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Afifi Ahmed SM, El-Medany Aly SM, Fouad Shaaban HA, Fathi Ateba KM. Comparative Study Between Desflurane and Sevoflurane Regarding Haemodynamics and Recovery Profiles in Obese Patients Undergoing Laparoscopic Sleeve Gastrectomy. EGYPTIAN JOURNAL OF ANAESTHESIA 2023. [DOI: 10.1080/11101849.2023.2179516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
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Flore G, Deledda A, Fosci M, Lombardo M, Moroni E, Pintus S, Velluzzi F, Fantola G. Perioperative Nutritional Management in Enhanced Recovery after Bariatric Surgery. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6899. [PMID: 37835169 PMCID: PMC10573058 DOI: 10.3390/ijerph20196899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 10/01/2023] [Accepted: 10/06/2023] [Indexed: 10/15/2023]
Abstract
Obesity is a crucial health problem because it leads to several chronic diseases with an increased risk of mortality and it is very hard to reverse with conventional treatment including changes in lifestyle and pharmacotherapy. Bariatric surgery (BS), comprising a range of various surgical procedures that modify the digestive tract favouring weight loss, is considered the most effective medical intervention to counteract severe obesity, especially in the presence of metabolic comorbidities. The Enhanced Recovery After Bariatric Surgery (ERABS) protocols include a set of recommendations that can be applied before and after BS. The primary aim of ERABS protocols is to facilitate and expedite the recovery process while enhancing the overall effectiveness of bariatric procedures. ERABS protocols include indications about preoperative fasting as well as on how to feed the patient on the day of the intervention, and how to nourish and hydrate in the days after BS. This narrative review examines the application, the feasibility and the efficacy of ERABS protocols applied to the field of nutrition. We found that ERABS protocols, in particular not fasting the patient before the surgery, are often not correctly applied for reasons that are not evidence-based. Furthermore, we identified some gaps in the research about some practises that could be implemented in the presence of additional evidence.
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Affiliation(s)
- Giovanna Flore
- Obesity Unit, Department of Medical Sciences and Public Health, University of Cagliari, 09124 Cagliari, Italy; (G.F.); (A.D.); (M.F.)
| | - Andrea Deledda
- Obesity Unit, Department of Medical Sciences and Public Health, University of Cagliari, 09124 Cagliari, Italy; (G.F.); (A.D.); (M.F.)
| | - Michele Fosci
- Obesity Unit, Department of Medical Sciences and Public Health, University of Cagliari, 09124 Cagliari, Italy; (G.F.); (A.D.); (M.F.)
| | - Mauro Lombardo
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Open University, Via di Val Cannuta, 247, 00166 Rome, Italy;
| | - Enrico Moroni
- Obesity Surgery Unit, Department of Surgery, Azienda di Rilievo Nazionale ed Alta Specializzazione G. Brotzu, 09134 Cagliari, Italy; (E.M.); (S.P.); (G.F.)
| | - Stefano Pintus
- Obesity Surgery Unit, Department of Surgery, Azienda di Rilievo Nazionale ed Alta Specializzazione G. Brotzu, 09134 Cagliari, Italy; (E.M.); (S.P.); (G.F.)
| | - Fernanda Velluzzi
- Obesity Unit, Department of Medical Sciences and Public Health, University of Cagliari, 09124 Cagliari, Italy; (G.F.); (A.D.); (M.F.)
| | - Giovanni Fantola
- Obesity Surgery Unit, Department of Surgery, Azienda di Rilievo Nazionale ed Alta Specializzazione G. Brotzu, 09134 Cagliari, Italy; (E.M.); (S.P.); (G.F.)
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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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Marinari G, Foletto M, Nagliati C, Navarra G, Borrelli V, Bruni V, Fantola G, Moroni R, Tritapepe L, Monzani R, Sanna D, Carron M, Cataldo R. Enhanced recovery after bariatric surgery: an Italian consensus statement. Surg Endosc 2022; 36:7171-7186. [PMID: 35953683 PMCID: PMC9485178 DOI: 10.1007/s00464-022-09498-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 12/31/2021] [Indexed: 12/03/2022]
Abstract
Background Enhanced recovery after bariatric surgery (ERABS) is an approach developed to improve outcomes in obese surgical patients. Unfortunately, it is not evenly implemented in Italy. The Italian Society for the Surgery of Obesity and Metabolic Diseases and the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care joined in drafting an official statement on ERABS. Methods To assess the effectiveness and safety of ERABS and to develop evidence-based recommendations with regard to pre-, intra-, and post-operative care for obese patients undergoing ERABS, a 13-member expert task force of surgeons and anesthesiologists from Italian certified IFSO center of excellence in bariatric surgery was established and a review of English-language papers conducted. Oxford 2011 Levels of Evidence and U.S. Preventive Services Task Force Grade Definitions were used to grade the level of evidence and the strength of recommendations, respectively. The supporting evidence and recommendations were reviewed and discussed by the entire group at meetings to achieve a final consensus. Results Compared to the conventional approach, ERABS reduces the length of hospital stay and does not heighten the risk of major post-operative complications, re-operations, and hospital re-admissions, nor does it increase the overall surgical costs. A total of 25 recommendations were proposed, covering pre-operative evaluation and care (7 items), intra-operative management (1 item, 11 sub-items), and post-operative care and discharge (6 items). Conclusions ERABS is an effective and safe approach. The recommendations allow the proper management of obese patients undergoing ERABS for a better outcome.
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Affiliation(s)
- Giuseppe Marinari
- Bariatric Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Mirto Foletto
- Bariatric Surgery Unit, Azienda Ospedale Università Padova, Padua, Italy
| | - Carlo Nagliati
- Department of Surgery, San Giovanni di Dio Hospital, Gorizia, Italy
| | - Giuseppe Navarra
- Department of Human Pathology, University of Messina, Messina, Italy
| | | | - Vincenzo Bruni
- Bariatric Surgery Unit, Campus Bio Medico University of Rome, Rome, Italy
| | - Giovanni Fantola
- Bariatric Surgery Unit, ARNAS, G. Brotzu Hospital, Cagliari, Italy
| | - Roberto Moroni
- Bariatric Surgery Unit, Policlinico Sassarese, Sassari, Italy
| | - Luigi Tritapepe
- Department of Anesthesia and Intensive Care, San Camillo-Forlanini Hospital, Sapienza University of Rome, Rome, Italy
| | - Roberta Monzani
- Department of Anesthesia and Intensive Care Units, Humanitas Research Hospital, Humanitas University Milan, Rozzano, Milan, Italy
| | - Daniela Sanna
- Emergency Department, Section of Anesthesiology and Intensive Care, ARNAS, G. Brotzu Hospital, Cagliari, Italy
| | - Michele Carron
- Department of Medicine-DIMED, Section of Anesthesiology and Intensive Care, University of Padua, Via V. Gallucci, 13, 35121, Padua, Italy.
| | - Rita Cataldo
- Unit of Anesthesia, Intensive Care and Pain Management, Campus Bio Medico University of Rome, Rome, Italy
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Ma G, Jiang P, Mo B, Luo Y, Zhao Y, Wang X, Shi C, Huang Y. Take-Home Video Shortens the Time to First Ambulation in Patients With Inguinal Hernia Repair Under General Anesthesia: A Retrospective Observational Study. Front Med (Lausanne) 2022; 9:848280. [PMID: 35847805 PMCID: PMC9278018 DOI: 10.3389/fmed.2022.848280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 06/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Data on the relationship between take-home video and the time to first ambulation remains scant. Here, we aimed to investigate whether viewed take-home video during pre-hospitalization is independently associated with the time to first ambulation in postoperative patients with inguinal hernia repair under general anesthesia. Methods We retrospectively reviewed and analyzed the relationship between viewed take-home video and the time to first ambulation between September 2020 and October 2021.The independent t-tests or Mann-Whitney U-tests was used to compare the means of two groups (viewed take-home video and non-viewed take-home video). Chi-square test was used to compare the rates between the two groups. We used a linear regression model to see if there was a difference between exposure and outcome variable. Both models were used to observe the effect size of the exposed variable. Subgroup analysis was employed to assess the impact of various factors. Results This study included a total of 120 patients with inguinal hernia repair under general anesthesia following day surgery. The average age of the participants in the two groups was 43.16 and 44.83 years, respectively, and about 82.5% of the patients were male. Our fully adjusted linear regression results showed that individuals in the viewed video group were associated with a decreased time to first ambulation (h) after adjusting for confounders (β = −0.50, 95%CI: −0.83, −0.17; P = 0.004). In addition, the linear regression analysis of the relationship between viewed video and length of stay showed that β = −2.10 (95%CI:CI: −3.85, −0.34; P = 0.021). Similarly, subgroup analysis yielded similar results for the viewed video group patients compared to those in the non-viewed video group. Conclusion Taken together, our findings demonstrated that viewed video could shorten the time to first ambulation, which in turn reduce the length of stay in postoperative patients under general anesthesia.
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Affiliation(s)
- Guozhen Ma
- Day Surgery Care Unit, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
- School of Nursing, Philippine Women's University, Manila, Philippines
| | - Pengjun Jiang
- Department of Anorectal Surgery, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Beirong Mo
- Department of Nursing, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
- *Correspondence: Beirong Mo
| | - Yijun Luo
- Department of Anesthesiology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Yongling Zhao
- Department of Gastrointestinal Surgery, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Xingguang Wang
- Day Surgery Care Unit, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Chunmiao Shi
- Day Surgery Care Unit, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Yanhui Huang
- Day Surgery Care Unit, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
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Ripollés-Melchor J, Sánchez-Santos R, Abad-Motos A, Gimeno-Moro AM, Díez-Remesal Y, Jove-Alborés P, Aragó-Chofre P, Ortiz-Sebastian S, Sánchez-Martín R, Ramírez-Rodríguez JM, Trullenque-Juan R, Valentí-Azcárate V, Ramiro-Ruiz Á, Correa-Chacón OC, Batalla A, Gimeno-Grauwinkel C, Sanahuja-Blasco JM, González-Valverde FM, Galán-Menéndez P, Díez-Zapirain MJ, Vilallonga R, Zorrilla-Vaca A, Pascual-Bellosta AM, Martínez-Ubieto J, Carrascosa-Mirón T, Ruiz-Escobar A, Martín-García-Almenta E, Suárez-de-la-Rica A, Bausili M, Palacios-Cordoba Á, Olvera-García MM, Meza-Vega JA, Sánchez-Pernaute A, Abad-Gurumeta A, Ferrando-Ortola C, Martín-Vaquerizo B, Torres-Alfonso JR, Aguado-Sánchez S, Sánchez-Cabezudo-Noguera F, García-Erce JA, Aldecoa C. 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. Obes Surg 2022; 32:1289-1299. [PMID: 35143011 DOI: 10.1007/s11695-022-05949-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/28/2022] [Accepted: 02/03/2022] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Javier Ripollés-Melchor
- Department of Anesthesia and Perioperative Medicine, Infanta Leonor University Hospital, Madrid, Spain.,Spanish Perioperative Audit and Research Network (RedGERM), Grupo Español de Rehabilitación Multimodal (GERM), Gran Vía del Este 80, 28031, Madrid, Spain
| | - Raquel Sánchez-Santos
- Department of General Surgery, University Hospital of Vigo, Galicia Sur Research Institute (IISGS), Vigo, Spain.,Spanish Society of Obesity Surgery (SECO), San Juan de Alicante, Spain
| | - Ane Abad-Motos
- Department of Anesthesia and Perioperative Medicine, Infanta Leonor University Hospital, Madrid, Spain. .,Spanish Perioperative Audit and Research Network (RedGERM), Grupo Español de Rehabilitación Multimodal (GERM), Gran Vía del Este 80, 28031, Madrid, Spain.
