How can lean thinking improve ERAS program in bariatric surgery?

More procedures, more efficiency: optimizing operating room during the phase of learning curve-experience of first 100 robotic bariatric procedures in a single center

Robotic bariatric surgery (RBS) is increasingly adopted worldwide. This study aims to evaluate the implementation and evolution of RBS at a high volume center over five years, focusing on operative time (OT), operating room (OR) efficiency, and cost outcomes. A prospective analysis was conducted on patients undergoing elective RBS between July 2021 and March 2025 at ARNAS G. Brotzu, Cagliari. Metrics included OT, OR session time, and surgical volume. Variables analyzed included OT, OR session time, and surgical volume. Efficiency metrics such as overall OR efficiency, defined as OR session time/OT (Eff1), and robotic console utilization, defined as OR session time/console time (Eff2) were derived. Cost analysis incorporated OR activation time, surgeon and material costs. Statistical analyses included t-tests, Pearson's correlation, and linear regression. 100 robotic-assisted procedures were recorded. Robotic adoption increased from 4.06% in 2021 to 38.98% in 2025. A learning curve (LC) was identified, with a significant OT reduction after the first 34 Roux-en-Y gastric bypass cases (p = 0.001). Full robotic manual anastomosis showed a notable cost decrease in later cases (p < 0.0001). Increased surgical volume correlated with both reduced OT (r = - 0.58) and improved Eff1 (r = - 0.49, p = 0.005). However, Eff2 changes were not statistically significant (r = - 0.31, p = 0.09), underscoring the need for team-wide coordination. RBS in high-volume centers enhance OR efficiency and cost-effectiveness over time. The LC, surgical volume, and institutional workflows were key factors in optimizing efficiency, highlighting the importance of a collective LC for the entire surgical team.

What affects operating room turnover time? A systematic review and mapping of the evidence

BACKGROUND

The operating room environment is a complex system associated with high operating costs and requires careful management to optimize patient outcomes and productivity. One of the most studied metrics of operating room efficiency is turnover time. This study systematically reviews mutable factors associated with improvements in operating room turnover time.

METHODS

In accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we identified observational and interventional approaches analyzing an association between a mutable factor and operating room turnover time (defined as the time between closure and next incision on the subsequent patient). We defined mutable factors as any generalizable element of the operating room environment amenable to change with intervention. Each study was categorized by the type of mutable factor and specific phase of turnover time affected.

RESULTS

Of 1,507 studies identified, 551 underwent abstract review with 105 meeting eligibility for this systematic review. There were 136 unique analyses of a relationship between a mutable factor and operating room turnover time. The mutable factors analyzed in these studies varied widely, including changes in anesthetic approach, communication/goal setting, allied health staff, artificial intelligence/information technology, operating room management, setup standardization, prearrival optimization, and operating room type. The analyzed literature showed the potential for mutable factors in each of these domains to improve operating room efficiency by reducing turnover time.

CONCLUSION

Operating room efficiency is critical to the financial health and success of a hospital. This review organizes a large body of information relating to turnover time with an approach that can guide scientists and leaders interested in operating room efficiency. The most impactful areas discovered were related to parallel processing, team dynamics, and a "focused factory" approach.

Exploring the incidence and influencing factors of postoperative nausea and vomiting after laparoscopic bariatric surgery: a protocol for a retrospective observational study

INTRODUCTION

The global prevalence of obesity and its associated comorbidities is rising, with bariatric surgery emerging as a highly efficacious intervention for obese patients. Postoperative nausea and vomiting (PONV) is a common complication following bariatric surgery, with a standardised protocol for its prevention and management yet to be established. This study aims to determine the incidence and the influencing factors of PONV following various types of bariatric surgeries, thereby facilitating the targeted prevention strategies.

METHODS AND ANALYSIS

This retrospective, single-centre observational study will be conducted at the Third People's Hospital of Chengdu, with an expected enrolment of 2500 patients who have undergone laparoscopic bariatric surgery from December 2019 to April 2024. The study aims to collect data regarding the incidence of PONV and analyse the potential risk and protective factors associated with its development in this patient population.

ETHICS AND DISSEMINATION

The study has been approved by the ethics committees of the Third People's Hospital of Chengdu. Given the retrospective nature of the study, informed consent was waived by the ethics committee, and all patient data were anonymised to safeguard privacy prior to the study authors' visit. The results of this study will be presented at various academic and healthcare conferences, spanning local to international levels and will also be submitted for publication in reputable, peer-reviewed journals.

TRIAL REGISTRATION NUMBER

This study has been registered with the Chinese Clinical Trial Register (ChiCTR) under registration number ChiCTR2400088738.

