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

Safety of Same-Day Discharge after Bariatric Surgery: Retrospective 6-Year North American Analysis

BACKGROUND

With increasing implementation of Enhanced Recovery After Surgery protocols and rising demand for inpatient hospital beds accentuated by COVID-19, there has been interest in same-day discharge (SDD) for bariatric surgery. The aim of this study was to determine the national trends, safety profile, and risk factors for complications of SDD for minimally invasive bariatric surgery.

STUDY DESIGN

We analyzed the MBSAQIP database from 2016 to 2021 to characterize trends in SDD for minimally invasive bariatric operation. Multivariate logistic regression was performed on preoperative patient characteristics predictive of increased complications associated with SDD. A comparative analysis of postoperative outcomes within 30 days was performed for SDD and admission after 1:1 nearest neighbor propensity score matching for patient demographics and preoperative comorbidities.

RESULTS

SDD increased from 2.4% in 2016 to 7.4% in 2021. Major preoperative factors associated with increased complications for SDD included Black race, history of MI, renal insufficiency, deep vein thrombosis, and smoking. SDD for Roux-en-Y gastric bypass had 72% increased risk of postoperative complications compared with sleeve gastrectomy. The overall major complications were lower in SDD cohort vs admission cohort (odds ratio [OR] 0.62, p < 0.01). However, there was a significant increase in deaths within 30 days (OR 2.11, p = 0.01), cardiac arrest (OR 2.73; p < 0.01), and dehydration requiring treatment (OR 1.33; p < 0.01) in SDD cohort compared with admission cohort.

CONCLUSIONS

Nationally, there has been a rise in SDD for bariatric operation from 2016 to 2021. Matched analysis demonstrates that SDD is associated with a significantly higher mortality rate. Additionally, the risk of complications with SDD is higher for RYGB compared with sleeve gastrectomy. Therefore, further studies are required to appropriately select patients for whom bariatric surgery can be safely performed as an outpatient.

Safety of Non-steroidal Anti-inflammatory Drugs as Part of Enhanced Recovery After Laparoscopic Sleeve Gastrectomy-A Systematic Review and Meta-Analysis

Laparoscopic sleeve gastrectomy (LSG) is an effective bariatric surgery option for managing extreme obesity in most patients. While non-steroidal anti-inflammatory drugs (NSAIDs) promise postoperative pain management after bariatric surgeries, their safety in LSG remains unexplored. In this systematic review, we studied the safety of NSAIDs following LSG reported by six studies involving 588 patients. Our study demonstrated that NSAIDs effectively alleviated the postoperative pain after LSG without major safety concerns. Most reported (>20% incidence) adverse events included postoperative nausea and vomiting (PONV, 21%). For patients undergoing LSG, NSAIDs offer a valuable option for pain management and improved care, potentially reducing opioid consumption. However, additional research is required to optimize NSAID usage and ensure safety, especially concerning renal and gastrointestinal issues.

Implementing novel modalities into an institutional enhanced recovery after bariatric surgery (ERABS) protocol

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.

Outcomes of same-day discharge sleeve gastrectomy and Roux-en-Y gastric bypass: a systematic review and meta-analysis