| | - Ana M Gimeno-Moro
- Department of Anesthesia and Perioperative Medicine, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - Yolanda Díez-Remesal
- Spanish Perioperative Audit and Research Network (RedGERM), Grupo Español de Rehabilitación Multimodal (GERM), Gran Vía del Este 80, 28031, Madrid, Spain.,Department of Anesthesia and Perioperative Medicine, Ramón y Cajal University Hospital, Madrid, Spain
| | - Patricia Jove-Alborés
- Department of General Surgery, University Hospital of Vigo, Galicia Sur Research Institute (IISGS), Vigo, Spain
| | - Pablo Aragó-Chofre
- Department of General Surgery, Hospital Universitario de Manises, Manises, Spain
| | | | - Rubén Sánchez-Martín
- Department of Anesthesia and Perioperative Medicine, Clínico San Carlos University Hospital, Madrid, Spain
| | - José M Ramírez-Rodríguez
- Spanish Perioperative Audit and Research Network (RedGERM), Grupo Español de Rehabilitación Multimodal (GERM), Gran Vía del Este 80, 28031, Madrid, Spain.,Department of General Surgery, Lozano Blesa University Hospital, Zaragoza, Spain.,Universidad de Zaragoza, Zaragoza, Spain
| | | | - Víctor Valentí-Azcárate
- Department of General Surgery, Clínica Universidad de Navarra, Pamplona, Spain.,CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Pamplona, Navarra, Spain
| | - Álvaro Ramiro-Ruiz
- Spanish Perioperative Audit and Research Network (RedGERM), Grupo Español de Rehabilitación Multimodal (GERM), Gran Vía del Este 80, 28031, Madrid, Spain.,Department of Anesthesia and Perioperative Medicine, 12 de Octubre University Hospital, Madrid, Spain
| | - Olga C Correa-Chacón
- Department of Anesthesia and Perioperative Medicine, Santa Lucía Hospital, Cartagena, Spain
| | - Astrid Batalla
- Department of Anesthesiology and Perioperative Medicine, Sant Pau University Hospital, Barcelona, Spain
| | | | | | | | - Patricia Galán-Menéndez
- Department of Anesthesia and Perioperative Medicine, Vall d´Hebrón University Hospital, Barcelona, Spain
| | - Miren J Díez-Zapirain
- Department of Anesthesia and Perioperative Medicine, Marqués de Valdecilla University Hospital, Santander, Spain
| | - Ramón Vilallonga
- Department of General Surgery, Bariatric surgery Department, Vall d´Hebrón University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Andrés Zorrilla-Vaca
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ana M Pascual-Bellosta
- Department of Anesthesiology and Perioperative Medicine, Miquel Servet University Hospital, Zaragoza, Spain
| | - Javier Martínez-Ubieto
- Department of Anesthesiology and Perioperative Medicine, Miquel Servet University Hospital, Zaragoza, Spain
| | | | - Alicia Ruiz-Escobar
- Department of Anesthesia and Perioperative Medicine, Infanta Leonor University Hospital, Madrid, Spain.,Spanish Perioperative Audit and Research Network (RedGERM), Grupo Español de Rehabilitación Multimodal (GERM), Gran Vía del Este 80, 28031, Madrid, Spain
| | | | - Alejandro Suárez-de-la-Rica
- Spanish Perioperative Audit and Research Network (RedGERM), Grupo Español de Rehabilitación Multimodal (GERM), Gran Vía del Este 80, 28031, Madrid, Spain.,Department of Anesthesia and Perioperative Medicine, Marqués de Valdecilla University Hospital, Santander, Spain
| | - Marc Bausili
- Department of Anesthesia and Perioperative Medicine, Clínica Diagonal, Esplugues de Llobregat, Spain
| | - Ángela Palacios-Cordoba
- Department of Anesthesia and Perioperative Medicine, Hospital Universitario Clínico San Cecilio, Granada, Spain
| | - María M Olvera-García
- Department of Anesthesia and Perioperative Medicine, Hospital Universitario Clínico San Cecilio, Granada, Spain
| | - Julio A Meza-Vega
- Department of Anesthesia and Perioperative Medicine, Hospital de Barcelona, Barcelona, Spain
| | - Andrés Sánchez-Pernaute
- Spanish Society of Obesity Surgery (SECO), San Juan de Alicante, Spain.,Department of General Surgery, Clínico San Carlos University Hospital, Madrid, Spain
| | - Alfredo Abad-Gurumeta
- Department of Anesthesia and Perioperative Medicine, Infanta Leonor University Hospital, Madrid, Spain.,Spanish Perioperative Audit and Research Network (RedGERM), Grupo Español de Rehabilitación Multimodal (GERM), Gran Vía del Este 80, 28031, Madrid, Spain
| | - Carlos Ferrando-Ortola
- Spanish Perioperative Audit and Research Network (RedGERM), Grupo Español de Rehabilitación Multimodal (GERM), Gran Vía del Este 80, 28031, Madrid, Spain.,Department of Anesthesia and Critical Care, Hospital Clínic de Barcelona, Barcelona, Spain.,CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Beatriz Martín-Vaquerizo
- Department of Anesthesia and Perioperative Medicine, Hospital Universitario Fundación Alcorcón, Alcorcón, Spain
| | | | - Sandra Aguado-Sánchez
- Department of Anesthesia and Perioperative Medicine, Hospital del Mar, Barcelona, Spain
| | | | - José A García-Erce
- Banco de Sangre y Tejidos de Navarra, Servicio Navarro de Salud-Osasunbidea, Pamplona, Spain
| | - César Aldecoa
- Spanish Perioperative Audit and Research Network (RedGERM), Grupo Español de Rehabilitación Multimodal (GERM), Gran Vía del Este 80, 28031, Madrid, Spain.,Department of Anesthesia and Perioperative Medicine, Hospital Universitario Río Hortega, Valladolid, Spain
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Ibrahim M, Elnabtity AM, Hegab A, Alnujaidi OA, El Sanea O. Combined opioid free and loco-regional anaesthesia enhances the quality of recovery in sleeve gastrectomy done under ERAS protocol: a randomized controlled trial. BMC Anesthesiol 2022; 22:29. [PMID: 35062872 PMCID: PMC8781357 DOI: 10.1186/s12871-021-01561-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 12/28/2021] [Indexed: 02/06/2023] Open
Abstract
Background It is debatable whether opioid-free anaesthesia (OFA) is better suited than multimodal analgesia (MMA) to achieve the goals of enhanced recovery after surgery (ERAS) in patients undergoing laparoscopic sleeve gastrectomy. Methods In all patients, anaesthesia was conducted with an i.v. induction with propofol (2 mg. kg-1), myorelaxation with cisatracurium (0.15 mg.kg-1), in addition to an ultrasound-guided bilateral oblique subcostal transverse abdominis plane block. In addition, patients in the OFA group (n = 51) received i.v. dexmedetomidine 0.1 μg.kg-1 and ketamine (0.5 mg. kg-1) at induction, then dexmedetomidine 0.5 μg. kg-1.h-1, ketamine 0.5 mg.kg-1.h-1, and lidocaine 1 mg. kg-1.h-1 for maintenance, while patients in the MMA group (n = 52) had only i.v. fentanyl (1 μg. kg-1) at induction. The primary outcome was the quality of recovery assessed by QoR-40, at the 6th and the 24th postoperative hour. Secondary outcomes were postoperative opioid consumption, time to ambulate, time to tolerate oral fluid, and time to readiness for discharge. Results At the 6th hour, the QoR-40 was higher in the OFA than in the MMA group (respective median [IQR] values: 180 [173–195] vs. 185 [173–191], p < 0.0001), but no longer difference was found at the 24th hour (median values = 191 in both groups). OFA also significantly reduced postoperative pain and morphine consumption (20 mg [1–21] vs. 10 mg [1–11], p = 0.005), as well as time to oral fluid tolerance (238 [151–346] vs. 175 min [98–275], p = 0.022), and readiness for discharge (505 [439–626] vs. 444 min [356–529], p = 0.001), but did not influence time to ambulate. Conclusion While regional anaesthesia achieved most of the intraoperative analgesia, avoiding intraoperative opioids with the help of this OFA protocol was able to improve several sensible parameters of postoperative functional recovery, thus improving our knowledge on the OFA effects. Clinical trial number Registration number NCT04285255.
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Moon T, Oh M, Chen J. Patients with sleep-disordered breathing for bariatric surgery. Saudi J Anaesth 2022; 16:299-305. [PMID: 35898522 PMCID: PMC9311179 DOI: 10.4103/sja.sja_300_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 04/10/2022] [Indexed: 11/04/2022] Open
Abstract
The prevalence of patients with obesity continues to rise worldwide and has reached epidemic proportions. There is a strong correlation between obesity and sleep-disordered breathing (SDB), and, in particular, obstructive sleep apnea (OSA). OSA is often undiagnosed in the surgical population. Bariatric surgery has been recognized as an effective treatment option for both obesity and OSA. Laparoscopic bariatric procedures, particularly laparoscopic sleeve gastrectomy (LSG), have become the most frequently performed procedures. OSA has been identified as an independent risk factor for perioperative complications and failure to recognize and prepare for patients with OSA is a major cause of postoperative adverse events, suggesting that all patients undergoing bariatric surgery should be screened preoperatively for OSA. These patients should be treated with an opioid-sparing analgesic plan and continuous positive airway pressure (CPAP) perioperatively to minimize respiratory complications. With the number of bariatric surgical patients with SDB likely to continue rising, it is critical to understand the best practices to manage this patient population.
