Less pain and earlier discharge after implementation of a multidisciplinary enhanced recovery after surgery (ERAS) protocol for laparoscopic sleeve gastrectomy

Reducing Opioid Consumption and Length of Stay After Bariatric Surgery: A Nonpharmacologic ERAS Intervention Bundle

PURPOSE

To reduce opioid consumption and decrease length of stay (LOS) in bariatric surgical patients by implementing an evidence-based, nonpharmacologic enhanced recovery after surgery (ERAS) intervention bundle.

DESIGN

Evidence-based practice project.

METHODS

We developed and implemented a nonpharmacologic ERAS bundle from existing American Society of PeriAnesthesia Nurses Standards and bariatric and subspecialty surgical ERAS protocols to standardize the postoperative nursing care of bariatric patients. The bundle consisted of early ambulation, immediate initiation and prolonged use of oxygenation, prevention of nausea and vomiting, frequent use of incentive spirometry, and application of ice packs to surgical sites. The two project outcomes were opioid consumption and patient LOS. We used descriptive statistics to summarize opioid consumption and LOS among surgical bariatric patients at baseline and post intervention and independent samples t tests to determine the statistical significance of pre- or post-LOS changes.

FINDINGS

After implementing the ERAS bundle in 31 bariatric surgical patients, we found that the percentage of patients given an opioid substantially decreased by 13.8%, with both fentanyl and hydromorphone (Dilaudid) consumption meaningfully decreasing by 11.0% and 25.6%, respectively. The average LOS significantly decreased (P = .015) by 23 minutes per patient following the intervention, from 1 hour and 58 minutes to 1 hour and 35 minutes, representing a 19.5% reduction in total patient time in the PACU.

CONCLUSIONS

Use of a nonpharmacologic ERAS bundle and standardizing postoperative care decreased overall PACU bariatric surgical patient opioid consumption and significantly reduced PACU LOS. Optimizing pain management for bariatric patients in the PACU could lead to improved pain control and reduced reliance on opioids during their entire hospital stay, enhancing health care outcomes and improving patient safety. Perioperative leaders and educators can use our example to develop initiatives that decrease opioid use and LOS to improve care for the high-acuity bariatric patient population.

Regional anaesthesia for postoperative pain management following laparoscopic, visceral, non-oncological surgery a systematic review and meta-analysis

BACKGROUND

Postoperative pain management following laparoscopic, non-oncological visceral surgery in adults is challenging. Regional anaesthesia could be a promising component in multimodal pain management.

METHODS

We performed a systematic review and meta-analysis with GRADE assessment. Primary outcomes were postoperative acute pain intensity at rest/during movement after 24 h, the number of patients with block-related adverse events and the number of patients with postoperative paralytic ileus.

RESULTS

82 trials were included. Peripheral regional anaesthesia combined with general anaesthesia versus general anaesthesia may result in a slight reduction of pain intensity at rest at 24 h (mean difference (MD) - 0.72 points; 95% confidence interval (CI) - 0.91 to - 0.54; I2 = 97%; low-certainty evidence), which was not clinically relevant. The evidence is very uncertain regarding the effect on pain intensity during activity at 24 h (MD -0.8 points; 95%CI - 1.17 to - 0.42; I2 = 99%; very low-certainty evidence) and on the incidence of block-related adverse events. In contrast, neuraxial regional analgesia combined with general anaesthesia (versus general anaesthesia) may reduce postoperative pain intensity at rest in a clinical relevant matter (MD - 1.19 points; 95%CI - 1.99 to - 0.39; I2 = 97%; low-certainty evidence), but the effect is uncertain during activity (MD - 1.13 points; 95%CI - 2.31 to 0.06; I2 = 95%; very low-certainty evidence). There is uncertain evidence, that neuraxial regional analgesia combined with general anaesthesia (versus general anaesthesia) increases the risk for block-related adverse events (relative risk (RR) 5.11; 95%CI 1.13 to 23.03; I2 = 0%; very low-certainty evidence).

CONCLUSION

This meta-analysis confirms that regional anaesthesia might be an important part of multimodal postoperative analgesia in laparoscopic visceral surgery, e.g. in patients at risk for severe postoperative pain, and with large differences between surgical procedures and settings. Further research is required to evaluate the use of adjuvants and the additional benefit of regional anaesthesia in ERAS programmes.