Qualitative and Economic Impact of Standardized and Digitalized Operation Room Processes in Obesity Surgery

PURPOSE

The introduction of innovative digital solutions in healthcare lags compared to other industries but promises high potential to create value in efficiency and quality. Increasing economic pressure forces hospitals to optimize operating room (OR) processes, in which such solutions might provide additional support.

MATERIALS AND METHODS

This retrospective case-control and monocentric study investigated if digitalized and standardized intraoperative surgical workflows of laparoscopic Roux-en-Y gastric bypass (LRYGB) have a significant impact on efficiency, quality, and economics. Logistic and linear regression models were used to apply propensity score matching (PSM) for efficiency and odds ratio for the quality analysis.

RESULTS

The study included 49 patients per group. The results demonstrate a significant increase in efficiency and cost-effectiveness in the treatment group. Length of stay (LoS) was 1.2 days less than in the control group (5.6 vs. 4.4). The mean of total OR and skin-to-skin time increased by 3.7% (142.00 vs. 136.80) and 8.5%, respectively (93.88 vs. 85.94). The standard deviation (SD) of total OR and skin-to-skin time decreased by 7.36 min (26.86 vs. 34.22) and 8.98 min (23.20 vs. 32.18) in the treatment group. The results of the odds ratio did not provide any conclusions on quality. Overall, costs were reduced by 318 € per patient and total revenue improved by 10,073 €.

CONCLUSION

The implementation of digital workflow management systems in obesity surgery improves economic efficiency. Hospital management and payors should evaluate further support in research of the digitization of the OR, followed by reimbursement to increase and facilitate the accessibility to digital support systems.

The paradox of Zeno in bariatric surgery weight loss: Superobese patients run faster than morbidly obese patients, but can't overtake them

Introduction

Superobesity (SO) is defined as a BMI > 50 Kg/m², and represents the extreme severity of the disease, resulting in a challenge for the surgeons.

Methods

In this retrospective study we aimed to compare the outcomes of SO patients compared to morbidly obese (MO) patients.

Results

We included in this study 154 MO patients, with a median preoperative BMI of 40.8 kg/m², and 19 SO patients with median preoperative BMI of 54.9 kg/m². The MO patients underwent sleeve gastrectomy (SG) in 62 (40.3%) cases, laparoscopic Roux-and-Y gastric bypass (LRYGBP) in 85 (55.2%) cases and One-Anastomosis Gastric Bypass (OAGB) in 7 (4.5%) cases. underwent OAGB. The patients in the SO group were submitted to SG in 11 (57.9%) cases, LRYGBP in 5 (26.3%) cases, and OAGB in 3 (15.8%). At 24-month follow-up, an excess weight loss (EWL) >50% was achieved in 129 (83.8%) patients in the MO group and in 15 (78.9%) in the SO group (p = 0.53). A BMI < 35 kg/m² was achieved in 137 (89%) patients in the MO group and from 8 (42.2%) patients in the SO group (p < 0.001). The total weight loss was significantly directly related to the initial BMI. Superobesity was identified as independent risk factor for surgical failure when considering the outcome of BMI < 35 kg/m².

Discussion

Our study confirms that, although SO patients tend to gain a greater weight loss than MO patients, they less frequently achieve the desired BMI target. In this setting, it should be necessary to re-consider malabsorptive procedures as first choice.

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.

Nutritional Management in Bariatric Surgery Patients

The obesity epidemic, mainly due to lifestyle changes in recent decades, leads to serious comorbidities that reduce life expectancy. This situation is affecting the health policies of many nations around the world. Traditional measures such as diet, physical activity, and drugs are often not enough to achieve weight loss goals and to maintain the results over time. Bariatric surgery (BS) includes various techniques, which favor rapid and sustained weight loss. BS is a useful and, in most cases, the best treatment in severe and complicated obesity. In addition, it has a greater benefit/risk ratio than non-surgical traditional therapies. BS can allow the obese patient to lose weight quickly compared with traditional lifestyle changes, and with a greater probability of maintaining the results. Moreover, BS promotes improvements in metabolic parameters, even diabetes remission, and in the quality of life. These changes can lead to an increase of life expectancy by over 6 years on average. The nutrition of people before and after BS must be the subject of indications from a trained staff, and patients must be followed in the subsequent years to reduce the risk of malnutrition and the associated problems. In particular, it is still debated whether it is necessary to lose weight prior to surgery, a procedure that can facilitate the surgeon's work reducing the surgical risk, but at the same time, lengthens preparation times increasing the risks associated with concomitant pathologies. Furthermore, preventing nutritional deficiencies prior to the intervention can improve the results and reduce short- and long-term mortality.