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Jarrar A, Eipe N, Wu R, Neville A, Yelle JD, Mamazza J. Effect of intraperitoneal local anesthesia on enhanced recovery outcomes after bariatric surgery: a randomized controlled pilot study. Can J Surg 2021; 64:E603-E608. [PMID: 34759045 PMCID: PMC8592778 DOI: 10.1503/cjs.017719] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 12/20/2022] Open
Abstract
Background: Patients with extreme obesity are at high risk for adverse perioperative events, especially when opioid-centric analgesic protocols are used, and perioperative pain management interventions in bariatric surgery could improve safety, outcomes and satisfaction. We aimed to evaluate the impact of intraperitoneal local anesthesia (IPLA) on enhanced recovery after bariatric surgery (ERABS) outcomes. Methods: We conducted a prospective double-blind randomized controlled pilot study in adherence to an a priori peer-reviewed protocol. Patients undergoing laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) with an established ERABS protocol between July 2014 and February 2015 were randomly allocated to receive either IPLA with 0.2% ropivacaine (intervention group) or normal saline (control group). We measured pain scores, analgesic consumption and adverse effects. Functional prehabilitation outcomes, including peak expiratory flow (PEF) and the Six Minute Walk Test (6MWT) and Quality of Recovery Survey-40 (QoR-40) scores, were assessed before surgery, and 1 day and 7 days postoperatively. Results: One hundred patients were randomly allocated to the study groups, of whom 92 completed the study, 46 in each group. There were no statistically significant differences between the 2 groups in baseline characteristics or any primary or secondary outcomes. Pain scores and analgesic consumption were low in both groups. There were no adverse events. Significant declines in PEF and 6MWT and QoR-40 scores were noted on postoperative day 1 in both groups; the values returned to baseline on postoperative day 7 in both groups. Conclusion: Intraperitoneal local anesthesia with ropivacaine did not reduce postoperative pain or analgesic consumption when administered intraoperatively to patients undergoing LRYGB. Standardization of the ERABS protocol benefited patients, with functional prehabilitation outcomes returning to baseline postoperatively. Trial registration:ClinicalTrials.gov no. NCT 02154763
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Affiliation(s)
- Amer Jarrar
- From the Department of Surgery, The Ottawa Hospital, Ottawa, Ont. (Jarrar, Wu, Neville, Yelle, Mamazza); and the Department of Anesthesiology, The Ottawa Hospital, Ottawa, Ont. (Eipe).
| | - Naveen Eipe
- From the Department of Surgery, The Ottawa Hospital, Ottawa, Ont. (Jarrar, Wu, Neville, Yelle, Mamazza); and the Department of Anesthesiology, The Ottawa Hospital, Ottawa, Ont. (Eipe)
| | - Robert Wu
- From the Department of Surgery, The Ottawa Hospital, Ottawa, Ont. (Jarrar, Wu, Neville, Yelle, Mamazza); and the Department of Anesthesiology, The Ottawa Hospital, Ottawa, Ont. (Eipe)
| | - Amy Neville
- From the Department of Surgery, The Ottawa Hospital, Ottawa, Ont. (Jarrar, Wu, Neville, Yelle, Mamazza); and the Department of Anesthesiology, The Ottawa Hospital, Ottawa, Ont. (Eipe)
| | - Jean-Denis Yelle
- From the Department of Surgery, The Ottawa Hospital, Ottawa, Ont. (Jarrar, Wu, Neville, Yelle, Mamazza); and the Department of Anesthesiology, The Ottawa Hospital, Ottawa, Ont. (Eipe)
| | - Joseph Mamazza
- From the Department of Surgery, The Ottawa Hospital, Ottawa, Ont. (Jarrar, Wu, Neville, Yelle, Mamazza); and the Department of Anesthesiology, The Ottawa Hospital, Ottawa, Ont. (Eipe)
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10
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Du D, Wang L, Sang Q, Zheng X, Lian D, Zhang N. Outcome Analysis of Single-Incision Trans-Umbilical Laparoscopic Sleeve Gastrectomy in Obese Chinese Adolescents. Bariatr Surg Pract Patient Care 2021. [DOI: 10.1089/bari.2020.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Dexiao Du
- Surgery Centre of Diabetes Mellitus, Peking University Ninth School of Clinical Medicine, Beijing, China
| | - Liang Wang
- Surgery Centre of Diabetes Mellitus, Peking University Ninth School of Clinical Medicine, Beijing, China
| | - Qing Sang
- Surgery Centre of Diabetes Mellitus, Peking University Ninth School of Clinical Medicine, Beijing, China
| | - Xuejing Zheng
- Surgery Centre of Diabetes Mellitus, Peking University Ninth School of Clinical Medicine, Beijing, China
| | - Dongbo Lian
- Surgery Centre of Diabetes Mellitus, Peking University Ninth School of Clinical Medicine, Beijing, China
| | - Nengwei Zhang
- Surgery Centre of Diabetes Mellitus, Peking University Ninth School of Clinical Medicine, Beijing, China
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11
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Chen YJ, Nie C, Lu H, Zhang L, Chen HL, Wang SY, Li W, Shen S, Wang H. Monitored Anesthetic Care Combined with Scalp Nerve Block in Awake Craniotomy: An Effective Attempt at Enhanced Recovery After Neurosurgery. World Neurosurg 2021; 154:e509-e519. [PMID: 34303853 DOI: 10.1016/j.wneu.2021.07.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 07/15/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Enhanced recovery after surgery has been attempted in neurosurgery at a greater rate. However, concern exists regarding the feasibility of using enhanced recovery after neurosurgery (ERANS). How to manage available resources to safely perform ERANS and improve clinical outcomes has been the subject of much debate and discussion. METHODS Owing to the paucity of data available on the use of ERANS protocols, we performed the present feasibility study. We studied the outcomes of the protocols used within a tertiary referral neurosurgery center. Data from patients who had undergone awake craniotomy within an ERANS protocol were prospectively recorded in our institution from September 2017 to December 2018. We also evaluated the safety and effectiveness of the novel ERANS protocol. RESULTS A total of 20 patients (mean age, 49.5 ± 17.8 years) were included in the present study. Intraoperative hypertension, hypotension, and bradycardia were present in 4 (20%), 1 (5%), and 1 (5%) patient, respectively. The postoperative morbidities included epilepsy in 1 (5%), pain in 3 (15%), and nausea or vomiting in 2 (10%). No significant changes had occurred in the mean arterial pressure, heart rate, blood glucose, or lactic acid level throughout the procedure. The median length of intensive care unit stay and postoperative hospital stay were 1 and 9.5 days, respectively. No 30-day readmissions or reoperations occurred during the present study. CONCLUSIONS Applying an ERANS protocol was feasible, associated with a low incidence of complications, and acceptable intensive care unit and postoperative hospital lengths of stay. The findings from the present study might provide a new approach for the further research of ERANS.
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Affiliation(s)
- Yan-Jun Chen
- Department of Anesthesiology, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China
| | - Cai Nie
- Department of Anesthesiology, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China
| | - Hao Lu
- Department of Anesthesiology, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China
| | - Liu Zhang
- Department of Neurosurgery, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China
| | - Hong-Lin Chen
- Medical Imaging Center, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China
| | - Shi-Yong Wang
- Department of Neurosurgery, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China
| | - Wei Li
- Department of Neurosurgery, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China
| | - Si Shen
- Medical Imaging Center, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China
| | - Hao Wang
- Department of Anesthesiology, The First Affiliated Hospital, Jinan University, Guangzhou, People's Republic of China.
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12
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Imaging after laparoscopic sleeve gastrectomy - literature review with practical recommendations. Pol J Radiol 2021; 86:e325-e334. [PMID: 34136051 PMCID: PMC8186309 DOI: 10.5114/pjr.2021.106795] [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: 08/14/2020] [Accepted: 09/06/2020] [Indexed: 11/17/2022] Open
Abstract
In the XXI century obesity has become one of the most demanding epidemiological threats worldwide. At the same time, bariatric surgery has established itself as an effective treatment for morbidly obese patients, with laparoscopic sleeve gastrectomy (LSG) emerging as the most popular bariatric procedure. This paper reviews the role of imaging studies of patients after LSG. Computed tomography is widely considered as the method of choice in detection of complications in early postoperative period. The dynamic character of upper gastrointestinal examination allows for the assessment of passage through the gastric remnant. The paper also discusses evaluation of the shape and volume of the gastric remnant assessed by imaging studies.
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13
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Díaz-Vico T, Cheng YL, Bowers SP, Arasi LC, Chadha RM, Elli EF. Outcomes of Enhanced Recovery After Surgery Protocols Versus Conventional Management in Patients Undergoing Bariatric Surgery. J Laparoendosc Adv Surg Tech A 2021; 32:176-182. [PMID: 33989060 DOI: 10.1089/lap.2020.0783] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background: Enhanced recovery after surgery (ERAS) pathways focus on decreasing surgical stress and promoting return to normal function for patients undergoing surgical procedures. The aim of our study was to evaluate the impact of an ERAS protocol on outcomes of patients undergoing primary sleeve gastrectomy and Roux-en-Y gastric bypass. Outcomes included hospital length of stay (LOS), and management of postoperative pain and postoperative nausea and vomiting (PONV) measured by pain medications and antiemetic use, respectively. Incidence of 90-day emergency department (ED) visits, readmissions, and complications were also analyzed. Methods: A retrospective review was performed from October 1, 2016 to October 31, 2018 of patients enrolled in the ERAS versus the conventional pathway. Patient baseline characteristics, pain and nausea scores, LOS, and postoperative outcome variables were collected. Results: Non-ERAS (n = 193) and ERAS (n = 173) groups had similar patient characteristics. Fewer ERAS patients required postoperative opioids and antiemetics (P < .01), with a significant difference in postoperative nausea control in favor of ERAS patients (P < .05). There was a decreasing trend in median LOS (2 versus 1, P = .28), 90-day postoperative readmissions (10.4% versus 8.1%, P = .47), and major adverse events (5.2% versus 1.7%, P = .07) after ERAS implementation. The ED visits and postoperative need for intravenous fluid for dehydration were significantly lower in the ERAS group (P = .01). Conclusion: Implementation of ERAS pathway for bariatric surgery was associated with less opioid usage, PONV, ED visits, and postoperative need for intravenous fluids, without increasing LOS, 90-day readmission or rates of adverse effects.