Length of stay after bariatric surgery has progressively shortened. Same-day discharge (SDD) has been reported for the 2 most common bariatric procedures, Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). The aim of this study is to evaluate the safety and success of SDD following SG and RYGB. Systematic literature search on SDD after bariatric surgery was conducted in Medline, Cochrane library, Google Scholar, and Embase. SDD was defined as discharging the patient during the day of the bariatric operation, without an overnight stay. The primary outcomes of interest were successful SDD, readmission, and morbidity rates. The secondary endpoints included reoperation and mortality rates. A proportion meta-analysis was performed to assess the outcomes of interest. A total of 14 studies with 33,403 patients who underwent SDD SG (32,165) or RYGB (1238) were included in the qualitative synthesis. Seven studies with 5000 patients who underwent SDD SG were included in the quantitative analysis, and pooled proportions (PPs) were calculated for the outcomes of interest. The SDD success rate was 63%-100% (PP: 99%) after SG and 88%-98.1% after RYGB. The readmission rate ranged from .6% to 20.8% (PP: 4%) after SDD SG and 2.4%-4% after SDD RYGB. Overall morbidity, reoperation, and mortality were 1.1%-10% (PP:4%), .3%-2.1% (PP: 1%), and 0%-.1% (PP: 0%), respectively, for SDD SG, and 2.5%-4%,1.9%-2.5%, and 0%-.9%, respectively, for SDD RYGB. SDD after SG seems feasible and safe. The outcomes of SDDRYGB seem promising, but the evidenceis stilllimitedto draw definitive conclusions. Selection criteria and perioperative protocolsmust be standardized to adequately introduce this practice.

Impact of Urinary Catheterization on Postoperative Outcomes After Roux-En-Y Gastric Bypass Surgery in Propensity-Matched Cohorts

BACKGROUND

The impact of urinary catheter avoidance in bariatric enhanced recovery after surgery (ERAS) protocols is yet to be established. The purpose of the current study is to determine whether urinary catheter use in patients undergoing Roux-en-Y gastric bypass (RYGB) procedures has an effect on postoperative outcomes.

METHODS

An institutional database was utilized to identify adult patients undergoing primary minimally invasive RYGB surgery. Outcomes included incidence of urinary tract infection (UTI) within 30 days postoperatively, 30-day readmission rates, proportion of patients discharged after postoperative day 1 (delayed discharge), length of stay (LOS), and operating room time. These were compared between propensity-matched groups with and without urinary catheter placement.

RESULTS

There were no significant differences in postoperative UTI's (2.2% for both cohorts, P = .593) or 30-day readmission rates for patients with and without urinary catheters (6.6% and 4.4%, respectively, P = .260). Mean LOS (1.7 vs. 1.5 days, P = .001) and the proportion of patients having a delayed discharge (47.3% vs. 33.7%, P = .001) was greater in patients with a catheter. Operating room time was longer in the urinary catheter group (221.8 vs. 207.9 minutes, P = .002).

DISCUSSION

Avoidance of indwelling urinary catheters in RYGB surgical patients decreased delayed discharges and LOS without affecting readmission or reoperation rates. Therefore, we recommend that avoidance of urinary catheters in routine RYGB surgery be considered for inclusion into standardized ERAS protocols. Urinary catheters should continue to be utilized in select cases, however, as these were not shown to affect rate of UTIs.

Difference in 30-Day Readmission Rates After Laparoscopic Sleeve Gastrectomy Versus Laparoscopic Roux-En-Y Gastric Bypass: a Propensity Score Matched Study Using ACS NSQIP Data (2015-2019)

PURPOSE

There are very few studies that have compared the short-term outcomes of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). Among short-term outcomes, hospital readmission after these procedures is an area for quality enhancement and cost reduction. In this study, we compared 30-day readmission rates after LSG and LRYGB through analyzing a nationalized dataset. In addition, we identified the reasons of readmission.

MATERIALS AND METHODS

The current study was a retrospective analysis of data from National Surgical Quality Improvement Program (NSQIP) All adult patients, ≥ 18 years of age and who had LSG or LRYGB during 2014 to 2019 were included. Current Procedural Terminology (CPT) codes were used to identify the procedures. Multivariate logistic regressions were used to calculate propensity score adjusted odds ratios (ORs) for all cause 30-day re-admissions.

RESULTS

There were 109,900 patients who underwent laparoscopic bariatric surgeries (67.5% LSG and 32.5% LRYGB). Readmissions were reported in 4168 (3.8%) of the patients and were more common among RYGB recipients compared to LSG (5.6% versus 2.9%, P < 0.001). The odds of 30-day readmissions were significantly higher among LRYGB group compared to LSG group (AOR, 2.20; 95% CI; 1.83, 2.64). In addition, variables such as age, chronic obstructive pulmonary disease, hypertension, bleeding disorders, blood urea nitrogen, SGOT, alkaline phosphatase, hematocrit, and operation time were significantly predicting readmission rates.