PROTOCOL REGISTRATION

PROSPERO CRD42021258281.

Postoperative virtual reality for recovery after bariatric surgery: study protocol for a randomised clinical trial

Background

Enhanced Recovery After Surgery (ERAS) protocols for bariatric surgery improve clinical outcomes. However, the impact of ERAS protocols on patient satisfaction is unknown. Virtual reality has been implemented as an effective adjunct to standard analgesic regimens. This study seeks to find out if immersive virtual reality in the immediate postoperative period could improve the subjective quality of recovery and further reduce opioid requirements for bariatric surgery patients compared with ERAS care alone.

Methods

This is a single-centre, randomised clinical trial of patients recovering from laparoscopic bariatric surgery. Once in the post-anaesthesia care unit (PACU), participants will receive either an immersive virtual reality plus ERAS protocol or ERAS protocol alone. The primary outcome will be the Quality of Recovery-15 (QoR-15) score at PACU discharge. Secondary outcomes include PACU opioid requirements, length of PACU stay, PACU pain scores, QoR-15 score on postoperative day 1, hospital length of stay, opioid requirements, and opioid-related adverse effects until hospital discharge.

Conclusions

Positive findings from this study could introduce virtual reality as a non-pharmacological adjunct during PACU care that improves subjective recovery for patients undergoing bariatric surgery.

Clinical trial registration

NCT04754165.

Ultrasonography Guided Modified BRILMA (Blocking the Cutaneous Branches of Intercostal Nerves in the Middle Axillary Line) Block in Bariatric Surgery

Background: Postoperative pain is one of the major problems after laparoscopic sleeve gastrectomy besides complications. Management of pain control is still unclear in the obese population. Modified BRILMA (blocking the cutaneous branches of intercostal nerves in the middle axillary line) is a new analgesia technique which is performed by ultrasonography guided through the way between eighth and ninth rib level. This study is to evaluate the efficiency of modified BRILMA in bariatric patients while comparing with trocar site infiltration. Materials and Methods: This is a prospective designed retrospective data analysis study. Patients undergoing laparoscopic sleeve gastrectomy between June 2019 and January 2020 were divided into two groups. One group underwent BRILMA block; the other group used traditional trocar site injection. Postoperative pain was followed by using visual analogue scale (VAS) (at 1, 3, 6, 12, 24, 36, 48 hours postoperatively). Results: Thirty patients were included in the study. Twenty-four (80%) of the patients were women, and 6 (20%) of the patients were men. Mean body mass index of patients were 39.83 ± 4.02 kg/m2. Mean operational time was calculated 86.16 ± 19.94 minutes. When the patients' VAS was compared, 12th hour VAS value was statistically less in the BRILMA group. There were no significant differences in other hours' VAS between two groups. When compared with the use of opioid amount, there were no statistically significant difference between the two groups (P = .66), but BRILMA group had less amount. Conclusion: Modified BRILMA is an alternative technique to the use of trocar site bupivacain injection in bariatric surgery. It is new technique that is tried in bariatric population, which is also cost-effective and has less opioid consumption.

Evaluation of Postoperative Care Protocol for Roux-en-Y Gastric Bypass Patients with Same-Day Discharge

INTRODUCTION

Same-day discharge (SDD) after bariatric surgery is increasingly being performed and is safe with careful patient selection. However, detecting early complications during the first postoperative days can be challenging. We developed a postoperative care protocol for these patients and aimed to evaluate its effectiveness in detecting complications and monitoring patient recovery.

METHODS

A single-center retrospective observational study was conducted with patients with who underwent Roux-en-Y Gastric Bypass (RYGB) with successful SDD. The study evaluated the effectiveness of the safety net that included simple remote monitoring with a pulsoximeter and thermometer, a phone consultation on postoperative day (POD) 1, and a physical consultation on POD 2-4. Furthermore, an analysis was performed on various factors including pain scores, painkiller usage, and incidences of nausea and vomiting on POD 1.