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Affiliation(s)
- Tamara Díaz-Vico
- Divisions of General Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Yilon Lima Cheng
- Divisions of General Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Steven P Bowers
- Divisions of General Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Lisa C Arasi
- Divisions of General Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Ryan M Chadha
- Divisions of Anesthesiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Enrique F Elli
- Divisions of General Surgery, Mayo Clinic, Jacksonville, Florida, USA
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14
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Gimeno-Moro AM, Errando CL, Escrig-Sos VJ, Laguna-Sastre JM. Analysis of the 'Evaluation Indicators' of an Enhanced Recovery After Bariatric Surgery Pathway in the First Six Months After Implementation. Obes Surg 2021; 31:2551-2566. [PMID: 33840012 DOI: 10.1007/s11695-021-05274-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/27/2021] [Accepted: 02/08/2021] [Indexed: 12/19/2022]
Abstract
The implementation of a clinical pathway in bariatric surgery (BS) might facilitate systemic care. Focusing on enhanced recovery after surgery (ERAS) programs may also improve surgical outcomes depending on the degree of adherence achieved. We hypothesized that the implementation of an ERAS clinical pathway in BS (ERABS) improves clinical outcomes compared to traditional treatment in a tertiary care hospital. The main objective was to assess the degree of adherence to the ERABS program. Secondary objectives were to evaluate compliance with the quality indicators of the Spanish Society for Obesity Surgery (SECO) and overall patients' satisfaction. A retrospective observational study was designed. Data from patients who underwent BS into an ERABS context were reviewed and compared with traditionally treated patients. Process and outcomes indicators adapted from RICA (Recuperación Intensificada en Cirugía Abdominal) pathway, degree of compliance with SECO quality indicators and patients' satisfaction were analyzed. Forty-three patients were included per group. Indicators' compliance rate per patient was 83.23%. Differences were found in postoperative bleeding, immediate morbidity and overall morbidity, but not in severity of complications. No patient felt dissatisfied or unsatisfied. Average compliance with indicators of process and outcome was 90.45%. Overall morbidity in ERABS group did not differ from that recommended by SECO, but traditional group did show significant increase. Adherence was 83.63% and overall incidence of complications was 7%. Our study shows improved clinical outcomes in ERABS group with a high degree of adherence. Quality indicators were met, improving overall morbidity with no difference in the severity of complications.
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Affiliation(s)
- Ana M Gimeno-Moro
- Service of Anesthesiology, Hospital General Universitario de Castellón, Av. Benicassim, 128, 12004, Castellón, Spain.
| | - Carlos L Errando
- Service of Anesthesiology, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Vicente J Escrig-Sos
- Service of General Surgery, Hospital General Universitario de Castellón, Castellón, Spain
- Jaume I University, Castellón, Spain
| | - José M Laguna-Sastre
- Jaume I University, Castellón, Spain
- Service of General Surgery, Hospital General Universitario de Castellón, Castellón, Spain
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15
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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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16
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Gastaldo N, Fitzgerald R, Bahr K, Gabra JN, Talmage L, Chlysta W, Daigle CR. Bariatric Enhanced Recovery Protocol: a Community Quality Perspective. Obes Surg 2020; 31:1233-1238. [PMID: 33205367 DOI: 10.1007/s11695-020-05122-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Bariatric enhanced recovery protocols can decrease length of stay (LOS) and hospital costs without compromising patient safety. Increased data is needed to compare patient outcomes before and after application of enhanced recovery pathways. We present a bariatric enhanced recovery protocol (BERP) at a community hospital. The objectives were to decrease hospital LOS and reduce schedule II substance use (medications with a high potential for abuse, potentially resulting in psychological or physical dependence), without compromising patient safety. METHODS This was a combined retrospective and prospective analysis of all patients undergoing bariatric surgery by two surgeons from September 2016 to April 2018. Mann-Whitney U, Pearson chi-square, and Fisher's exact tests were used to compare demographics, comorbidities, and outcomes. RESULTS Two hundred patients were evaluated. Overall median (interquartile range) age was 43.0 (36.0-54.0) years and body mass index (BMI) was 45.0 (40.6-50.3) kg/m2. Pre-protocol mean hospital LOS was 2.3 days while enhanced recovery protocol patients mean LOS was 1.4 days (p < 0.001). Sixty-five percent of BERP patients were discharged on hospital day 1, while no patients prior to the protocol were discharged before hospital day 2. Only 9% of BERP patients were discharged with schedule II medications, compared to 100% of the pre-protocol patients (p < 0.001). Intraoperative, in-hospital, and 30-day complication rates were not statistically significant between the two groups. CONCLUSION Community hospitals can reduce length of stay and narcotic prescribing without compromising safety-related outcomes. Significant reductions in the amount of schedule II medications can be achieved when using multimodal enhanced recovery protocol approaches.
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Affiliation(s)
- Nicholas Gastaldo
- Department of General Surgery, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH, USA.
| | - Ryan Fitzgerald
- Department of General Surgery, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH, USA
| | - Kelly Bahr
- Department of Care Management, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH, USA
| | - Joseph N Gabra
- Department of Research, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH, USA
| | - Lance Talmage
- Department of Anesthesiology, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH, USA
| | - Walter Chlysta
- Department of Bariatric and General Surgery, Western Reserve Hospital, 1900 23rd St, Cuyahoga Falls, OH, USA
| | - Christopher R Daigle
- Department of General Surgery, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH, USA
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17
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Endoscopic management of early GI tract bleeding in a group of bariatric patients undergoing a fast track protocol. Wideochir Inne Tech Maloinwazyjne 2020; 16:139-144. [PMID: 33786127 PMCID: PMC7991939 DOI: 10.5114/wiitm.2020.99146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 05/15/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Enhanced recovery after bariatric surgery (ERABS) and other fast track protocols are currently being implemented in bariatric surgery. This approach has several benefits. However, early complications may occur and require urgent re-hospitalization and management. Gastrointestinal (GI) bleeding following bariatric surgery remains one of the most serious complications requiring endoscopic treatment. Aim To evaluate the potential influence of early endoscopic intervention on bariatric patients’ management. Material and methods A clinical database was searched for patients undergoing endoscopic treatment because of GI tract bleeding following bariatric surgery under the ERABS protocol. 14 out of 1431 patients operated on were identified and their data were extracted for the purposes of this study. Patients readmitted to the hospital due to developing GI tract bleeding (group 2) were compared with patients undergoing endoscopic intervention during the initial stay (group 1), for the same purpose. Results We found no statistically significant differences in hemoglobin level or length of hospital stay before endoscopy between groups. Based on the analyzed data, the percentage of GI bleeding in patients operated on under the ERABS protocol in our center is 0.97% (n = 14). The rate of early (up to 30 days) readmissions due to GI tract bleeding is 0.4% (n = 5) with an overall early readmission rate of 0.91% (n = 13) in the study period since the ERABS protocol was implemented. Conclusions Long-term effects (% total weight loss, %TWL) of bariatric surgery do not depend on the need of early endoscopic intervention and rehospitalization. Endoscopic intervention is a safe treatment modality, not associated with risk of reoperation or complications.
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Bona D, Micheletto G, Bonitta G, Panizzo V, Cavalli M, Rausa E, Cirri S, Aiolfi A. Does C-reactive Protein Have a Predictive Role in the Early Diagnosis of Postoperative Complications After Bariatric Surgery? Systematic Review and Bayesian Meta-analysis. Obes Surg 2020; 29:3448-3456. [PMID: 31240535 DOI: 10.1007/s11695-019-04013-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Postoperative leak and intra-abdominal infections are common after bariatric surgery with a significant impact on perioperative outcomes, hospital length of stay, and readmission rates. In the era of enhanced recovery programs, with patients being discharged from the hospital 24-36 h after surgery and potentially before developing any complications, an early indicator of postoperative complications may be decisive. The aim of this study was to evaluate the predictive role of the C-reactive protein (CRP) in the early diagnosis of complications in patients undergoing laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS PubMed, Embase, and Web of Science databases were consulted. A systematic review and a fully Bayesian meta-analysis were conducted. RESULTS Seven studies met the inclusion criteria for a total of 1401 patients. Overall, 57.7% underwent LSG while 42.3% underwent LRYGB. The pooled prevalence of postoperative complications was 9.8% (95% CI = 5-16%). The estimated pooled CRP cut-off value on postoperative day 1 (POD1) was 6.1 mg/dl with a significant diagnostic accuracy and a pooled area under the curve of 0.92 (95% credible interval (CrI) 0.73-0.98). The positive and negative likelihood ratios were 13.6 (95% CrI 8.40-15.9) and 0.16 (95% CrI 0.04-0.31), respectively. CONCLUSION A CRP value lower than the derived cut-off of 6.1 mg/dl on POD1, combined with reassuring clinical signs, could be useful to rule out early postoperative leak and complications after LSG and LRYGB. In the context of enhanced recovery after surgery protocols, the integration of a CRP-based diagnostic algorithm as an additional complementary instrument may be valuable to reduce cost and improve outcomes and patient care.
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Affiliation(s)
- Davide Bona
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy.
| | - Giancarlo Micheletto
- Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, Istitituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Gianluca Bonitta
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Valerio Panizzo
- Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, Istitituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Marta Cavalli
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Emanuele Rausa
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Silvia Cirri
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Alberto Aiolfi
- Department of Biomedical Science for Health, Division of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
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19
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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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20
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Palumbo D, Socci C, Martinenghi C, Guazzarotti G, Leone R, Nicoletti R, Rosati R, De Cobelli F. Leakage Risk Stratification After Laparoscopic Sleeve Gastrectomy (LSG): Is There a Role for Routine Postoperative CT Scan? Obes Surg 2020; 30:3370-3377. [PMID: 32291703 DOI: 10.1007/s11695-020-04586-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE Leakage of the gastric remnant after laparoscopic sleeve gastrectomy (LSG) represents an unpredictable, dreadful occurrence. Our aim was to assess whether routine postoperative CT scan is an effective tool for early prediction of leakage after LSG. MATERIALS AND METHODS From a prospectively acquired database, all consecutive patients who underwent LSG between January 2015 and December 2018 were identified; within this database, all patients who were evaluated with at least one contrast-enhanced CT scan within 48 h from surgery were enrolled in this retrospective study. The selected CT findings included twisting of the gastric remnant, perigastric air bubbles, and hematoma; the antral segment proximal from the pylorus to the first staple firing was also analyzed in terms of distance (StP, stapler to pylorus distance) and linearity (LI, linearity index). RESULTS After exclusions, 250 patients were included; 10 patients suffered from gastric leakage. Patients with perigastric hematoma and/or twisting of the distal part of the gastric remnant on routine postoperative CT scan were found to be more likely to develop leakage after LSG (p = 0.005 and p < 0.001, respectively). The mean StP was 45 ± 19.1 mm; the mean LI was 1.54 ± 0.4. Patients with subsequent development of leakage had significantly lower StP (26.7 ± 12.5 mm vs. 45.9 ± 18.9 mm; p = 0.001) and LI values (1.16 ± 0.11 vs. 1.55 ± 0.39; p = 0.002). CONCLUSION Routine postoperative CT scan after LSG permits early stratification of leakage risk, thus providing an actual aid for patients' management.
