutes (FT) (P<0.001) and a reduction in median length of hospital stay from three to two days (P=0.001), with a significant reduction in early postoperative complications (9.9% [CC] vs. 5% [FT], P=0.016) was achieved. The amount of late complications was comparable for both groups (5.1% [CC] vs. 4.4% [FT] [P=0.738]).

CONCLUSIONS

Implementation of a fast-track protocol for sleeve gastrectomy is safe and efficient. It effectively reduces operation time and length of hospital stay, while improving postoperative outcome. This pleads for standard implementation of the fast-track protocol in sleeve gastrectomy.

Enhanced Recovery after Bariatric Surgery: Systematic Review and Meta-Analysis

Enhanced recovery after surgery (ERAS) protocol is well established in many surgical disciplines and leads to a decrease in the length of hospital stay and morbidity. Multimodal protocols have also been introduced to bariatric surgery. This review aims to evaluate the current literature on ERAS in obesity surgery and to conduct a meta-analysis of primary and secondary outcomes. MEDLINE, Embase, Scopus and Cochrane Library were searched for eligible studies. Key journals were hand-searched. We analysed data up to May 2016. Eligible studies had to contain four described ERAS protocol elements. The primary outcome was the length of hospital stay; the secondary outcomes included overall morbidity, specific complications, mortality, readmissions and costs. Random effect meta-analyses were undertaken. The initial search yielded 1151 articles. Thorough evaluation resulted in 11 papers, which were analysed. The meta-analysis of the length of stay presented a significant reduction standard mean difference (Std. MD) = −2.39 (−3.89, −0.89), p = 0.002. The analysis of overall morbidity, specific complications and Clavien-Dindo classification showed no significant variations among the study groups. ERAS protocol in bariatric surgery leads to the reduction of the length of hospital stay while maintaining no or low influence on morbidity.

Enhanced recovery after surgery: Current research insights and future direction

Since the concept of enhanced recovery after surgery (ERAS) was introduced in the late 1990s the idea of implementing specific interventions throughout the peri-operative period to improve patient recovery has been proven to be beneficial. Minimally invasive surgery is an integral component to ERAS and has dramatically improved post-operative outcomes. ERAS can be applicable to all surgical specialties with the core generic principles used together with added specialty specific interventions to allow for a comprehensive protocol, leading to improved clinical outcomes. Diffusion of ERAS into mainstream practice has been hindered due to minimal evidence to support individual facets and lack of method for monitoring and encouraging compliance. No single outcome measure fully captures recovery after surgery, rather multiple measures are necessary at each stage. More recently the pre-operative period has been the target of a number of strategies to improve clinical outcomes, described as prehabilitation. Innovation of technology in the surgical setting is also providing opportunities to overcome the challenges within ERAS, e.g., the use of wearable activity monitors to record information and provide feedback and motivation to patients peri-operatively. Both modernising ERAS and providing evidence for key strategies across specialties will ultimately lead to better, more reliable patient outcomes.

Outcomes of laparoscopic sleeve gastrectomy at a bariatric unit in South Africa

Background

Laparoscopic sleeve gastrectomy (LSG) has gained popularity over the years as a standalone procedure. In 2014, it was the most rapidly growing bariatric procedure. The aim of this study was to describe the outcomes of LSG at a single bariatric unit in Johannesburg, South Africa, using the Bariatric Analysis and Reporting Outcome System (BAROS) standardised scoring.

Methods

A retrospective record review and analysis was carried out using data collected from patients who had LSGs. The information obtained included patient demographics, comorbidities, preoperative weight and height, operative technique, time and complications, postoperative gastrografin swallow results, hospital stay, and weight at 6 months postoperatively. The percentage of excess body mass index (BMI) loss (%EBMIL) was calculated at 6 months, and included in the BAROS questionnaire completed by the patients at the 6-month follow-up visit. Statistical significance was set at p < 0.05.

Results

A total of 103 patients were included in the study; of these, 85.4% were female and 14.6% were male. The mean preoperative BMI was 42.1 kg/m²; additionally, 77.7% of the patients in the study had comorbidities prior to the procedure. The mean operative time was 104.3 min, with a mean hospital stay of 2.5 days. No mortalities occurred, and a complication rate of 7.7% was encountered. At the 6-month follow-up, the mean %EBMIL was 65%. When followed up at 6 months, all 103 patients demonstrated no failures according to the BAROS assessment. It was found that 96.1% had good, very good or excellent outcomes. In total, 9.7% of the patients had an excellent outcome.