RESULTS

In this study, 373 consecutive patients were included, of whom 19 (5.1%) were readmitted until POD 4. Among these, 12 patients (3.2%) reached out to the hospital themselves, while 7 (1.9%) were readmitted after phone or physical consultations. Ten of the readmitted patients had tachycardia. On POD 1, the mean numeric rating scale was 4 ± 2, and 96.6% of the patients used acetaminophen, 35.5% used naproxen, and 9.7% used oxynorm. Of the patients, 13.9% experienced nausea and 6.7% reported vomiting.

CONCLUSION

A postoperative care protocol for SDD after RYGB, comprising simple remote monitoring along with a phone consultation on POD 1 and a physical checkup on POD 2-4, was effective in monitoring patient recovery and detecting all early complications.

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.

Short-Term Outcomes of Enhanced Recovery after Surgery (ERAS) for Ankle Fracture Patients: A Single-Center Retrospective Cohort Study

OBJECTIVE

Enhanced recovery after surgery (ERAS) has been successfully adopted for the improvement of medical quality and efficacy in many diseases, but the effect thereof for ankle fracture patients can vary. The aim of the present study was to explore the short-term postoperative outcomes of ERAS among ankle fracture patients.

METHODS

The present study was a retrospective cohort study conducted between January 2019 and May 2019. One hundred and sixty ankle fracture participations (58 males and 102 females, aged 41.71 ± 14.51 years) were included. The participants treated with open reduction and internal fixation were divided into two groups (non-ERAS vs. ERAS) depending on whether ERAS was applied. Postoperative outcomes included American Orthopedic Foot and Ankle Society (AOFAS) score, length of stay (LOS), hospital cost, complications, and consumption of opioids. To assess the association between the groups and outcomes, generalized estimating equation (GEE) modeling and multivariable linear regression analysis were performed.

RESULTS

The average follow-up periods of the participations were 24 months postoperatively. No significant differences were detected between the non-ERAS group and ERAS group with respect to the demographic of patients in terms of gender, age, Danis-Weber classification of fracture, dislocation of ankle joint, and comorbidity (P > 0.05). Significant differences in terms of a higher AOFAS score were found in the ERAS group compared with the non-ERAS group (6.73, 95% CI, 5.10-8.37, p < 0.001) at 3 months postoperatively (PO3M) and (4.73, 95% CI, 3.02-6.45, p < 0.001) at 6 months postoperatively (PO6M). However, similar AOFAS scores were found at 12 months postoperatively (PO12M) (0.28, 95% CI, -0.32 to 0.89, P > 0.05) and at 24 months postoperatively (PO24M) (0.56, 95% CI, -0.07 to 1.19, P > 0.05). Additionally, the GEE analysis and group-by-time interaction of AOFAS score revealed that the ERAS protocol could facilitate faster recovery for ankle fracture patients, with higher PO3M and PO6M (both P < 0.05). At the same time, significant differences in terms of a shorter length of stay (-3.19, 95% CI, -4.33 to -2.04, P < 0.01) and less hospital cost (-6501.81, 95% CI, -10955.21 to -2048.42, P < 0.01) were found in the ERAS group compared with the non-ERAS group.

CONCLUSION

By reducing LOS and hospital cost, the ERAS protocol might improve the medical quality and efficacy. The present study can provide a realistic evaluation and comparison of the ERAS protocol among ankle fracture patients, and ultimately guide clinical decision making.

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.

Perioperative pain management based on enhanced recovery after surgery in children undergoing adenotonsillectomy: A prospective, randomized controlled trial

Background

Pain management, as a key component of enhanced recovery after surgery (ERAS), can effectively relieve perioperative pain and anxiety. However, there are few studies on the application of pain management based on ERAS in pediatric surgery patients. We aimed to examine the effect of ERAS-based perioperative pain management in children with obstructive sleep apnea (OSA) undergoing adenotonsillectomy.

Methods

From March 2021 to July 2021, a randomized controlled single-blind study was conducted on children with OSA and scheduled to undergo adenotonsillectomy. The children were randomly assigned to either control group (n = 60) or ERAS group (n = 60). Traditional analgesia measures were provided to children in the control group, whereas ERAS-based optimized analgesia measures were provided to children in the ERAS group. The pain scores, anxiety scores and diet quality scores were compared between the two groups.