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Affiliation(s)
- Diego Palumbo
- Radiology Unit, San Raffaele Scientific Institute, San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy. .,San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy.
| | - Carlo Socci
- Metabolic, Bariatric and Transplant Surgery Unit, San Raffaele Scientific Institute, San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy
| | - Carlo Martinenghi
- Radiology Unit, San Raffaele Scientific Institute, San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy
| | - Giorgia Guazzarotti
- Radiology Unit, San Raffaele Scientific Institute, San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy
| | - Riccardo Leone
- Radiology Unit, San Raffaele Scientific Institute, San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy
| | - Roberto Nicoletti
- Radiology Unit, San Raffaele Scientific Institute, San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy
| | - Riccardo Rosati
- San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy.,GastroIntestinal Surgery Unit, San Raffaele Scientific Institute, San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy
| | - Francesco De Cobelli
- Radiology Unit, San Raffaele Scientific Institute, San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy.,San Raffaele Vita Salute University, via Olgettina 60, 20132, Milan, Italy
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21
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How can I manage anaesthesia in obese patients? Anaesth Crit Care Pain Med 2020; 39:229-238. [DOI: 10.1016/j.accpm.2019.12.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 12/01/2019] [Accepted: 12/09/2019] [Indexed: 12/17/2022]
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22
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Mechanick JI, Apovian C, Brethauer S, Timothy Garvey W, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. 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. Obesity (Silver Spring) 2020; 28:O1-O58. [PMID: 32202076 DOI: 10.1002/oby.22719] [Citation(s) in RCA: 145] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 10/09/2019] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Jeffrey I Mechanick
- Guideline Task Force Chair (AACE); Professor of Medicine, Medical Director, Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart; Director, Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York; Past President, AACE and ACE
| | - Caroline Apovian
- Guideline Task Force Co-Chair (TOS); Professor of Medicine and Director, Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Stacy Brethauer
- Guideline Task Force Co-Chair (ASMBS); Professor of Surgery, Vice Chair of Surgery, Quality and Patient Safety; Medical Director, Supply Chain Management, Ohio State University, Columbus, Ohio
| | - W Timothy Garvey
- Guideline Task Force Co-Chair (AACE); Butterworth Professor, Department of Nutrition Sciences, GRECC Investigator and Staff Physician, Birmingham VAMC; Director, UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- Guideline Task Force Co-Chair (ASA); Professor of Anesthesiology, Service Chief, Otolaryngology, Oral, Maxillofacial, and Urologic Surgeries, Associate Medical Director, Respiratory Care, University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Guideline Task Force Co-Chair (ASMBS); Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Guideline Task Force Co-Chair (TOS); Professor of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Richard Lindquist
- Guideline Task Force Co-Chair (OMA); Director, Medical Weight Management, Swedish Medical Center; Director, Medical Weight Management, Providence Health Services; Obesity Medicine Consultant, Seattle, Washington
| | - Rachel Pessah-Pollack
- Guideline Task Force Co-Chair (AACE); Clinical Associate Professor of Medicine, Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Guideline Task Force Co-Chair (OMA); Adjunct Assistant Professor, Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | - Richard D Urman
- Guideline Task Force Co-Chair (ASA); Associate Professor of Anesthesia, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stephanie Adams
- Writer (AACE); AACE Director of Clinical Practice Guidelines Development, Jacksonville, Florida
| | - John B Cleek
- Writer (TOS); Associate Professor, Department of Nutrition Sciences, University of Alabama, Birmingham, Alabama
| | - Riccardo Correa
- Technical Analysis (AACE); Assistant Professor of Medicine and Endocrinology, Diabetes and Metabolism Fellowship Director, University of Arizona College of Medicine, Phoenix, Arizona
| | - M Kathleen Figaro
- Technical Analysis (AACE); Board-certified Endocrinologist, Heartland Endocrine Group, Davenport, Iowa
| | - Karen Flanders
- Writer (ASMBS); Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Writer (AACE); Associate Professor, Department of Surgery, University of Alabama at Birmingham; Staff Surgeon, Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Writer (AACE); Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Shanu Kothari
- Writer (ASMBS); Fellowship Director of MIS/Bariatric Surgery, Gundersen Health System, La Crosse, Wisconsin
| | - Michael V Seger
- Writer (OMA); Bariatric Medical Institute of Texas, San Antonio, Texas, Clinical Assistant Professor, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Writer (TOS); Medical Director, Center for Nutrition and Weight Management Director, Geisinger Obesity Institute; Medical Director, Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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Bree K, Mitko J, Hussain L, Tymitz K, Kerlakian G, Meister K. The Impact of an Enhanced Recovery Protocol for Patients Undergoing Laparoscopic Revisional Bariatric Surgery. Obes Surg 2020; 30:2844-2846. [PMID: 32077059 DOI: 10.1007/s11695-020-04493-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Enhanced Recovery After Surgery (ERAS) protocols have been instituted in various subspecialties of surgery. This study aims to provide evidence that ERAS protocols are safe and feasible in revisional bariatric surgery. A retrospective chart review was performed for all patients who underwent conversion from laparoscopic gastric band (LAGB) or sleeve gastrectomy (SG) to Roux-en-Y gastric bypass (RYGB) from January 2016 to February 2018 at a single independent academic medical center. We calculated the average LOS for these patients as well as the 30-day readmission and 30-day reoperation rates. Median length of stay (LOS) was 1 day (range 1-5) with 92.9% of all patients leaving by postoperative day 3. No patients were readmitted to the hospital within 30 days and none required reoperation.
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Affiliation(s)
- Kevin Bree
- Good Samaritan Hospital, 375 Dixmyth Avenue, Cincinnati, OH, 45220, USA.
| | - John Mitko
- Good Samaritan Hospital, 375 Dixmyth Avenue, Cincinnati, OH, 45220, USA
| | - Lala Hussain
- Trihealth Hatton Research Institute, Cincinnati, OH, USA
| | - Kevin Tymitz
- Good Samaritan Hospital, 375 Dixmyth Avenue, Cincinnati, OH, 45220, USA
| | - George Kerlakian
- Good Samaritan Hospital, 375 Dixmyth Avenue, Cincinnati, OH, 45220, USA
| | - Katherine Meister
- Good Samaritan Hospital, 375 Dixmyth Avenue, Cincinnati, OH, 45220, USA
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Less pain and earlier discharge after implementation of a multidisciplinary enhanced recovery after surgery (ERAS) protocol for laparoscopic sleeve gastrectomy. Surg Endosc 2020; 34:5574-5582. [PMID: 31938928 DOI: 10.1007/s00464-019-07358-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 12/24/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) may be complicated by postoperative pain, nausea, and vomiting, with consequent increases in length of stay (LOS), decreased patient satisfaction, and higher costs. While enhanced recovery after surgery (ERAS) protocols have been in circulation for many years, there is no standard ERAS protocol for bariatric surgery. METHODS Data were collected prospectively and compared to a historical control. All patients undergoing LSG, ages 18 to 75, were included in the pathway; those with preoperative chronic opioid use were excluded from our results. Statistical analysis was performed using t-statistics and chi-squared test. Ninety patients undergoing LSG, performed by a single surgeon, were included in our ERAS group from November 26, 2018, to April 30, 2019, and were compared to a historical control of 570 patients who underwent LSG over the previous 5 years (pre-ERAS). Measured outcomes included discharge opioid prescriptions issued, hospital length of stay, 30-day readmissions, reoperations, morbidity, and mortality. RESULTS Ten (11%) ERAS patients vs 100% of pre-ERAS patients received opioid prescriptions upon, or after, discharge (p < 0.001). The ERAS group LOS decreased to 1.36 days vs 2.40 days in the pre-ERAS group (p < 0.001). 30-day readmission rates were 0% for ERAS patients vs 3.09% for pre-ERAS patients (p = 0.149). 30-day reoperation rates were 0% for ERAS patients vs 0.54% for pre-ERAS patients (p = 1). Thirty-day morbidity rates were 3.33% (3) for ERAS patients vs 3.27% for pre-ERAS patients (p = 1); there was no 30-day mortality in either group. CONCLUSION ERAS for LSG results in a clinical and statistically significant reduction in postoperative opioid use and LOS, without increasing 30-day readmissions, reoperations, morbidity, or mortality.
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Ruiz-Tovar J, Sanchez-Santos R, Martín-García-Almenta E, García Villabona E, Hernandez AM, Hernández-Matías A, Ramírez JM. Rehabilitación multimodal en cirugía bariátrica. Cir Esp 2019; 97:551-559. [DOI: 10.1016/j.ciresp.2019.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/07/2019] [Accepted: 05/01/2019] [Indexed: 12/21/2022]
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26
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Mechanick JI, Apovian C, Brethauer S, Garvey WT, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. 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. Surg Obes Relat Dis 2019; 16:175-247. [PMID: 31917200 DOI: 10.1016/j.soard.2019.10.025] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Jeffrey I Mechanick
- Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart, New York, New York; Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Caroline Apovian
- Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | | | - W Timothy Garvey
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama; UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Rachel Pessah-Pollack
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | | | - Stephanie Adams
- American Association of Clinical Endocrinologists, Jacksonville, Florida
| | - John B Cleek
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama
| | | | | | - Karen Flanders
- Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama; Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | | | - Michael V Seger
- Bariatric Medical Institute of Texas, San Antonio, Texas, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Center for Nutrition and Weight Management Director, Geisinger Obesity Institute, Danville, Pennsylvania; Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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Noel P, Eddbali I, Nedelcu M, Lutfi R. The Interest of Enhanced Recovery After Surgery in a New Bariatric Center. J Laparoendosc Adv Surg Tech A 2019; 30:6-11. [PMID: 31573396 DOI: 10.1089/lap.2019.0456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: With the creation of a new bariatric center in Abu Dhabi, United Arab Emirates (UAE) and the organization of this bariatric department according to the international guidelines, a new activity of bariatric surgery started in January 2015. The surgeon had 20 years of experience in this field and he had performed over 5000 major laparoscopic bariatric procedures before starting this new bariatric program. The concept of enhanced recovery after bariatric surgery (ERABS) was applied from the beginning of the program. We decided to analyze the first 2 years of ERAS activity after having split them in two different periods: the 1st year of activity included restrictive procedures and the 2nd year associated malabsorptive surgeries. Materials and Methods: The results of the use of a fast-track program could be measured by different parameters like operative time, length of hospital stay, rate of complications, and rate of readmission and reoperation. Results: Between January and December 2015, 116 patients underwent a bariatric procedure. The mean age was 34.6 years (16-61) and average body mass index (BMI) was 41.7 kg/sqm (32-72.2). Sixty percent of patients were women and 37% of patients had at least one comorbidity (diabetes type 2, high blood pressure, hyperlipidemia, or sleep apnea). Ninety-four percent of the procedures were laparoscopic sleeve gastrectomy (LSG), 2.6% were laparoscopic Roux-en-Y gastric bypass, and 3.4% band removal. The mean operative time was 20 minutes for an LSG (14-45 minutes) and the average hospital stay was 1.2 days (standard deviation [SD]: 0.9-3.3). The rate of complications was 1.7% with 1 postoperative hematoma drained by CT scan on day 14 after the surgery and 1 relative stenosis endoscopically dilated on postoperative day 45. No reoperation was done. No leak was observed. At 1 year, the mean excess weight loss (EWL) was 64% (47-124) in 89 patients with a 76% rate of follow-up. For the 2nd year of activity in 2016, 142 patients went in the program. The mean age was 32.7 years (17-64) and average BMI was 42.3 kg/sqm (31-68). Seventy-two percent were women and 41% of the patients had one comorbidity or more. The majority of surgeries performed were LSG for 83.1% of the patients. RYGB was realized in 4.2% of cases, resleeve gastrectomy in 4.2%, and band removal in 1.4%. Some malabsorptive surgeries were performed as well, such as one anastomosis gastric bypass for 3 patients (4.2%), and single anastomosis duodeno-ilelal in 2 cases (2.8%). The average hospital stay was 1.5 days (SD: 0.9-3.5). No complication was observed. No reoperation was done. Two patients (1.4%) came back to the hospital on postoperative day 2 and 8 after a LSG for one or several episodes of vomiting without further complication. At 1 year, the mean EWL was 68% (49-154) in 98 patients with a 69% rate of follow-up. Conclusions: This new program of bariatric surgery in two steps using fast-track protocols, respecting international guidelines and with an experienced surgeon showed on its 1st year of implementation a 1.7% rate of readmission on 116 patients without reoperation or major complication and a hospital stay of 1.2 days. For the 2nd year of implementation with the inclusion of malabsorptive procedures only 2 patients (1.4%) were readmitted for a short episode of vomiting and the hospital stay was 1.5 days.