Conclusions

LSG was shown to produce an adequate %EBMIL loss at 6 months, resulting in a significant improvement in the quality of life (QoL), coupled with good BAROS outcomes. The results of this research are comparable to other studies of LSGs, and the low complication rate supports the use of the procedure and accounts for no observed mortality.

•

First study of laparoscopic sleeve gastrectomy performed in South Africa.

•

Laparoscopic sleeve gastrectomy produces an adequate percentage excess BMI loss at 6 months.

•

A significant improvement in the quality of life was observed.

•

Results of this research are comparable to other studies of LSGs.

•

Low complication rate supports the use of the procedure.

Postoperative pain after conventional laparoscopic versus single-port sleeve gastrectomy: a prospective, randomized, controlled pilot study

BACKGROUND

Laparoscopic approach is the gold standard for surgical treatment of morbid obesity. The single-port (SP) approach has been demonstrated to be a safe and effective technique for the treatment of morbid obesity in several case control studies.

OBJECTIVES

Compare conventional multiport laparoscopy (LAP) with an SP approach for the treatment of morbid obesity using sleeve gastrectomy in terms of postoperative pain using a visual analog scale (VAS) 0-100, surgical outcome, weight loss, and aesthetical satisfaction at 6 months after surgery.

SETTING

University Hospital, Spain.

METHODS

Randomized, controlled pilot study. The trial enrolled patients suitable for bariatric surgery, with a body mass index lower than 50 kg/m² and xiphoumbilical distance lower than 25 cm. Patients were randomly assigned to receive LAP or SP sleeve gastrectomy.

RESULTS

A total of 30 patients were enrolled; 15 were assigned to LAP group and 15 to SP group. No patients were lost during follow-up. Baseline characteristics were similar in both groups. A significantly higher level of pain during movement was noted for the patients in the LAP group on the first (mean VAS 49.3±12.2 versus 34.1±8.9, P = .046) and second days (mean VAS 35.9±10.2 versus 22.1±7.9, P = .044) but not the third day (mean VAS 20.1±5.2 versus 34.12.9 ±4.3, P = .620). No differences regarding pain at rest, operative time, complications, or weight loss at 6 months were observed. Higher aesthetical satisfaction was noticed in SP group.

CONCLUSIONS

In selected patients, SP surgery presented less postoperative pain in sleeve gastrectomy compared with the conventional laparoscopic approach with similar surgical results.

Best anaesthetic drug strategy for morbidly obese patients

PURPOSE OF REVIEW

The purpose of this review is to describe an evidence-based drug strategy applicable to any obese patient, rather than to present one standard 'ideal' anaesthetic drug combination. The ultimate choice of specific drugs in any given situation will depend upon clinician experience, patient specifics, and drug availability. The fundamental principle in anaesthesia for the obese patient is to use the shortest acting, least fat soluble agents to ensure rapid recovery to safe levels of alertness and mobility.

RECENT FINDINGS

No new drugs have been introduced over the past few years, but we have seen an introduction of enhanced recovery after surgery-based protocols into bariatric surgery. Our understanding of how obesity affects pharmacokinetics/dynamics of our drugs is improving, with new and better use of established drugs. Allometric scaling is being tested in the different pharmacokinetic/dynamic models used in target controlled infusion devices, with improved performance as a result. Obstructive sleep apnoea has a significant impact upon outcome and utilization of clinical resources, including critical care beds. If an improved drug dosing strategy will reduce this impact, then this would be a step forward.

SUMMARY

This review introduces newer findings to help us use anaesthetic and analgesic drugs more safely in the morbidly obese. However, there remain many areas of uncertainty with a lack of consensus on many issues.

Comparative analysis of respiratory muscle strength before and after bariatric surgery using 5 different predictive equations

STUDY OBJECTIVE

Obesity has detrimental effects on general health and respiratory function. This study aimed to evaluate respiratory muscle strength in the morbidly obese population, before and after bariatric surgery, and to compare these estimates with the predictive values using different mathematical equations available.

DESIGN

Prospective cohort study.