Results

The pain scores after surgery in the ERAS group were significantly lower than those in the control group at 6 h, 1 day, 3 days, and 5 days after surgery. Furthermore, the diet quality scores in the ERAS group were significantly higher than those in the control group at 6 h, 1 day, 3 days, and 5 days after surgery. The anxiety scores after surgery in the ERAS group were significantly lower than those in the control group.

Conclusions

Perioperative pain management based on ERAS can significantly alleviate postoperative pain, improve quality of life, and promote the accelerated rehabilitation of children with OSA undergoing adenotonsillectomy.

Level of evidence

1.

Pre-incisional Laparoscopic Preperitoneal Local Anesthetic Technique in Laparoscopic Sleeve Gastrectomy

Background:

The increasing prevalence of obesity is a significant concern worldwide. Laparoscopic sleeve gastrectomy (LSG) is an effective and standard procedure for sustained weight loss. However, optimal pain control is essential for enhanced recovery after surgery. The aim of this randomized controlled study was to investigate the efficacy of a pre-incisional laparoscopic preperitoneal local anesthetic technique (PLPLAT) on recovery characteristics following LSG.

Methods:

A total of 120 obese patients scheduled to undergo LSG were randomized into the PLPLAT or placebo group (n = 60 patients in both groups). All patients received conventional intravenous or other analgesics postoperatively, as required. The primary outcome was the postoperative pain score. The secondary outcomes included morphine consumption, other analgesics, length of stay in the postanesthesia care unit (PACU), hemodynamic changes, postoperative nausea and vomiting (PONV), early mobilization, and length of hospital stay.

Results:

Pain scores in the PACU and at 12 hours after surgery in the ward were significantly lower in the PLPLAT group than in the placebo group (P < 0.05). The morphine consumption was significantly less in PLPLAT group with mean dosage of 2.95 mg (± 0.39) compared to 6.0 mg (± 0.4) in placebo group. PONV, mean arterial pressure, and PACU stay were significantly higher in the placebo group than in the PLPLAT group (P < 0.05).

Conclusion:

Intraoperative PLPLAT provide effective postoperative pain relief for patients undergoing LSG. The findings indicated the efficacy of PLPLAT in reducing postoperative pain, enhancing recovery, and facilitating early discharge.

Immediate postoperative pain does not predict pain at home after ambulatory single-port sleeve gastrectomy

PURPOSE

Single-port sleeve gastrectomy (SPSG) is increasingly performed in an ambulatory setting. Pain intensity when returning home remains a problem. The challenge is to be able to predict the evolution of postoperative pain (POP) at home by using parameters collected during the hospital stay. This study aimed to investigate whether immediate POP in the postanesthesia care unit (PACU) can predict pain intensity 24 h after surgery.

METHODS

Single-center retrospective study in patients with obesity who underwent ambulatory SPSG. POP and opiate requirements during PACU stay were registered. Patients were followed up at home during the first 4 postoperative days. The primary outcome was the correlation between opiate requirements in the PACU and Numerical Rating Scale (NRS) at home 24 h after surgery. Secondly, logistic regression was used to identify risk factors for moderate/intense pain 24 h after surgery.

RESULTS

Ninety-four patients were included during the study period. Twenty-two patients had NRS > 3/10 24 h after surgery. No correlation was found between the total dose of morphine in the PACU and pain intensity 24 h after surgery (r² =  - 0.07; P = 0.49). No predictive factor for moderate/intense pain 24 h after surgery was found.

CONCLUSION

No correlation was found between opiate requirements in the PACU and pain at home 24 h after SPSG. Based on these results, it does not seem possible to predict intense pain at home from pain profile and morphine requirement during the immediate postoperative period.

Trends, Outcomes, and Impact of Early Discharge Following Bariatric Surgery: a Retrospective MBSAQIP Analysis of 748,955 Patients

INTRODUCTION

Decreasing the length of stay following bariatric surgery can reduce pressure on hospitals and surgical costs and increase patient satisfaction. We examine trends in length of hospital stay following bariatric surgery and in post-operative complications.