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Affiliation(s)
- Patrick Noel
- Bariatric and Metabolic Surgery Department, Mediclinic Parkview Hospital, Dubai, United Arab Emirates.,Bariatric and Metabolic Surgery Department, Centre de Chirurgie de l'Obésité de la clinique Saint Michel, Toulon, France
| | - Imane Eddbali
- Bariatric and Metabolic Surgery Department, Mediclinic Parkview Hospital, Dubai, United Arab Emirates
| | - Marius Nedelcu
- Bariatric and Metabolic Surgery Department, Centre de Chirurgie de l'Obésité de la clinique Saint Michel, Toulon, France
| | - Rami Lutfi
- Bariatric and Metabolic Surgery Department, Mercy Hospital and Medical Center, Chicago, Illinois
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Emile SH, Elgamal M, Elshobaky A, Shalaby M, Fadaly A, AbdelMawla A, Elbanna HG, Abdel-Razik MA. Identifying Patients at High Risk of Having Pulmonary Dysfunction Before Laparoscopic Bariatric Surgery and Its Impact on Postoperative Pulmonary Complications. J Laparoendosc Adv Surg Tech A 2019; 29:1456-1461. [PMID: 31536447 DOI: 10.1089/lap.2019.0459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background: Morbid obesity is associated with variable degrees of pulmonary dysfunction that may predispose to postoperative complications. This study aimed to identify high risk patients to have pulmonary dysfunction before bariatric surgery in terms of age, sex, and body mass index (BMI) and the impact of pulmonary dysfunction on postoperative pulmonary complications. Methods: Prospective database of patients with morbid obesity who underwent bariatric surgery was reviewed. Data on patients' demographics, parameters of pulmonary function tests, and postoperative pulmonary complications were collected. The correlation between patients' age, sex and BMI, and pulmonary function was investigated using Pearson's correlation coefficient test. Results: Ninety-seven patients (82 female) with morbid obesity were included in the study. Twenty-eight (28.9%) patients had pulmonary dysfunction. Patients >40 years had higher odds of pulmonary dysfunction than patients ≤40 years (odds ratio [OR]: 2.54, P = .05). Male patients had significantly higher odds of pulmonary dysfunction than female patients (OR: 2.5, P = .03). Patients with BMI >50 had significantly higher odds of pulmonary dysfunction than patients with BMI <50 (OR: 4.9, P = .002). Patients with pulmonary dysfunction had significantly higher odds of developing pulmonary complications than patients with normal spirometry (OR: 9.13, P = .009). Conclusion: Around 30% of patients undergoing bariatric surgery had pulmonary dysfunction. Pulmonary dysfunction in preoperative spirometry was able to predict postoperative pulmonary complications. Men, patients older than 40 years, and superobese individuals had higher odds of having pulmonary dysfunction and are at higher risk to develop pulmonary complications after bariatric surgery.
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Affiliation(s)
- Sameh Hany Emile
- General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Mohamed Elgamal
- Department of Thoracic Medicine, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Ayman Elshobaky
- General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Mostafa Shalaby
- General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Ahmed Fadaly
- General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Ahmed AbdelMawla
- General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Hosam Ghazy Elbanna
- General Surgery Department, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
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De Jong A, Verzilli D, Chanques G, Futier E, Jaber S. [Preoperative risk and perioperative management of obese patients]. Rev Mal Respir 2019; 36:985-1001. [PMID: 31521434 DOI: 10.1016/j.rmr.2019.01.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 01/07/2019] [Indexed: 12/18/2022]
Abstract
The obese patient is at an increased risk of perioperative complications. Most importantly, these include difficult access to the airways (intubation, difficult or impossible ventilation), and post-extubation respiratory distress secondary to the development of atelectasis or obstruction of the airways, sometimes associated with the use of morphine derivatives. The association of obstructive sleep apnea syndrome (OSA) with obesity is very common, and induces a high risk of peri- and postoperative complications. Preoperative OSA screening is crucial in the obese patient, as well as its specific management: use of continuous positive pre, per and postoperative pressure. For any obese patient, the implementation of protocols for mask ventilation and/or difficult intubation and the use of protective ventilation, morphine-sparing strategies and a semi-seated positioning throughout the care, is recommended, combined with close monitoring postoperatively. The dosage of anesthetic drugs should be based on the theoretical ideal weight and then titrated, rather than dosed to the total weight. Monitoring of neuromuscular blocking should be used where appropriate, as well as monitoring of the depth of anesthesia. The occurrence of intraoperative recall is indeed more frequent in the obese patient than in the non-obese patient. Appropriate prophylaxis against venous thromboembolic disease and early mobilization are recommended, as thromboembolic disease is increased in the obese patient. The use of non-invasive ventilation to prevent the occurrence of acute post-operative respiratory failure and for its treatment is particularly effective in obese patients. In case of admission to ICU, an individualized ventilatory management based on pathophysiology and careful monitoring should be initiated.
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Affiliation(s)
- A De Jong
- PhyMedExp, University of Montpellier, Inserm, CNRS, CHU Montpellier, 371 avenue du doyen Gaston Giraud, 34080 Montpellier, France; Département d'Anesthésie-Réanimation, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, 34295 Montpellier cedex, France
| | - D Verzilli
- Département d'Anesthésie-Réanimation, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, 34295 Montpellier cedex, France
| | - G Chanques
- PhyMedExp, University of Montpellier, Inserm, CNRS, CHU Montpellier, 371 avenue du doyen Gaston Giraud, 34080 Montpellier, France; Département d'Anesthésie-Réanimation, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, 34295 Montpellier cedex, France
| | - E Futier
- CHU de Clermont-Ferrand, Department of Perioperative Medicine, GReD, UMR/CNRS6293, University, Clermont Auvergne, Inserm, U1103, Clermont-Ferrand, France
| | - S Jaber
- PhyMedExp, University of Montpellier, Inserm, CNRS, CHU Montpellier, 371 avenue du doyen Gaston Giraud, 34080 Montpellier, France; Département d'Anesthésie-Réanimation, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, 34295 Montpellier cedex, France.
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Ma P, Lloyd A, McGrath M, Shuchleib Cung A, Akusoba I, Jackson A, Swartz D, Boone K, Higa K. Efficacy of liposomal bupivacaine versus bupivacaine in port site injections on postoperative pain within enhanced recovery after bariatric surgery program: a randomized clinical trial. Surg Obes Relat Dis 2019; 15:1554-1562. [DOI: 10.1016/j.soard.2019.06.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 05/22/2019] [Accepted: 06/10/2019] [Indexed: 01/31/2023]
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31
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Enhanced Recovery Protocol for Laparoscopic Sleeve Gastrectomy: Are Narcotics Necessary? J Gastrointest Surg 2019; 23:1541-1546. [PMID: 30693426 DOI: 10.1007/s11605-018-04091-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/19/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols have improved patient experience and outcomes in a variety of fields, including bariatric surgery. Given the increasing opioid epidemic in the USA, we sought to determine the impact of our own ERAS protocol on narcotic usage following laparoscopic sleeve gastrectomy. METHODS Retrospective chart review was performed on patients undergoing primary laparoscopic sleeve gastrectomy for 6 months before and after implementation of an ERAS protocol. Our protocol strongly discouraged the use of narcotics in the postoperative period. Specific outcomes of interest were postoperative narcotic usage, length of stay, complications, and readmissions. RESULTS Patient characteristics were similar in the two groups. ERAS implementation did not correlate with changes in length of stay, complications, or readmissions. However, ERAS implementation was associated with dramatic reductions in the use of intravenous narcotics (100% vs 47%, p < 0.01) and oral schedule 2 narcotics (56% vs 6%, p < 0.01), with an increase in the usage of tramadol (0% vs 36%, p < 0.01). After ERAS implementation, 52% of patients were managed without the use of schedule 2 narcotics (0% pre-ERAS, p < 0.01) and 33% received no narcotics of any kind (0% pre-ERAS, p < 0.01). CONCLUSION Implementation of an ERAS protocol for laparoscopic sleeve gastrectomy is associated with a dramatic reduction in the use of narcotics in the postoperative period. This has implementation for the usage of narcotics for laparoscopic surgery and potential elimination of narcotics for certain patients and procedures.
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Tankel J, Rotem R, Wiess J, Mintz A, Spira RM. Routine Early Fluoroscopy and Clinical Observations Following Laparoscopic Roux-En-Y Gastric Bypass for Obesity Fail to Predict Subsequent Anastomotic Leakage. Indian J Surg 2019. [DOI: 10.1007/s12262-018-1802-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Taylor J, Canner J, Cronauer C, Prior D, Coker A, Nguyen H, Magnuson T, Adrales G, Schweitzer M. Implementation of an enhanced recovery program for bariatric surgery. Surg Endosc 2019; 34:2675-2681. [DOI: 10.1007/s00464-019-07045-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/24/2019] [Indexed: 12/13/2022]
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34
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Reduction of opioid use after implementation of enhanced recovery after bariatric surgery (ERABS). Surg Endosc 2019; 34:2184-2190. [DOI: 10.1007/s00464-019-07006-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 07/19/2019] [Indexed: 12/19/2022]
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35
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Billing P, Billing J, Harris E, Kaufman J, Landerholm R, Stewart K. Safety and efficacy of outpatient sleeve gastrectomy: 2534 cases performed in a single free-standing ambulatory surgical center. Surg Obes Relat Dis 2019; 15:832-836. [DOI: 10.1016/j.soard.2019.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/21/2019] [Accepted: 03/01/2019] [Indexed: 12/22/2022]
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Major P, Stefura T, Małczak P, Wysocki M, Witowski J, Kulawik J, Wierdak M, Pisarska M, Pędziwiatr M, Budzyński A. Postoperative Care and Functional Recovery After Laparoscopic Sleeve Gastrectomy vs. Laparoscopic Roux-en-Y Gastric Bypass Among Patients Under ERAS Protocol. Obes Surg 2018; 28:1031-1039. [PMID: 29058236 PMCID: PMC5880856 DOI: 10.1007/s11695-017-2964-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background The most commonly performed bariatric procedures are laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). There are major differences between LSG and LRYGB during postoperative period. Optimization of the postoperative care may be achieved by using enhanced recovery after surgery (ERAS) protocol, which allows earlier functional recovery. Purpose The aim was to assess differences in the course of postoperative care conducted in accordance with ERAS protocol among patients after LSG and LRYGB. Material and Methods Data concerning patients treated for morbid obesity were prospectively gathered in one academic center. Patients were divided into two groups: LSG (n = 364, 63.41%) and LRYGB (n = 210, 36.59%). Multiple factors were used as endpoints to determine the influence of the type of bariatric procedure on postoperative course. Results The rate of postoperative nausea and vomiting and incidence of intravenous fluid administration during the operation was higher in LSG group. LRYGB patients were able to tolerate higher oral fluid intake volumes during the first and the second postoperative day. Mean diuresis during the second and the third postoperative day was significantly higher in LRYGB group. Administration of diuretics and painkillers was comparable between groups, while the risk of fever after the operation was higher in LRYGB group. Mean length of stay was higher in LSG group (LRYGB vs. LSG, 3.46 days ± 1.58 vs. 3.64 days ± 4.41, p = 0.039). Conclusions In our opinion, postoperative treatment after LSG requires more supervision and longer time until functional recovery is achieved.