SETTING

Outpatient clinic for the treatment of obesity.

PATIENTS

Patients scheduled for elective bariatric surgery.

INTERVENTION

Bariatric surgery.

MEASUREMENTS

The maximal inspiratory pressure (MIP) was measured at screening and 3, 6, and 9 months postoperative. Predictive values were calculated using 5 different mathematical equations. Visual inspection of Bland-Altman plots was performed to determine the agreement between the equations studied.

MAIN RESULTS

In total 125 patients were found eligible and 122 patients were available for the final analysis, among them were 104 women and 18 men, with a mean age of 43.02 ± 11.11 years and mean BMI of 43.10 ± 5.25 kg/m(2). In the preoperative period, the predicted MIPs according to the Harik-Khan, Neder, Costa, and Wilson equations were significantly different compared with the actual MIP (P < .05). The predicted MIP according to the Enright equation was not significantly different (P > .05). Postoperatively, there was a significant difference between the MIP values after 3 and 6 months and the predicted MIP values according to Harik Khan, Neder, and Enright equations. After 9 months, all predicted MIP values were significantly different from the predicted values. Bland-Altman analysis showed that the Enright equation was best suitable for predicting the MIP.

CONCLUSION

Of the 5 mathematical equations studied, that of Enright and colleagues was found best suitable for predicting the MIP in the obese population studied.

Do Changes in Perioperative and Postoperative Treatment Protocol Influence the Frequency of Pulmonary Complications? A Retrospective Analysis of Four Different Bariatric Groups

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.

Implementing enhanced recovery after bariatric surgery protocol: a retrospective study

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.

Fast-track bariatric surgery improves perioperative care and logistics compared to conventional care

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.

Identificação dos diagnósticos de enfermagem da classe de respostas cardiovasculares/pulmonares em pacientes submetidos à cirurgia bariátrica

O objetivo deste estudo foi identificar as respostas humanas apresentadas por pacientes no pós-operatório de cirurgia bariátrica que se configurem como diagnósticos de enfermagem da classe respostas cardiovasculares/pulmonares. Estudo observacional de caráter transversal realizado no período de julho de 2010 a maio de 2011, em um hospital referência em cirurgia bariátrica em Fortaleza-CE. Os diagnósticos de enfermagem identificados foram: risco de perfusão gastrintestinal ineficaz (87,9%), risco de intolerância à atividade (70,7%), perfusão tissular periférica ineficaz (67,2%), risco de choque (63,8%), débito cardíaco diminuído (60,3%), risco de perfusão tissular cardíaca diminuída (58,6%), intolerância à atividade (51,7%), risco de perfusão tissular cerebral ineficaz (48,3%), ventilação espontânea prejudicada (46,5%), risco de perfusão renal ineficaz (43,1%), padrão respiratório ineficaz (37,9%) e resposta disfuncional ao desmame ventilatório (36,2%). Assim, com base nesses resultados será possível direcionar a assistência de enfermagem prestada aos pacientes submetidos à cirurgia bariátrica e, consequentemente, reduzir complicações pós-operatórias.

Obesity: physiologic changes and implications for preoperative management

The proportion of patients defined as obese continues to grow in many westernized nations, particularly the United States (USA). This trend has shifted the perioperative management of obese patients into the realm of routine care. As obese patients present for all types of procedures, it is crucial for anesthesiologists, surgeons, internists, and perioperative health care providers alike to have a firm understanding of their altered multi-organ physiology in order to safely prepare the obese patient for an operation. A careful preoperative evaluation may also serve to identify risk factors for postoperative adverse events. Subsequently, preoperative measures may be implemented to mitigate these complications. In this manuscript we address the major considerations for the preoperative evaluation of the severely obese patient.

Is there a role for enhanced recovery after laparoscopic bariatric surgery? Preliminary results from a specialist obesity treatment center

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.

Enhanced recovery after bariatric surgery (ERABS): clinical outcomes from a tertiary referral bariatric centre

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.