METHODS AND PROCEDURES

The 2015-2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was used to compile patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy. Patients were categorized into either early discharge (within one day of surgery) or late discharge, and patient and non-patient factors were compared between the two groups. A multivariable logistic regression was carried out to determine predictive factors for early discharge.

RESULTS

We evaluated 748,955 patients, with 399,918 (53%) being discharged early. Patients discharged early were younger and had fewer associated medical problems. The rate of early discharge increased between 2015 and 2019 (42.1% in 2015 vs 62.0% in 2019), while complication rates decreased or were unchanged. Multivariable analysis revealed lower ASA classification (OR 1.07; CI 1.06-1.09; p < 0.0001) and operative year (2019 vs. 2015 OR 2.26; CI 2.22-2.29; p < 0.0001) to be independently associated with early discharge. Several factors including undergoing RYGB (OR 0.44 CI 0.44-0.45; p < 0.0001), and dialysis dependence (OR 0.50; CI 0.45-0.55; p < 0.0001) among others, were associated with reduced early discharge likelihood.

CONCLUSIONS

There is a trend in bariatric surgery towards the practice of early discharge, which is safe for patients. Further work is needed to develop a set of criteria to determine which patients are best suited for this practice.

Patients Older Than 75 Years Undergoing Polysegmental Lumbar Fusion Surgery Can also Benefit from Enhanced Recovery After Surgery Program

Purpose

To compare pain scores (visual analog scale) on postoperative days 1–3 and length of stay after implementing enhanced recovery after surgery (ERAS) in elderly patients undergoing multi-segments lumbar fusion surgery.

Methods

We performed a retrospective analysis of prospectively collected data, patients older than 75 years were enrolled in the study. We selected two periods, before (Pre-ERAS, n =54 patients) and after (ERAS, n =46 patients) implementation of ERAS. Data were collected on patient demographics, operative and perioperative details, 30-day readmission. The primary outcome was the length of stay (LOS), and the secondary outcomes were postoperative mean pain scores on postoperative days (POD) 1–3 and 30-day readmission rates.

Results

A total of 100 patients (46 in ERAS and 54 in pre-ERAS) were enrolled in this study. There were no significant differences in age, sex, body mass index (BMI), smoking and comorbidities between the groups. However, there was a significant difference in pain on postoperative day (POD) 1 (5.31 ± 1.98 vs 4.37 ± 0.85, p = 0.002), while there was no difference in postoperative complications. The mean LOS was significantly shorter in the ERAS than in the pre-ERAS group, it reduced from 12.29 ± 3.93 to 9.45 ± 2.72 days (p < 0.001).

Conclusion

To our knowledge, this is the first ERAS protocol used in patients (older than 75 years) undergoing polysegmental lumbar fusion surgery. Pain scores on POD 1 and LOS were significantly lower without increased adverse events after implementation of ERAS. This finding suggests that elderly people (>75 years of age) undergoing polysegmental lumbar fusion surgery could also benefit from ERAS.

Prophylactic Administration of Diphenhydramine/Acetaminophen and Ondansetron Reduced Postoperative Nausea and Vomiting and Pain Following Laparoscopic Sleeve Gastrectomy: a Randomized Controlled Trial

PURPOSE

Postoperative nausea and vomiting (PONV) and pain following bariatric surgery are problematic and affect the outcome of patients. Intraoperative multimodal antiemetic prophylaxis is essential to improve postoperative outcomes. This study investigated the effect of adding diphenhydramine to acetaminophen and ondansetron in reducing postoperative nausea and vomiting and pain following laparoscopic sleeve gastrectomy (LSG).

MATERIALS AND METHODS

Eighty-two patients scheduled for LSG were assigned to receive a single preinduction dose of diphenhydramine 0.4 mg/kg VI (D group) in addition to acetaminophen 1g and ondansetron 4 mg IV at the end of surgery and just acetaminophen 1 g and ondansetron 4 mg IV (C group) in a randomized, double-blind trial. PONV was assessed in recovery and 24 hours after surgery in the ward. Postoperative pain, analgesic requirements, and patients' level of sedation were also assessed.

