First Successful Large-Scale Introduction of an Enhanced Recovery after Bariatric Surgery (ERABS) Program in the Middle East: The Results and Lessons Learned of Tawam Hospital/Johns Hopkins, a Tertiary Governmental Center in the UAE

Implementation of updated enhanced recovery after bariatric surgery guidelines: adapted protocol in a single tertiary center

The aim of this study is to evaluate the effects of an adapted protocol of enhanced recovery after bariatric surgery (ERABS) on outcomes. This is a single-center observational study comparing patients managed according to adapted ERABS protocol (March-May 2022) with a control group of old method (January 2021-February 2022). Totally, 253 bariatric patients were included in the study (n = 68) and control (n = 185) groups. Patients were mostly females (57.3% vs 70.2%; p = 0.053), of mean age 38.8 years and body mass index 41 ± 6.53 vs. 44.60 ± 7.37 kg/m2 (p = 0.007) in study and control groups, respectively. The majority (90.5%) underwent primary bariatric surgery. Adapted ERABS protocol compliance was 98.5%. The study group had shorter hospital stay (mean 2.86 ± 0.51 vs. 4.03 ± 0.28 days; p < 0.001), similar rates of total (3% vs. 2.7%, p = 0.92) and major complications (1.5% vs. 0, p = 0.10). Readmission rates were similar (1.5% vs 1.6%, p = 0.92). Applied only in the study group, early ambulation (p < 0.001), opioid restriction, and preventing postoperative nausea and vomiting (PONV), resulted in satisfactory scores (mean total visual analogue score 1.93 ± 0.80, morphine milligram equivalent 34.0 ± 14.5, and mean total PONV grade 0.17 ± 0.36). In conclusion, implementing adapted ERABS guidelines improved patients' postoperative care, raising awareness to pain management. Length of stay was shortened without safety compromise. Efforts to abandon old-school routines seem worthwhile, even if ERABS is partially implemented.

Long-term effect of sleeve gastrectomy vs Roux-en-Y gastric bypass in people living with severe obesity: a phase III multicentre randomised controlled trial (SleeveBypass)

Background

Sleeve gastrectomy is the most performed metabolic surgical procedure worldwide. However, conflicting results offer no clear evidence about its long-term clinical comparability to Roux-en-Y gastric bypass. This study aims to determine their equivalent long-term weight loss effects.

Methods

This randomised open-label controlled trial was conducted from 2012 until 2017 in two Dutch bariatric hospitals with a 5-year follow-up (last follow-up July 29th, 2022). Out of 4045 patients, 628 were eligible for metabolic surgery and were randomly assigned to sleeve gastrectomy or Roux-en-Y gastric bypass (intention-to-treat). The primary endpoint was weight loss, expressed by percentage excess body mass index (BMI) loss. The predefined clinically relevant equivalence margin was -13% to 13%. Secondary endpoints included percentage total kilograms weight loss, obesity-related comorbidities, quality of life, morbidity, and mortality. This trial is registered with Dutch Trial Register NTR4741: https://onderzoekmetmensen.nl/nl/trial/25900.

Findings

628 patients were randomised between sleeve gastrectomy (n = 312) and Roux-en-Y gastric bypass (n = 316) (mean age 43 [standard deviation (SD), 11] years; mean BMI 43.5 [SD, 4.7]; 81.8% women). Excess BMI loss at 5 years was 58.8% [95% CI, 55%-63%] after sleeve gastrectomy and 67.1% [95% CI, 63%-71%] after Roux-en-Y gastric bypass (difference 8.3% [95% CI, -12.5% to -4.0%]). This was within the predefined margin (P < 0.001). Total weight loss at 5 years was 22.5% [95% CI, 20.7%-24.3%] after sleeve gastrectomy and 26.0% [95% CI, 24.3%-27.8%] after Roux-en-Y gastric bypass (difference 3.5% [95% CI, -5.2% to -1.7%]). In both groups, obesity-related comorbidities significantly improved after 5 years. Dyslipidaemia improved more frequently after Roux-en-Y gastric bypass (83%, 54/65) compared to sleeve gastrectomy (62%, 44/71) (P = 0.006). De novo gastro-oesophageal reflux disease occurred more frequently after sleeve gastrectomy (16%, 46/288) vs Roux-en-Y gastric bypass (4%, 10/280) (P < 0.001). Minor complications were more frequent after Roux-en-Y gastric bypass (5%, 15/316) compared to sleeve gastrectomy (2%, 5/312). No statistically significant differences in major complications and health-related quality of life were encountered.

Interpretation

In people living with obesity grades 2 and 3, sleeve gastrectomy and Roux-en-Y gastric bypass had clinically comparable excess BMI loss according to the predefined definition for equivalence. However, Roux-en-Y gastric bypass showed significantly higher total weight loss and significant advantages in secondary outcomes, including dyslipidaemia and GERD, yet at a higher rate of minor complications. Major complications, other comorbidities, and overall HRQoL did not significantly differ between the groups.

Funding

Not applicable.