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Affiliation(s)
- Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Tomasz Stefura
- Students' Scientific Group at 2nd Department of Surgery, JUMC, Krakow, Poland.
| | - Piotr Małczak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Michał Wysocki
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland.,Students' Scientific Group at 2nd Department of Surgery, JUMC, Krakow, Poland
| | - Jan Witowski
- Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland.,Students' Scientific Group at 2nd Department of Surgery, JUMC, Krakow, Poland
| | - Jan Kulawik
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland
| | - Mateusz Wierdak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Magdalena Pisarska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Andrzej Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Kraków, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
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Enhanced Recovery in Bariatric Surgery: A Study of Short-Term Outcomes and Compliance. Obes Surg 2018; 29:492-498. [DOI: 10.1007/s11695-018-3579-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Bevilacqua LA, Obeid NR, Spaniolas K, Bates A, Docimo S, Pryor A. Early postoperative diet after bariatric surgery: impact on length of stay and 30-day events. Surg Endosc 2018; 33:2475-2478. [PMID: 30374793 DOI: 10.1007/s00464-018-6533-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 10/12/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pathways for enhanced recovery after surgery (ERAS) have been shown to improve length-of-stay (LOS) and post-operative complications across various surgical fields, however there is a lack of evidence-based studies in bariatric surgery. Specifically, the value of early feeding within an ERAS program in bariatric surgery is unclear. The objective of the current study was to determine the effect of early feeding on LOS for patients who underwent primary or revisional laparoscopic sleeve gastrectomy (LSG) and Roux-en-y gastric bypass (RYGB). METHODS Retrospective single institution study of implementation of a new diet protocol in which initiation of oral intake changed from post-operative day 1 to day 0. LOS and 30-day events were compared. Patients were excluded if they were planned for 23-h stay, had significant intra-operative complications, or required reoperation within the same admission. Mann-Whitney U tests were done to compare LOS and chi-squared tests to compare 30-day events pre- and post-intervention. RESULTS A total of 244 patients were included; 84.4% were primary cases. 50.8% of cases occurred prior to early feeding implementation. Median age was 43.5 years (IQR 33-53) and majority of patients were female (78.7%). Median LOS was 32.6 (IQR 30.0-50.6). Median LOS across the whole sample was shorter in the early feeding group (36.2 vs. 31.0 h; p < 0.001). This difference remained statistically significant for primary, but not revisional cases. Post-operative events at 30 days were similar between pre- and post-intervention groups. CONCLUSIONS Early feeding the day of surgery is associated with significantly shorter LOS for patients who undergo bariatric surgery with no difference in 30-day readmissions.
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Affiliation(s)
- Lisa A Bevilacqua
- Department of Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Nabeel R Obeid
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | | | - Andrew Bates
- Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Salvatore Docimo
- Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA
| | - Aurora Pryor
- Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA.
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Laparoscopic Roux-en-Y gastric bypass is as safe as laparoscopic sleeve gastrectomy. Results of a comparative cohort study. Ann Med Surg (Lond) 2018; 35:38-43. [PMID: 30275949 PMCID: PMC6161416 DOI: 10.1016/j.amsu.2018.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 08/19/2018] [Accepted: 09/10/2018] [Indexed: 12/13/2022] Open
Abstract
Background A meta-analysis and six randomized controlled trials show higher 30-day complication rates with laparoscopic Roux-en-Y gastric bypass (LRYGB) than with laparoscopic sleeve gastrectomy (LSG). Aim To identify any difference in 30-day outcomes of patients treated with LRYGB or LSG when a standardized technique and identical post-operative protocol was followed with all procedures being conducted either by or under the supervision of a single consultant surgeon who had significant experience in bariatric surgery prior to commencing independent practice. Methods A prospectively collected database of all patients under primary LRYGB or LSG, between March 2010 and February 2017, was analyzed. Data on demographics, length-of-stay (LOS), conversion to open, 30-day complications and mortality were reviewed. Results Over a seven-year period, 485 patients (LRYGB-279 and LSG-206) were included. There were no significant demographic differences and no difference in the pre-operative risk scoring [American Society of Anesthesiologists (ASA) and obesity surgery mortality risk score (OSMRS)] between the groups. There was no significant difference between the groups in terms of LOS (p = 0.275), complications (p = 0.920), re-admissions (p = 0.593) or re-operations (p = 0.366) within 30-days. There were no conversions to open or in-patient mortality in either group. Conclusions Unlike previous studies, we found no difference in early complication rates between LRYGB and LSG in a comparable cohort when performed by a surgeon with sufficient experience in bariatric surgery. Low complication rates with both procedures. Most complications were minor (Clavien-Dindo ≤ IIIa). LRYGB is as safe as SG in the early post-operative period when performed by a surgeon with adequate experience. Bariatric fellowships play an important role in ensuring optimal outcomes.
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40
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Aktimur R, Kirkil C, Yildirim K, Kutluer N. Enhanced recovery after surgery (ERAS) in one-anastomosis gastric bypass surgery: a matched-cohort study. Surg Obes Relat Dis 2018; 14:1850-1856. [PMID: 30545595 DOI: 10.1016/j.soard.2018.08.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 07/25/2018] [Accepted: 08/27/2018] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Recep Aktimur
- Istanbul Aydin University, Faculty of Medicine, Department of General Surgery, Istanbul, Turkey
| | - Cuneyt Kirkil
- Firat University, Faculty of Medicine, Department of General Surgery, Elazig, Turkey
| | - Kadir Yildirim
- Department of General Surgery, Liv Hospital, Samsun, Turkey.
| | - Nizamettin Kutluer
- Department of General Surgery, Elazig Education and Research Hospital, Elazig, Turkey
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Early intake of solid food after Roux-en-Y gastric bypass and complications. A cohort study from the Scandinavian Obesity Surgery Registry. Surg Obes Relat Dis 2018; 14:1256-1260. [PMID: 30001890 DOI: 10.1016/j.soard.2018.05.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 04/17/2018] [Accepted: 05/26/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is the most common bariatric procedure worldwide. There are few studies investigating how early return to solid food affects complications. OBJECTIVE The aim of this study was to explore how oral intake was resumed in RYGB patients and how the postoperative food regimen affects outcomes, such as complications and length of stay. SETTING Retrospective nationwide registry study. METHODS The Scandinavian Obesity Surgery Registry included prospective data from RYGB patients operated in 2009 to 2014. A questionnaire assessed the postoperative reintroduction of solid food applied at each bariatric center. The postoperative regimen was established in 23,589 patients. Outcomes were recorded at 30-day follow-up according to the standard Scandinavian Obesity Surgery Registry routine. RESULTS Nine percent of patients (n = 2074) returned to solid food within the first week after surgery. Most commonly solid food was resumed in week 4 (37%, n = 8659). Median length of stay was 2 days for all. Of all, 2.8% suffered from a severe complication (>Clavien-Dindo 3a). After adjusting for the annual volume of procedures at hospitals, there was no correlation that the timing of solid food affected complication rates. The odds ratio for a severe complication was significantly lower for intermediate- (odds ratio .64 95% confidence interval .48-.85) or high- (odds ratio .52 95% confidence interval .42-.66) volume centers. The rate of leaks and small bowel obstructions were evenly distributed between the different postoperative food regimens. CONCLUSION Early return to solid food after RYGB did not affect the risk of severe complications. Patients operated at centers with an annual volume of >100 procedures have a lower risk of severe complications.
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De Jong A, Verzilli D, Geniez M, Chanques G, Nocca D, Jaber S. Pourquoi le patient obèse morbide est-il un patient à risque anesthésique élevé ? Presse Med 2018; 47:453-463. [DOI: 10.1016/j.lpm.2018.01.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 01/04/2018] [Indexed: 10/17/2022] Open
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Shea B, Boyan W, Botta J, Ali S, Fenig Y, Paulin E, Binenbaum S, Borao F. Five Years, Two Surgeons, and over 500 Bariatric Procedures: What Have We Learned? Obes Surg 2018; 27:2742-2749. [PMID: 28795300 DOI: 10.1007/s11695-017-2873-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Bariatric surgery has become an increasingly popular method for weight loss and mitigation of co-morbidities in the obese population. Like any field, there is a desire to standardize and accelerate the postoperative period while maintaining safe outcomes. METHODS All laparoscopic sleeve gastrectomies (LSG) and gastric bypasses (LGB) were performed over a 5-year period were logged along with several aspects of postoperative care. Trends were followed in aspects of postoperative care over years as well as any documentation of complications or re-admissions. RESULTS A total of 545 LSGs and LBPs were performed between 2012 and 2016. Improvements were noted in nearly every field over time, including faster Foley removal, decreased length of hospital stay, decreased use of patient controlled analgesics (PCAs), and faster advancement of diet. There was also an abandonment of utilization of the ICU and step down setting for these patients, leading to significant decreases in hospital cost. There was no change in complications, re-operations, or re-admission in this time period. CONCLUSIONS The surgeons involved in this project have built a busy bariatric surgery practice, while continually evolving the postoperative algorithm. Nearly every aspect of postoperative care has been deescalated while decreasing length of stay and cost to the hospital. All of this has been obtained without incurring any increase in complications, re-operations, or re-admissions. The authors of this paper hope to use this article as a launching point for a formal advanced recovery pathway for bariatric surgery at their institution and others.
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Affiliation(s)
- Brian Shea
- Monmouth Medical Center, Long Branch, NJ, USA
| | - William Boyan
- Monmouth Medical Center, Long Branch, NJ, USA.