RESULTS

The PONV rates in the recovery of the D group and the C group were 30% and 56% (P = .001). It also had a more significant reduction in the D group than in the C group in the first 24 h after surgery (40% vs. 66%). The severity of pain score and level of sedation and analgesic requirements was significantly reduced in this period in the D group.

CONCLUSION

Prophylactic diphenhydramine 0.4 mg/kg at the induction of general anesthesia in combination with acetaminophen 1 g and ondansetron 4 mg at the end of surgery reduced the incidence of PONV and postoperative severity of pain in laparoscopic sleeve gastrectomy.

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.

Predictive factors for opioid-free management after robotic radical prostatectomy: the value of the SP® robotic platform

BACKGROUND

The aim of this study was to evaluate perioperative factors associated with opioid-free management after robotic radical prostatectomy in a single institution.

METHODS

From January 2019 to January 2020, data from patients who underwent robotic radical prostatectomy was retrospectively entered in a preapproved IRB database. Data were analyzed according to the postoperative opioid administration in hospital and/or after discharge. Robotic radical prostatectomy was performed using either the standard multi-port Da Vinci Si robotic platform with a transperitoneal approach (MP-RALP) or the novel DaVinci SP^® robotic platform (Intuitive Surgical, Inc., Sunnyvale, CA, USA) with an extraperitoneal approach (SP-EPP). Patients undergoing minimally invasive surgery were included in the "enhanced recovery after surgery" (ERAS) protocol regardless of the surgery approach.

RESULTS

During the study period, 210 patients matched the selection criteria. Of those, 158(75%) patients received opioids during the hospital stay or after discharge and 52(25%) patients never received opioids. SP-EPP surgical approach and shorter LOS were predictors of never receiving opioids (Odds Ratio [OR]=4.97, (95% CI 1.81-14.77, P=0.002 and OR=0.56, CI 95% 0.35-0.86, P=0.011, respectively). SP-EPP surgical approach was increasing the odds of remaining opioid free whether in-hospital or after discharge (OR= 11.97, 95% CI 4.8-32, P<0.0001 and OR=11.6, 95% CI 4.6-31, P<0.0001, respectively). Finally, a high BMI increased the odds of receiving opioid in hospital or after discharge (OR=0.89, 95% CI 0.82-0.96, P=0.003 and OR=0.89, 95% CI 0.82-0.96, P=0.002, respectively).

CONCLUSIONS

In this series, after robotic radical prostatectomy the use of a less invasive approach (SP-EPP), a shorter LOS and a lower BMI, were predictive of opioid-free status.

The Analgesic Efficacy of Transversus Abdominis Plane Block After Bariatric Surgery: a Systematic Review and Meta-analysis with Trial Sequential Analysis

The transversus abdominis plane (TAP) block has been used to relieve pain after bariatric surgery but with conflicting data on its analgesic efficacy. We conducted this systematic review and meta-analysis with trial sequential analysis to clarify whether TAP block provides effective postoperative analgesia in patients undergoing bariatric surgery. We systematically searched the literature for any trials comparing TAP block with a control group (no block or sham injection). The primary outcome was pain scores at rest (analog scale, 0-10) at 2 postoperative hours. Secondary pain-related outcomes included pain scores at rest at 12 and 24 h and both dynamic pain scores and intravenous morphine equivalent consumption at 2, 12 and 24 h. Additional secondary outcomes sought were rates of postoperative infection, haematoma, visceral injury and local anaesthetic systemic toxicity. Thirteen trials totalling 1025 patients were identified. Pain scores at rest at 2 postoperative hours were significantly lower in the TAP block group compared with the control group, with a mean (95% CI) difference of - 1.8 (- 2.5, - 1.1); I2 = 85%; p < 0.00001. All other secondary pain-related outcomes were also significantly lower in the intervention group with the exception of dynamic pain scores and intravenous morphine equivalent consumption at 2 postoperative hours. Rates of block-related complications were not significantly different between groups. The overall quality of evidence was moderate-to-low. There is moderate-to-low level evidence that the TAP block improves postoperative analgesia after bariatric surgery up to 24 postoperative hours, when compared with a control group, without major reported complications. Clinical Trial NumberPROSPERO - registration number: CRD42019136542.