Role of Enhanced Recovery after Surgery (ERAS) Protocol in the Management of Elderly Patients with Glioblastoma

OBJECTIVE

Among the already difficult management of neuro-oncological patients, the elderly population remains vulnerable. Because of the pathology and the comorbidities, they present a significantly higher rate of medical issues related to surgical management. Despite this, the surgical option, if feasible, remains the gold standard in these patients, and an Enhanced Recovery After Surgery (ERAS) protocol could improve the postoperative safety of the patients. With this purpose, we prepared this study with the aim of defining the postoperative hospital length of stay (LOS), but also of evaluating the postoperative morbidity, perioperative complications, and postoperative pain scores.

METHODS

This was a retrospective, single-cohort study performed at an academic hospital (Department of Neurosurgery, Neurocenter of South Switzerland, Switzerland) on elderly patients who underwent craniotomy for glioblastoma. Patients were enrolled in a novel ERAS protocol from January 2022 to December 2022. Since this is a feasibility study and a direct comparison was not possible, we used a historical cohort of elderly patients who had undergone elective craniotomy surgery for glioblastoma as a control group.

RESULTS

A total of 19 patients treated in our center for glioblastoma multiforme (GBM) who were aged over 75 years were included in this study. Among those, seven were newly recruited patients included in the ERAS protocol, while the remaining twelve were part of a historical cohort of previously treated patients. From a statistical point of view, the two cohorts were comparable in terms of baseline demographics. In the follow-up, it was shown that in the ERAS group, there was a reduction in the use of opioids after the surgical procedures that could be seen at 30 days (36.2% vs. 71.7%, p < 0.001), but also at 3 months, after surgery (33.0% vs. 80.0%, p < 0.001). A significant difference has also been documented in terms of mobilization and ambulation: compared to the historical cohort, in the ERAS group, there was a higher rate of mobilization (60.0% vs. 10.0%, p < 0.001), but also of ambulation (36.1% vs. 10.0%, p < 0.001).

CONCLUSIONS

The ERAS protocol for the management of glioblastoma in elderly patients seems to be an effective option for reducing LOS in the hospital, as well as for reducing the number of days spent in the ICU, improving the general recovery of the patient, and reducing the costs associated with hospitalization.

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Enhanced recovery after bariatric surgery: an Italian consensus statement

Background

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

Methods

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

Results

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

Conclusions

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

Enhanced Recovery After Surgery strategies for elective craniotomy: a systematic review

OBJECTIVE

Enhanced Recovery After Surgery (ERAS) has led to a paradigm shift in perioperative care through multimodal interventions. Still, ERAS remains a relatively new concept in neurosurgery, and there is no summary of evidence on ERAS applications in cranial neurosurgery.

METHODS

The authors systematically reviewed the literature using the PubMed/MEDLINE, Embase, Scopus, and Cochrane Library databases for ERAS protocols and elements. Studies had to assess at least one pre-, peri-, or postoperative ERAS element and evaluate at least one of the following outcomes: 1) length of hospital stay, 2) length of ICU stay, 3) postoperative pain, 4) direct and indirect healthcare cost, 5) complication rate, 6) readmission rate, or 7) patient satisfaction.

RESULTS

A final 27 articles were included in the qualitative analysis, with mixed quality of evidence ranging from high in 3 cases to very low in 1 case. Seventeen studies reported a complete ERAS protocol. Preoperative ERAS elements include patient selection through multidisciplinary team discussion, patient counseling and education to adjust expectations of the postoperative period, and mental state assessment; antimicrobial, steroidal, and antiepileptic prophylaxes; nutritional assessment, as well as preoperative oral carbohydrate loading; and postoperative nausea and vomiting (PONV) prophylaxis. Anesthesiology interventions included local anesthesia for pin sites, regional field block or scalp block, avoidance or minimization of the duration of invasive monitoring, and limitation of intraoperative mannitol. Other intraoperative elements include absorbable skin sutures and avoidance of wound drains. Postoperatively, the authors identified early extubation, observation in a step-down unit instead of routine ICU admission, early mobilization, early fluid de-escalation, early intake of solid food and liquids, early removal of invasive monitoring, professional nutritional assessment, PONV management, nonopioid rescue analgesia, and early postoperative imaging. Other postoperative interventions included discharge criteria standardization and home visits or progress monitoring by a nurse.

CONCLUSIONS

A wide range of evidence-based interventions are available to improve recovery after elective craniotomy, although there are few published ERAS protocols. Patient-centered optimization of neurosurgical care spanning the pre-, intra-, and postoperative periods is feasible and has already provided positive results in terms of improved outcomes such as postoperative pain, patient satisfaction, reduced length of stay, and cost reduction with an excellent safety profile. Although fast-track recovery protocols and ERAS studies are gaining momentum for elective craniotomy, prospective trials are needed to provide stronger evidence.

Impact of Excess Body Weight on Postsurgical Complications

BACKGROUND

Obesity is considered a risk factor for postoperative complications as it can limit exposure to the operation field, thereby significantly prolonging surgery time. Obesity-associated comorbidities, such as low-grade systemic inflammation, impaired functional status, and type 2 diabetes, are independent risk factors for impaired anastomotic wound healing and nonsurgical site infections. If obesity itself is an independent risk factor for surgical complications remains controversial, but the reason for this is largely unexplored.