Review article: Perioperative care in enhanced recovery for total hip and knee arthroplasty

Enhanced recovery pathways for total hip and knee arthroplasty can reduce length of hospital stay and perioperative morbidity. 22 studies were reviewed for identification of perioperative care interventions, including preoperative (n=4), intra-operative (n=8), and postoperative (n=4) care interventions. Factors that improve outcomes included use of pre-emptive and multimodal analgesia regimens to reduce opioid consumption, identification of patients with poor nutritional status and provision of supplements preoperatively to improve wound healing and reduce length of hospital stay, use of warming systems and tranexamic acid, avoidance of drains to reduce operative blood loss and subsequent transfusion, and early ambulation with pharmacological and mechanical prophylaxis to reduce venous thromboembolism and to speed recovery.

A systematic review to assess cost effectiveness of enhanced recovery after surgery programmes in colorectal surgery

AIM

Enhanced recovery after surgery (ERAS) programmes have been shown to reduce length of stay and peri-operative morbidity. However, there are comparatively few data on their cost effectiveness. The object of this systematic review was to appraise the current literature to determine the cost effectiveness of ERAS and to characterize how cost is reported and evaluated.

METHOD

An electronic database search identified studies comparing ERAS with standard peri-operative care in colorectal surgery where an evaluation of cost effectiveness was a primary or secondary outcome. Cost data were converted to euros to enable a more standardized comparison of the studies. There were no limits on study design.

RESULTS

Seven articles were included in the analysis. The reporting and evaluation of cost data were inconsistent. Reported cost for ERAS ranged from €1989 to €12,805 per patient. Although not all statistically significant, all studies demonstrated cost reductions with ERAS compared with non-ERAS although they were highly variable, ranging from €153 to €6537 per patient.

CONCLUSION

Although the review has shown ERAS to be cost effective, there are some important inconsistencies and deficiencies regarding the reporting of data. Authors should therefore be encouraged to report cost data to supplement the literature detailing clinical efficacy.

Integrative Complementary Medicine for Treatment of Bariatric Perioperative Symptoms: Patients' Experiences and Staff Evaluations

BACKGROUND

A unique integrative complementary medicine (CM) pilot program was launched in a general surgery department at a public teaching hospital in Israel. In addition to standard supportive care, CM treatments are used to support patients undergoing laparoscopic sleeve gastrectomy (LSG) in coping with perioperative distresses. We examined the experiences of patients and how the nursing staff evaluate these treatments.

METHODS

Qualitative semi-structured open-ended interviews were used.

RESULTS

Most patients reported that the treatments helped them to cope better with preoperative anxiety, and facilitated postoperative breathing and pain relief. Nurses reported that CM treatments enabled them to reduce doses of analgesics. Both patients and nurses suggested that preoperative CM treatment facilitated a better postoperative CM-associated outcome.

CONCLUSIONS

Integrative perioperative CM treatments improved pain and anxiety care in patients undergoing LSG. More research is needed to examine CM efficacy in improving standard LSG perioperative supportive care and to evaluate cost effectiveness.

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

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).

Análise de agrupamentos para a classificação de pacientes submetidos à cirurgia bariátrica Fobi-Capella

RACIONAL: Indivíduos classificados como obesos mórbidos necessitam de tratamentos eficientes para promover a redução de peso. Em consequência da ineficácia dos tratamentos conservadores e medicamentos atuais, a operação de Fobi-Capella (gastric bypass) tem sido indicada para esse grupo de indivíduos. OBJETIVO: Identificar subgrupos de pacientes obesos com a finalidade de encontrar padrões que dificultem a perda de peso e a recuperação dele após essa operação. MÉTODO: Foram analisadas variáveis dos prontuários de 50 pacientes em dois momentos distintos: antes da operação bariátrica e após seis meses utilizando a metodologia estatística de Análise de Agrupamentos. RESULTADOS: A análise propiciou a divisão dos pacientes em dois grandes grupos. A variável IMC não influenciou na divisão dos pacientes. O grupo em piores condições metabólicas não foi necessariamente formado pelos indivíduos mais obesos, porém a Análise de Agrupamento associou os pacientes de acordo com quatro indicativos da síndrome metabólica. Houve clara relação entre as alterações metabólicas e de pressão arterial com a obesidade, porém neste estudo não se verificou dependência direta em relação ao IMC. CONCLUSÕES: As medidas que poderiam incrementar a recuperação após cirurgia bariátrica visam o controle da síndrome metabólica e não apenas a perda de peso, visto que o IMC foi reduzido em todos os pacientes e não foi o fator diferencial do pós-operatório.