- , 110 Robinson Place, Shrewsbury, NJ, 07702, USA.
| | - James Botta
- Monmouth Medical Center, Long Branch, NJ, USA
| | - Syed Ali
- School of Medicine, St. George's University, West Indies, Grenada
| | - Yaniv Fenig
- Monmouth Medical Center, Long Branch, NJ, USA
| | | | | | - Frank Borao
- Monmouth Medical Center, Long Branch, NJ, USA
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Lin S, Guan W, Hans P, Liang H. Status of Laparoscopic Sleeve Gastrectomy in China: A National Survey. Obes Surg 2018; 27:2968-2973. [PMID: 28527155 DOI: 10.1007/s11695-017-2727-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is a favorable bariatric procedure. This study evaluated the status of LSG in China. METHODS During the 4th International Forum of Bariatric and Metabolic Surgery in May 2016, Nanjing China, an on-the-spot questionnaire was filled out by 105 attending surgeons with experience of LSG. The feedback data was collected and analyzed. RESULTS For preoperative preparations, surgeons preferred blood glucose control with insulin (61.0%), bowel cleaning (33.3%), and fasting and water deprivation (75.2%). For surgical techniques, surgeons preferred 36/38F bougie (86.7%), greater curvature mobilization with ultrasonic energy device (89.5%), direct transection of short gastric vessels (80%), antrum resection within 2-6 cm to the pylorus (84.8%) with 4.8 mm height stapler (72.4%), and 3.5 mm for corpus (94.3%). Whole stapler-line reinforcement, gastric sleeve fixation, leaking test, and abdominal drainage were preferred by 48.6, 62.9, 39, and 47.6% surgeons. For postoperative managements, surgeons preferred nasogastric tube insertion (33.3%), early liquid diet (69.6%), 4 weeks of liquid diet (55.2%), 2000 ml daily water intake before discharge (79%), 4 weeks of PPI (69.5%), and multi-vitamin supplementation 1 week after operation (77.1%). For postoperative complications, preferences were tachycardia as the onset of leak (81.0%) and oral contrast radiography for leak diagnosis (72.4%). Leak managements include US-guided percutaneous drainage (68.6%), nasogastric tube (87.6%), and parenteral nutrition (61%). For prolonged leak, enteral nutrition (87.6%) and Roux-en-Y bypass (84.8%) as the salvage procedure were preferred. 95.2% preferred endoscopic dilation for stricture. CONCLUSIONS LSG is gaining its wide application in China, but standardization of LSG is urgently needed.
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Affiliation(s)
- Shibo Lin
- Department of General Surgery, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu, 210029, China
| | - Wei Guan
- Department of General Surgery, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu, 210029, China
| | - Pankaj Hans
- Department of General Surgery, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu, 210029, China
| | - Hui Liang
- Department of General Surgery, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu, 210029, China.
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Rahman U, Docimo S, Pryor AD, Bates A, Obeid NR, Spaniolas K. Routine contrast imaging after bariatric surgery and the effect on hospital length of stay. Surg Obes Relat Dis 2018; 14:517-520. [DOI: 10.1016/j.soard.2017.12.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 12/21/2017] [Accepted: 12/26/2017] [Indexed: 10/18/2022]
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Barriers to Enhanced Recovery after Surgery after Laparoscopic Sleeve Gastrectomy. J Am Coll Surg 2018; 226:605-613. [DOI: 10.1016/j.jamcollsurg.2017.12.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 12/14/2017] [Indexed: 11/21/2022]
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47
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Albalawi Z, Laffin M, Gramlich L, Senior P, McAlister FA. Enhanced Recovery After Surgery (ERAS ®) in Individuals with Diabetes: A Systematic Review. World J Surg 2018; 41:1927-1934. [PMID: 28321553 DOI: 10.1007/s00268-017-3982-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prevalence of diabetes in surgical patients is 10-40%. It is well recognized that they have higher rates of complications, and longer stays in hospital compared to patients without diabetes. Enhanced recovery after surgery (ERAS) is an evidence-based multimodal surgical care pathway that improves postoperative complications and length of stay in patients without diabetes. This review evaluates the evidence on whether individuals with diabetes would benefit from ERAS implementation. METHODS MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL) and EMBASE searched with no language restrictions applied. Conference proceedings and bibliographies were reviewed. Experts in the field were contacted, and www.clinicaltrials.gov searched for ongoing trials. SELECTION CRITERIA Randomized controlled trials (RCT) looking at individuals with diabetes undergoing surgery randomized to ERAS® or conventional care. Non-randomized controlled trials, controlled before-after studies, interrupted time series, and cohort studies with concurrent controls were also considered. Two authors independently screened studies. RESULTS The electronic search yielded 437 references. After removing duplicates, 376 were screened for eligibility. Conference proceedings and bibliographies identified additional references. Searching www.clinicaltrials.gov yielded 59 references. Contacting experts in the field identified no further studies. Fourteen full articles were assessed and subsequently excluded for the following reasons: used an intervention other than ERAS®, did not include patients with diabetes, or used an uncontrolled observational design. CONCLUSIONS To date, the effects of ERAS® on patients with diabetes have not been rigorously evaluated. This review highlights the lack of evidence in this area and provides guidance on design for future studies.
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Affiliation(s)
- Zaina Albalawi
- Department of Medicine, University of Alberta, Edmonton, Canada. .,Endocrinology and Metabolism, Alberta Health Services, Edmonton, Canada.
| | - Michael Laffin
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Edmonton, Canada.,Gastroenterology, University of Alberta, Edmonton, Canada
| | - Peter Senior
- Department of Medicine, University of Alberta, Edmonton, Canada.,Endocrinology and Metabolism, University of Alberta, Edmonton, Canada
| | - Finlay A McAlister
- Department of Medicine, University of Alberta, Edmonton, Canada.,General Internal Medicine, University of Alberta, Edmonton, Canada
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King AB, Spann MD, Jablonski P, Wanderer JP, Sandberg WS, McEvoy MD. An enhanced recovery program for bariatric surgical patients significantly reduces perioperative opioid consumption and postoperative nausea. Surg Obes Relat Dis 2018; 14:849-856. [PMID: 29555468 DOI: 10.1016/j.soard.2018.02.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/05/2018] [Accepted: 02/04/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients frequently remain in the hospital after bariatric surgery due to pain, nausea, and inability to tolerate oral intake. Enhanced recovery after surgery (ERAS) concepts address these perioperative complications and therefore improve length of stay for bariatric surgery patients. OBJECTIVES To determine if ERAS concepts increase the proportion of patients discharged on postoperative day 1. Secondary objectives included mean length of stay, perioperative opioid use, emergency department visits, and readmissions. SETTING A large metropolitan university tertiary hospital. METHODS A quantitative before and after study was conducted for patients undergoing bariatric surgical patients. Data were collected surrounding length of stay, perioperative opioid consumption, antiemetic therapy requirements postoperatively, multimodal analgesia compliance, emergency department visits, and hospital readmission rates. Wilcoxon rank-sum and χ2 test were used to compare continuous and categorical variables, respectively. A secondary analysis was performed using Aligned Rank Transformation and Cochran-Mantel-Haenszel χ2 tests to account for an increase in sleeve gastrectomies in the intervention group. RESULTS The 2 groups had clinically similar baseline characteristics. Comparison group (N = 366) and ERAS group (N = 715) patients underwent a primary bariatric surgery procedure. There was an increase in the number of patients undergoing a laparoscopic sleeve gastrectomy in the intervention group. After accounting for this increase, the percentage of patients discharged on postoperative day 1 was unchanged (79.8% non-ERAS versus 83.1% ERAS, P = .52). ERAS length of stay was statistically significantly lower for gastric bypass (P<.001) and robotic gastric bypass (P = .01). Perioperative opioid consumption was reduced (41.0 versus 16.2 morphine equivalents, P<0.001), and fewer ERAS patients required postoperative antiemetics (68.8% versus 46.2%, P<.001). Emergency department visits at 7 days were reduced (6.0% versus 3.2%, P = .04), but hospital readmission rates were unchanged. CONCLUSIONS Implementing ERAS did not reduce the percentage of patients discharged on postoperative day 1 in a bariatric surgery program with historically low length of stay, but it led to significant reductions in perioperative opioid use, decreases in postoperative nausea, and early emergency room visits.
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Affiliation(s)
- Adam B King
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew D Spann
- Department of Surgical Science, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Patrick Jablonski
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Fletcher R, Deal R, Kubasiak J, Torquati A, Omotosho P. Predictors of Increased Length of Hospital Stay Following Laparoscopic Sleeve Gastrectomy from the National Surgical Quality Improvement Program. J Gastrointest Surg 2018; 22:274-278. [PMID: 29209980 DOI: 10.1007/s11605-017-3642-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 11/14/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy is the most commonly performed bariatric procedure in the USA. Identifying preoperative risk factors for prolonged postoperative hospital stay will help appropriately select patients for fast-track protocols and avoid costly readmissions. To date, there has been no large national database analysis of risk factors for prolonged length of stay following laparoscopic sleeve gastrectomy. METHODS Laparoscopic sleeve gastrectomy procedures reported to the American College of Surgeons National Surgical Quality Improvement Program between 2009 and 2012 were reviewed. Open procedures and revisional procedures were excluded. Baseline patient characteristics and preoperative lab values were reviewed. Univariate analysis was conducted to identify patient factors that predicted prolonged hospitalization (defined as ≥ 3 days). Multivariate logistic regression was used to identify factor associated with prolonged length of stay. RESULTS We identified 11,430 patients who underwent laparoscopic sleeve gastrectomy. The median length of stay was 2 days and 18.4% required hospitalization ≥ 3 days. Multivariate analysis revealed that female sex, age greater than 65, body mass index greater than 50, chronic obstructive pulmonary disease, hypertension, renal insufficiency, anemia, and prolonged operative time were significantly associated with prolonged hospital stay. CONCLUSIONS Preoperative patient characteristics as well as operative details predict prolonged length of stay following laparoscopic sleeve gastrectomy. As the utilization of fast-track protocols in bariatric surgery programs expands, these data may be used to assist in the selection of patients who may be inappropriate for rapid discharge from the hospital after sleeve gastrectomy as well as guide medical optimization strategies preoperatively.
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Affiliation(s)
- Reid Fletcher
- Department of Surgery, Rush University Medical Center, 1750 W Harrison St, Chicago, IL, 60612, USA.
| | - Rebecca Deal
- Department of Surgery, Rush University Medical Center, 1750 W Harrison St, Chicago, IL, 60612, USA
| | - John Kubasiak
- Department of Surgery, Rush University Medical Center, 1750 W Harrison St, Chicago, IL, 60612, USA
| | - Alfonso Torquati
- Department of Surgery, Rush University Medical Center, 1750 W Harrison St, Chicago, IL, 60612, USA
| | - Philip Omotosho
- Department of Surgery, Rush University Medical Center, 1750 W Harrison St, Chicago, IL, 60612, USA
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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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