Enhanced Recovery after Bariatric Surgery: 202 Consecutive Patients in an Italian Bariatric Center

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.

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

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

Management of leaks following one-anastomosis gastric bypass: an updated systematic review and meta-analysis of 44 318 patients

INTRODUCTION

One-anastomosis gastric bypass (OAGB) complication, such as leakage, can be dangerous and should be managed properly, yet little data exist in the literature regarding the management of leaks after OAGB, and there are no guidelines to date.

METHODS

The authors performed a systematic review and meta-analysis of the literature and 46 studies, examining 44 318 patients were included.

RESULTS

There were 410 leaks reported in 44 318 patients of OAGB published in the literature, which represents a prevalence of 1% of leaks after OAGB. The surgical strategy was very variable among all the different studies; 62.1% of patients with leaks had to undergo another surgery due to the leak. The most commonly performed procedure was peritoneal washout and drainage (with or without T-tube placement) in 30.8% of patients, followed by conversion to Roux-en-Y gastric bypass in 9.6% of patients. Medical treatment with antibiotics, with or without total parenteral nutrition alone, was conducted in 13.6% of patients. Among the patients with the leak, the mortality rate related to the leak was 1.95%, and the mortality due to the leak in the population of OAGB was 0.02%.

CONCLUSION

The management of leaks following OAGB requires a multidisciplinary approach. OAGB is a safe operation with a low leak risk rate, and the leaks can be managed successfully if detected in a timely fashion.

Enhanced Recovery After Surgery Promotes Recovery in Sleeve Gastrectomy: A Randomized Controlled Trial

Introduction: The most popular approach for treating obesity is laparoscopic sleeve gastrectomy (LSG). The enhanced recovery after surgery (ERAS) protocol aims to reduce the patient's surgical stress response, optimize their physiological function, and facilitate recovery. The purpose of this study was to investigate the efficacy and safety of the ERAS protocol in patients who have undergone LSG. Methods: Between January 2020 and March 2021, a single-center randomized controlled study with patients undergoing LSG was planned. Patient demographics, duration of surgery and anesthetic induction, postoperative nausea-vomiting (PONV) and pain scores, length of hospital stay, and emergency room readmissions within the first 30 days were also documented. Patients were divided into two groups: those who followed the ERAS protocol and those who did not. The senior surgeon was blinded for the preoperative and postoperative period, whereas the other surgeon was not. The groups were compared in terms of length of hospital stay, duration of surgery, visual analog scale (VAS) scores, PONV effect scores, and emergency service admissions within the first 30 days after surgery. Results: A total of 96 patients were included in this study. Of these, 49 were in the ERAS protocol group and 47 were in the traditional treatment group. The mean age of the patients in the ERAS and traditional treatment groups were 37.47 ± 10.11 years and 35.77 ± 9.62 years, respectively. While the ERAS group patients were hospitalized for a mean of 30.46 ± 11.26 hours, the traditional group patients were hospitalized for 52.02 ± 6.63 hours (P: .001). There was no difference between the groups in terms of the first 30-day readmission to the emergency department (P: .498). Both VAS and PONV effect scores at the 2nd and 12th hours of the ERAS group patients were lower (P: .001, .002, .001, .001, respectively). Conclusions: When compared with the conventional method, the ERAS protocol reduced patient hospitalization time, decreased postoperative nausea, vomiting, and pain scores, and did not vary in postoperative emergency department readmissions. In patients receiving LSG, the ERAS protocol can be employed safely and successfully. Clinical Trial Registration number: NCT04442568.

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.

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.

How can lean thinking improve ERAS program in bariatric surgery?

INTRODUCTION

Enhanced recovery after bariatric surgery protocol (ERABS) decreased length of hospital stay (LOS) without influencing clinical outcomes. ERABS improved logistics aspects in operating room (OR) with OR time savings. Lean management was used to reorganize OR logistics and to improve its efficiency. This study analyzed clinical and OR logistic aspects in ERABS protocols.

METHODS

Retrospective analysis of prospectively maintained database of obese patients undergoing bariatric surgery from 2017 to 2019 was performed. Since September 2018, patients were treated with ERABS protocol (ERABS group). All patients treated with a standard protocol between January 2017 and September 2018 (control group) were compared to ERABS group. Preoperative (anthropometric data, surgical and medical history) and intraoperative (type of procedure) were analyzed in two groups. LOS was the primary outcomes parameter analyzed; complications, readmissions and reoperations within 30 days were the secondary outcomes. Logistic endpoints were evaluated in time saving and efficiency: surgical time, team work time and total anesthesia time.

RESULTS

471 patients underwent bariatric surgery: 239 patients (control group) compared to 232 patients (ERABS group). ERABS presented more previous surgical history rate (p = 0.04) compared to control group with difference of type of procedure performed (p < 0.001). Roux-en-Y gastric bypass was mainly procedure in both groups (61.1% in control group compared to 52.6% in ERABS groups). Mean LOS was shorter in ERABS (3.16 days) compared to control group (4.81 days) with no difference in clinical outcomes rate. All logistics endpoints showed a time savings in ERABS group compared to control group (surgical procedure, total anesthesia and team work time, p < 0.001). In multivariate analysis, LOS was associated to ERAS status (IRR 0.722; p < 0.0001), team work time (IRR 1.002; p = 0.002), surgical procedure time (IRR 1.002; p < 0.0001). ERAS status was not associated with complication neither readmission, but surgical procedure time was a factor associated with complication (IRR 1.011; p = 0.0008).

CONCLUSION

This study confirmed that ERABS protocol is safe and a feasible alternative with improved LOS. OR reorganization and logistic efficiency achieved using lean management helped reduce all OR times and these are likely related to the improvement in LOS and complication.

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.