CONCLUSIONS

Readmission rates were significantly higher among those receiving LRYGB, compared to LSG. Readmission was also affected by many patient factors. The factors could help patients and providers to make informed decisions for selecting appropriate procedures.

Compliance with Enhanced Recovery After Surgery (ERAS) protocol recommendations for bariatric surgery in an obesity treatment center

INTRODUCTION

The higher risk of perioperative complications associated with obesity has made anesthesiologists increasingly concerned with the management of obese patients. Measures that improve bariatric surgery patient safety have become essential. The implementation of ERAS protocols in several surgical specialties has made it possible to achieve appropriate outcomes as to surgery safety. The aim of this study was to evaluate patient compliance with the recommendations of an ERAS protocol for Bariatric Surgery (ERABS) at a hospital specialized in obesity treatment.

METHODS

Cross-sectional study, using a medical record database, in a hospital certified as an International Center of Excellence in Bariatric and Metabolic Surgery. The definition of the variables to be assessed was based on the most recent ERABS proposed by Thorell et al. Results were analyzed using descriptive epidemiology.

RESULTS

The study evaluated all patients undergoing bariatric surgery in 2019. Mean compliance with the recommendations per participant was 42.8%, with a maximum of 55.5%, and was distributed as follows: 22.6% of compliance with preoperative recommendations, 60% to intraoperative recommendations, and 58.1% to postoperative recommendations. The anesthesiologist is the professional who provides most measures for the perioperative optimization of bariatric surgery patients. In our study we found that anesthesiologists complied with only 39.5% of ERABS recommendations.

CONCLUSIONS

Mean compliance with ERABS recommendations per participant was 42.8%. Considering that the study was carried out at a hospital certified as an international center of excellence, the need for introducing improvements in the care of patients to be submitted to bariatric surgery is evident.

ERAS reduces postoperative hospital stay and complications after bariatric surgery: A retrospective cohort study

Enhanced recovery after surgery (ERAS) is a multimodal, multidisciplinary approach for caring surgical patients. The present study aimed to compare the perioperative outcomes of laparoscopic bariatric surgery between patients with ERAS and those with conventional care.The clinical data of all patients undergoing primary laparoscopic bariatric surgery between January 2014 and June 2017 were retrospectively collected and reviewed. Patients were managed with conventional care during 2014 to 2015 (conventional care group) and with ERAS protocols during 2016 to 2017 (ERAS group). The 2 groups were compared in terms of postoperative length of hospital stay (LOS) and postoperative day 1 discharge rate.A total of 435 consecutive patients were included with 198 patients in the conventional care group and 237 patients in the ERAS group. The ERAS group had significantly shorter LOS (2.2 ± 0.9 vs 4.0 ± 2.6 days, P < .01) and significantly higher day 1 discharge rate (15.2% vs 1%, P < .01) compared with the conventional care group. During postoperative 30 days, the ERAS group had significantly less complications (2.1% vs 8.6%, P < .01) and readmissions (1.3% vs 4.5%, P = .02) compared with the conventional care group.Compared with conventional care, ERAS significantly reduces postoperative LOS, complications, and readmissions in patients undergoing laparoscopic bariatric surgery.

Outcomes of Enhanced Recovery After Surgery Protocols Versus Conventional Management in Patients Undergoing Bariatric Surgery

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.

Randomized, Double-Blind Study of the Effect of Intraoperative Intravenous Lidocaine on the Opioid Consumption and Criteria for Hospital Discharge After Bariatric Surgery

BACKGROUND AND OBJECTIVES

Surgical trauma, pain and opioids can cause nausea, vomiting, ileus and increased length of hospital stay. The primary objective of the study was to evaluate the time to recovery of gastrointestinal function and the time to meet hospital discharge criteria after laparoscopic bariatric surgery with intraoperative intravenous lidocaine administration. Secondary objectives were to evaluate morphine consumption during the first 24 h and the side effects of opioids.