SUMMARY

A MEDLINE literature search was performed using the terms: "obesity," "excess body weight," and "surgical complications." Out of 65,493 articles 432 meta-analyses were screened, of which 25 meta-analyses were on the subject. The vast majority of complex oncologic procedures in the field of visceral surgery have shown higher complication rates in obese patients. Meta-analyses from the last 10 to 15 years with high numbers of patients enrolled consistently have shown longer operation times, higher blood loss, longer hospital stay for colorectal procedures, oncologic upper gastrointestinal (GI) procedures, and pancreatic surgery. Interestingly, these negative effects seem not to affect the overall survival in oncologic patients, especially in esophageal resections. A selection bias in oncologic upper GI patients may have influenced the results with higher BMI in upper GI cancer to be a predictor for better nutritional and performance status.

KEY MESSAGES

Contrary to bariatric surgery, only limited evidence indicated that site and type of surgery, the approach to the abdominal cavity (laparoscopic vs. open), institutional factors, and the type of perioperative care such as ERAS protocols may play a role in determining postsurgical complications in obese patients. The initial question remains therefore partially unanswered. Large nationwide register-based studies are necessary to better understand which aspects of obesity and its related comorbidities define it as a risk factor for surgical complications.

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

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

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

OVERVIEW

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

OBJECTIVE

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

SETTING

Santa Marcelina Hospital, São Paulo, Brazil.

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Enhanced recovery programmes versus conventional care in bariatric surgery: A systematic literature review and meta-analysis

BACKGROUND

With obesity prevalence projected to increase, the demand for bariatric surgery will consequently rise. Enhanced recovery programmes aim for improved recovery, earlier discharge, and more efficient use of resources following surgery. This systematic literature review aimed to evaluate the evidence available on the effects of enhanced recovery programmes after three common bariatric procedures: laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG), and one anastomosis gastric bypass (OAGB).

METHODS

MEDLINE, Embase, the Cochrane Library and the National Health Service Economic Evaluation Database were searched for studies published in 2012-2019 comparing outcomes with enhanced recovery programmes versus conventional care after bariatric surgery in Europe, the Middle East and Africa. Data were extracted and meta-analyses or descriptive analyses performed when appropriate using R.

RESULTS

Of 1152 screened articles, seven relevant studies including 3592 patients were identified. Six reported outcomes for 1434 patients undergoing LRYGB; however, as only individual studies reported on LSG and OAGB these could not be included in the analyses. The meta-analysis revealed a significantly shorter mean duration of hospital-stay for LRYGB enhanced recovery programmes than conventional care (mean difference [95% CI]: -1.34 days [-2.01, -0.67]; p<0.0001), supported by sensitivity analysis excluding retrospective studies. Meta-analysis found no significant difference in 30-day readmission rate (risk ratio [95% CI]: 1.39 [0.84, 2.28]; p = 0.2010). Complication rates were inconsistently reported by Clavien-Dindo grade, but descriptive analysis showed generally higher low-grade rates for enhanced recovery programmes; the trend reversed for high-grade complications. Reoperation rates were rarely reported; no significant differences were seen.

CONCLUSION

These results support enhanced recovery programmes allowing shorter inpatient stay without significant differences in readmission rate following LRYGB, although complication and reoperation rate comparisons were inconclusive. Further research is needed to fill current data gaps including the lack of studies on LSG and OAGB.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Enhanced recovery after surgery among adolescents undergoing bariatric surgery

Enhanced recovery after surgery (ERAS) has evolved over the past two decades. Originally aimed to standardize care among adults undergoing colorectal surgery, the tenets that developed have since been broadly accepted by a large number of adult surgical subspecialties, including bariatric surgery. This multidisciplinary, patient-centered approach involving optimizing pre-, intra-, and postoperative phases of care has resulted in shorter hospitalizations, fewer complications, and lower mortality rates. Recently, multiple pediatric surgery subspecialties have adopted ERAS principles and have documented similar favorable outcomes. Among adolescent bariatric patients, outcomes following the implementation of ERAS have not yet been described. We will review the history and goals of ERAS and detail pediatric surgery specific implementations. We will also review outcomes associated with ERAS within specific pediatric surgical subspecialties. Lastly, we will discuss the current ERAS protocol developed at Children's Hospital Colorado for adolescent bariatric surgery.

Perioperative Exercise Therapy in Bariatric Surgery: Improving Patient Outcomes

Nowadays, obesity and related comorbidities like type 2 diabetes, hypertension, dyslipidaemia and obstructive sleep apnoea syndrome are considered one of the medical challenges of the 21st century. Even with the rise of bariatric and metabolic surgery, obesity and metabolic syndrome are reaching endemic proportions. Even in 2020, obesity is still a growing problem. There is increasing evidence that next to bariatric surgery, exercise interventions in the perioperative period could give extra beneficial effects. In this regard, effects on anthropometrics, cardiovascular risk factors and physical fitness. The aim of this review is to summarise effects of preoperative and postoperative exercise, tools for screening and directions for future research and implementations.