METHODS

Fifty-eight patients aged 18 to 60 years who underwent bariatric surgery were allocated into two groups. Group 1 patients received intravenous lidocaine (1.5 mg/kg) 5 min before induction of anaesthesia, followed by infusion (2 mg/kg/h) until the end of surgery. Group 2 patients were given 0.9% saline solution (placebo) and infusion of 0.9% saline solution during surgery, in same volume as group 1. Anaesthesia was performed with fentanyl (5 μg/kg), propofol (2 mg/kg), rocuronium (0.6 mg/kg) and sevoflurane. Postoperative patient-controlled analgesia was with morphine. There were two groups that were evaluated: time to recovery of gastrointestinal function and time to meet discharge criteria.

RESULTS

There was no significant difference between groups regarding the time to first flatus, time to meet discharge criteria and occurrence of side effects. Consumption of intraoperative sevoflurane and morphine over 24 h was significantly lower in the lidocaine group. Side effects observed were nausea and vomiting, with no difference between groups.

CONCLUSIONS

Perioperative intravenous lidocaine is feasible and easily accessible when administered at appropriate doses. Lidocaine reduces morphine consumption.

Connected Surveillance for Detection of Complications After Early Discharge from Bariatric Surgery

As part of a bariatric enhanced recovery after surgery (ERAS) program, at-home follow-up using a novel Internet application was used to detect early complications. The study aimed to evaluate the safety and effectiveness of this "connected surveillance" protocol over a 10-day follow-up. Patients were monitored 24/7 by a trained nursing team with daily surgeon review of patient self-reports. Morbidly obese patients (n = 281) underwent OAGB (126, 47.70%) or sleeve gastrectomy (138, 52.3%). Of 264 who completed the study (mean age 40 years [20-66]), 3 (1.1%) underwent revision for early complications; there were 6 (2.1%) readmissions and 22 (8.3%) consultations. In a bariatric surgery ERAS program, "Internet-connected surveillance" proved safe and effective in detecting 100% of early complications, and most patients were satisfied with their care.

Enhanced Recovery after Surgery (ERAS): a Systematic Review of Randomised Controlled Trials (RCTs) in Bariatric Surgery

OBJECTIVE

Our aim was to conduct an up-to-date systematic review of randomised controlled trials (RCTs) to determine the benefits and harms of enhanced recovery after surgery (ERAS) programme in bariatric surgery.

METHODS

MEDLINE, Embase, PubMed, CINAHL and the Cochrane Library were searched for RCTs on ERAS versus standard care (SC) until April 2020. The primary endpoint was the length of hospital stay (LOS).

RESULTS

Five RCTs included a total of 610 procedures. ERAS adoption is capable of significantly reducing LOS (MD of - 0.51; 95% CI - 0.92 to - 0.10; P = 0.01) and postoperative nausea and vomiting (PONV) (OR 0.42; 95% CI 0.19 to 0.95; P = 0.04). No significant differences in terms of adverse events and readmissions.

CONCLUSIONS

The implementation of ERAS in bariatric surgery produces a significant reduction in LOS and PONV.

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

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Fast Track Program in Conversion Bariatric Surgery, as Safe as in Primary Bariatric Surgery?

OBJECTIVES

Evaluate the safety of fast track (FT) surgery program in patients undergoing primary and revisional bariatric surgery (conversion from one procedure to another); identify limiting factors for early discharge and predictive factors for readmission.

METHODS

This is a retrospective review of 730 consecutive morbidly obese patients who underwent bariatric surgery between January 2016 and December 2017. Fast track protocol was applied on all patients. Target discharge was after one-night stay. The primary end point is length of stay. The secondary end point is frequency of hospital contact after discharge, readmissions and reinterventions within 30 days.

RESULTS

Primary procedures (n = 633) were banded Roux-en-Y gastric bypass (BRYGB, 79.3%), sleeve gastrectomy (10.7%), gastric band (4.7%) and others (5.3%). Mean age (± SD) was 44.32 ± 11.26 years, and mean BMI (± SD) was 43.58 ± 6.12 kg/m². Conversion procedures (n = 97) were gastric band to BRYGB (40.2%), or to adjustable BRYGB (39.2%), Mason to BRYGB (11.3%), sleeve to BRYGB (4.1%) and others (5.2%). Mean age (± SD) was 47.22 ± 9.1 years, and mean BMI (± SD) was 37.9 ± 7.27 kg/m². Mean LOS in primary patients was 1.3 ± 0.99, and that in conversion patients was 1.5 ± 1.4. Successful discharge at one night or less was achieved in 650 cases (573 primary and 77 conversion). After one-night discharge, incidence of contact to the hospital, readmission and reintervention was 23.9%, 5.9% and 1.9%, in the primary group and 31.2%, 13% and 5.2% in the conversion group.

CONCLUSION

One-night discharge in FT managed conversion procedures is safe, compared to primary procedures. It is associated with higher readmission rates; however, the postdischarge hospital contacts and surgical complications were not statistically significant different.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Trends in Drain Utilization in Bariatric Surgery: an Analysis of the MBSAQIP Database 2015-2017

Background

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (SG) are the two most common bariatric operations. With the implementation of enhanced recovery protocols, the use of drains should decrease.

Methods

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was queried for the years 2015–2017. Our inclusion criteria included all patients undergoing a primary LRYGB, SG, and revisions. We examined demographics, operative characteristics, the use of drains, and postoperative complications. Continuous variables were summarized using means and standard deviations (SD). Categorical variables were summarized using frequencies and proportions. Student’s T test (Wilcoxon sum rank test in the case of skewed data) and chi-squared analysis were used to assess the baseline differences in drain utilization.

Results

From 2015 to 2017, there were 388,239 bariatric cases performed without drains and 100,221 performed with drains. Twenty-nine percent of LRYGB patients had a drain placed but only 16.7% of SG patients. The percentage of LRYGB that had a drain dropped from 33.1 to 24.6% during the study period and that of SG dropped from 20.3 to 13.6%. Patients that had drains placed were more likely to have a provocative test at the time of surgery (prevalence ratio (PR) 2.24) and to have a postoperative swallow study (PR 1.93).

Conclusions

Drains are still commonly used in bariatric patients. Over the study period, there was a decrease in the use of drains in both bypass and sleeve patients. Patients with a drain were more likely to have had a provocative test and a swallow study and have a higher rate of complications and mortality.

Electronic supplementary material

The online version of this article (10.1007/s11695-019-04215-6) contains supplementary material, which is available to authorized users.

Four-Year Evolution of a Thrombophylaxis Protocol in an Enhanced Recovery After Surgery (ERAS) Program: Recent Results in 485 Patients

“Enhanced recovery after surgery” (ERAS) protocols may reduce morbidity, length of hospital stay (LOS), and costs. During the 4-year evolution of a bariatric ERAS protocol, we found that administration of thrombophylaxis selectively to high-risk morbidly obese patients (assessed postoperatively by Caprini score ≥ 3) undergoing omega loop gastric bypass (“mini” gastric bypass) or sleeve gastrectomy resulted in safe outcomes. Both procedures proved equally effective with this protocol. The vast majority of rapidly mobilized, low-risk patients did not appear to require antithrombotic heparin. Similar to other reported ERAS outcomes, our recent year’s results in 485 patients included a mean LOS of 1.08 ± 0.64 days (range 1–14), with 460 (95.0%) discharged on day 1 and 99.6% by day 2. There were 13 30-day complications (2.7%), two reinterventions (0.4%), and no hemorrhages.

A Single-center Experience Examining the Length of Stay and Safety of Early Discharge After Laparoscopic Roux-en-Y Gastric Bypass Surgery

PURPOSE

This study's objective was to describe our experience and evaluate the safety of early discharge (ED) following laparoscopic Roux-en-Y gastric bypass (LRYGB) in a specific patient population.

MATERIALS AND METHODS

Patients undergoing LRYGB at Montefiore Medical Center were retrospectively reviewed. Patients readmitted in the first 30 days following surgery were compared to those patients who were not readmitted. Data analysis was used to compare groups and to determine factors associated with readmission. In addition to patient demographics, length of stay (LOS) was analyzed as an independent risk factor for readmission.

RESULTS

A total of 630 LRYGB were performed during this period. There were 5.1% (n = 32) of patients that required readmission within 30 days of discharge. Readmitted patients had a higher BMI (50.0 vs. 45.8; p = 0.006) and there was a trend for them to be younger (38.4 years vs. 42.0; p = 0.07). There was an increased rate of ED in 2015 (36.7%, n = 121) compared to 2014 (29.9%, n = 90). The readmission rate for ED for the study period was 4.7% (n = 10). There were no observed mortalities in our early discharge group of patients.

CONCLUSIONS

Discharge on post-operative day 1 following a LRYGB is safe and is not associated with an increased likelihood of being readmitted within 30 days of discharge. Our single-center experience helps to better characterize current patient profiles and length of stay trends within the field and can be used to establish a randomized controlled trial for discharging patients early after LRYGB.

The Interest of Enhanced Recovery After Surgery in a New Bariatric Center

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.

Enhanced Recovery Protocol for Laparoscopic Sleeve Gastrectomy: Are Narcotics Necessary?

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.

Postoperative Care and Functional Recovery After Laparoscopic Sleeve Gastrectomy vs. Laparoscopic Roux-en-Y Gastric Bypass Among Patients Under ERAS Protocol

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.

Laparoscopic Roux-en-Y gastric bypass is as safe as laparoscopic sleeve gastrectomy. Results of a comparative cohort study

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).

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LRYGB is as safe as SG in the early post-operative period when performed by a surgeon with adequate experience.

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Bariatric fellowships play an important role in ensuring optimal outcomes.

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

BACKGROUND

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

OBJECTIVES

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

SETTING

Turkey.

METHODS

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

RESULTS

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

CONCLUSION

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

Meta-Analysis of Enhanced Recovery Protocols in Bariatric Surgery

BACKGROUND

Enhanced recovery after surgery (ERAS) guidelines, fast-track protocols, and alternative clinical pathways have been widely promoted in a variety of disciplines leading to improved outcomes in post-operative morbidity and length of stay (LOS). This meta-analysis assesses the implications of standardized management protocols in bariatric surgery.

METHODS

The PRISMA guidelines were adhered to. Databases were searched with the application of pre-defined inclusion and exclusion criteria. Results were reported as mean differences or pooled odds ratios (OR) with 95% confidence intervals (95% CI). Individual protocols and surgical approaches were assessed through subgroup analysis, and sensitivity analysis of methodological quality was performed.

RESULTS

A total of 1536 studies were screened; 13 studies were eventually included for meta-analysis involving a total of 6172 patients. Standardized perioperative techniques were associated with a savings of 19.5 min in operative time (p < 0.01), as well as a LOS which was shortened by 1.5 days (p < 0.01). Pooled post-operative morbidity rates also favored enhanced recovery care protocols (OR 0.7%, 95% CI 0.6-0.9%, p < 0.01).

CONCLUSION

Bariatric surgery involves a complex cohort of patients who require high-quality evidence-based care to improve outcomes. Consensus guidelines on the feasibility of ERAS and alternative clinical pathways are required in the setting of bariatric surgery.

Perioperative outcomes and anesthetic considerations of robotic bariatric surgery in a propensity-matched cohort of super obese and super-super obese patients

BACKGROUND

The use of the robotic platform has not been well established in patients with super obesity (SO; body mass index, BMI ≥ 50) and super-super obesity (SSO, BMI ≥ 60). We aimed to determine safety and feasibility of robotic bariatric surgery in this cohort.

METHODS

Review of a prospectively maintained database was performed of consecutive patients undergoing robotic bariatric surgery between 2015 and 2017. Propensity score analysis with 1:2 nearest neighbor matching was performed to control for baseline characteristics and procedure type.

RESULTS

A propensity-matched cohort of 47 SO patients (median BMI 55.3, range 50.1-92.5) and 94 morbidly obese (MO; median BMI 41.8, range 35.1-48.8) patients were analyzed. After matching, there were no difference in baseline characteristics including age, American Society of Anesthesiologists (ASA) score, or preoperative comorbidities. Most patients in each group underwent sleeve gastrectomy (81% of SO patients versus 76% of MO patients) or Roux-en-Y gastric bypass (13% vs. 18%, respectively), p = 0.66. There were no differences in operative time, intraoperative complications, postoperative complications, or re-admissions between groups. Length of stay was slightly longer in the MO group (2.2 days, IQR 1.8-3.2 vs. 1.8 days, IQR 1.2-2.7; p = 0.01). A subset of SSO patients (n = 11, median BMI 67, range 60-92) was analyzed; there was no increase in operation time, and zero intraoperative complications, conversions to open, or postoperative complications in this subset.

CONCLUSIONS

Robotic bariatric surgery can safely be performed on patients with SO or SSO with low perioperative morbidity and no increase in operating time.

Five Years, Two Surgeons, and over 500 Bariatric Procedures: What Have We Learned?

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.

The evaluation of risk prediction models in predicting outcomes after bariatric surgery: a prospective observational cohort pilot study

Background

As the prevalence of obesity is increasing, the number of patients requiring surgical intervention for obesity-related illness is also rising. The aim of this pilot study was to explore predictors of short-term morbidity and longer-term poor weight loss after bariatric surgery.

Methods

This was a single-centre prospective observational cohort pilot study in patients undergoing bariatric surgery. We assessed the accuracy (discrimination and calibration) of two previously validated risk prediction models (the Physiological and Operative Severity Score for the enumeration of Morbidity and Mortality, POSSUM score, and the Obesity Surgical Mortality Risk Score, OS-MS) for postoperative outcome (postoperative morbidity defined using the Post Operative Morbidity Survey). We then tested the relationship between postoperative morbidity and longer-term weight loss outcome adjusting for known patient risk factors.

Results

Complete data were collected on 197 patients who underwent surgery for obesity or obesity-related illnesses between March 2010 and September 2013. Results showed POSSUM and OS-MRS were less accurate at predicting Post Operative Morbidity Survey (POMS)-defined morbidity on day 3 than defining prolonged length of stay due to poor mobility and/or POMS-defined morbidity. Having fewer than 28 days alive and out of hospital within 30 days of surgery was predictive of poor weight loss at 1 year, independent of POSSUM-defined risk (odds ratio 2.6; 95% confidence interval 1.28-5.24).

Conclusions

POSSUM may be used to predict patients who will have prolonged postoperative LOS after bariatric surgery due to morbidity or poor mobility. However, independent of POSSUM score, having less than 28 days alive and out of hospital predicted poor weight loss outcome at 1 year. This adds to the literature that postoperative complications are independently associated with poor longer-term surgical outcomes.

Status of Laparoscopic Sleeve Gastrectomy in China: A National Survey

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a favorable bariatric procedure. This study evaluated the status of LSG in China.

METHODS

During the 4^th 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.

An enhanced recovery program for bariatric surgical patients significantly reduces perioperative opioid consumption and postoperative nausea

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.

Same-Day Discharge after Laparoscopic Roux-en-Y Gastric Bypass: An Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Database

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been performed with successful discharge on postoperative day 1 (POD1). There are limited studies on same-day discharge after LRYGB. The objective of this study was to examine the frequency and outcomes of same-day discharge after LRYGB.

STUDY DESIGN

The 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was analyzed for adult patients who underwent elective LRYGB cases with same-day vs POD1 discharge. Open and revisional cases were excluded. Multivariate analysis was performed to compare risk-adjusted 30-day mortality, overall morbidity, readmission, and reoperation.

RESULTS

There were 354 (0.9%) patients who were discharged on the same day as surgery after LRYGB. After exclusion criteria, 319 patients with same-day discharge and 9,402 patients with POD1 discharge were examined. For same-day vs POD1 discharge groups, mean ages were 45.0 and 44.5 years, respectively, and mean BMIs were 47.3 kg/m² and 45.9 kg/m², respectively. The unadjusted mortality rate was significantly higher for same-day compared with POD1 discharge (0.94% vs. 0.05%, respectively; p = 0.0017). Compared with POD1 discharge, same-day discharge had higher overall morbidity (3.76% vs 1.54%; adjusted odds ratio [AOR] 2.41; p = 0.0216), but no statistically significant differences for readmissions (3.45% vs. 3.66%; AOR 0.85; p = 0.9999) or reoperations (1.88% vs. 0.89%; AOR 2.33; p = 0.2428).

CONCLUSIONS

Same-day discharge after LRYGB is associated with increased morbidity and mortality compared with POD1 discharge. The practice of same-day discharge after LRYGB should be considered experimental until further studies confirm which patient characteristics will ensure safe same-day discharge.

Experience with an Enhanced Recovery After Surgery (ERAS) Program for Bariatric Surgery: Comparison of MGB and LSG in 374 Patients

BACKGROUND

Strategic multidisciplinary protocols for "enhanced recovery after surgery" (ERAS) have demonstrated reductions in length of hospital stay (LOS), morbidity, and costs in conjunction with bariatric procedures.

METHODS

We prospectively investigated the effectiveness and safety of an ERAS protocol with laparoscopic omega loop gastric bypass ("mini" gastric bypass, MGB) and LSG in morbidly obese patients.

RESULTS

Average LOS was 1.24 days (range 1-14); 86.1% discharged on day 1; 96.9% by day 2, a value comparable or better than that of other ERAS studies vs standard care according to meta-analysis. Complications 2.9%; readmission 2.1%; reintervention 1.3%.

CONCLUSION

The program was equally safe with both procedures. Postoperative antithrombotic heparin does not appear necessary in low-risk patients. Bariatric surgical ERAS programs are evolving and not yet standardized.

The impact of fast track protocols in upper gastrointestinal surgery: A meta-analysis of observational studies

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.

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

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

The Development of Enhanced Recovery After Surgery Across Surgical Specialties

BACKGROUND

Enhanced recovery after surgery (ERAS^®) principles have gained traction in variety of surgical disciplines. The promise of a reduced length of stay without compromising patient safety or increasing readmission rates has produced a body of literature examining the implementation of ERAS in the care of general, thoracic, urologic, and gynecologic surgery patients.

METHODS

We performed a review of the literature pertaining to studies of ERAS implementation across colorectal surgery, general surgery, thoracic surgery, urology, and gynecology. The extent of ERAS implementation and reported outcomes across key studies as well as systematic reviews and meta-analyses in each field were summarized.

RESULTS

The implementation of ERAS protocols has not been uniform across surgical specialties. Despite this, ERAS has produced improvements in patient outcomes. The most commonly described benefit of ERAS application has been reduced length of stay; complication and readmission rates are most consistently decreased in the colorectal literature. Studies have started to measure more nuanced measures of postoperative patient well-being. Efforts are growing to standardize ERAS protocols across diverse fields and call attention to the need for quality control.

CONCLUSIONS

Challenges remain in the study and execution of ERAS. Controlling for adherence to ERAS components and implementing uniform ERAS protocols across studies are burgeoning topics that have significant implications for study design. The practice of ERAS and its benefits to patients are expected to evolve. Assessing improvements in postdischarge quality of life, timing of return to work and independent living, and adherence to scheduled delivery of adjuvant treatments will strengthen future ERAS investigations.