Enhanced recovery after bariatric surgery (ERABS) in a high-volume bariatric center

Is it Safe to Perform Concomitant Cholecystectomy in Patients With Confirmed Gallbladder Disease Undergoing Metabolic and Bariatric Surgery? An Updated Meta-Analysis

INTRODUCTION

Obesity is a global public health issue, and metabolic and bariatric surgery (MBS) remains most effective intervention for achieving and maintaining long-term weight loss. However, rapid weight loss following MBS increases the risk of gallstone formation. Concomitant cholecystectomy (CC) during MBS has been proposed to mitigate this risk, but recent studies present conflicting evidence regarding its safety and efficacy, leaving no clear consensus.

METHODS

We conducted a meta-analysis by systematically searching MEDLINE, Cochrane Central, Embase, and ClinicalTrials.gov for studies comparing CC plus BS versus BS alone. Odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Statistical analyses were performed with Review Manager v5.4 and RStudio v4.3.3.

PROSPERO ID

CRD42023480360.

RESULTS

We included 26 studies encompassing 656,830 patients with confirmed gallstones, among whom 34,409 (5.2%) underwent CC.The mean age was 41.5 years, and 79.2% were female. Patients undergoing CC + MBS had increased postoperative bleeding (OR 1.31; 95% CI 1.06-1.62; p = 0.01), wound complications (OR 1.61; 95% CI 1.34-1.95; p < 0.01), respiratory complications (OR 1.49; 95% CI 1.13-1.95; p < 0.01), and anastomotic complications (OR 1.86; 95% CI 1.28-2.70; p < 0.01). No significant differences in operation time, rates of postoperative mortality, length of hospital stay, and vein thrombosis were found between groups.

CONCLUSION

CC during MBS increases operative time and postoperative complications, though only anastomotic complications are clinically significant. Therefore, CC should be reserved for high-risk or symptomatic patients and avoided in bariatric procedures involving an anastomosis due to the elevated risk of complications.

Postoperative care pathways for patients following coronary artery bypass grafting surgery: An observational study

AIMS

The aim of this study was to describe the postoperative care pathway, with phase 1 cardiac rehabilitation (CR) delivery, for adult patients following coronary artery bypass grafting (CABG) surgery at one large hospital in Queensland, Australia.

DESIGN AND METHODS

This observational study involved structured observations, patient electronic medical record audits, and field notes to gather postoperative data. Four continuous hours of patient and healthcare professional (HCP) observations gathered at 30-min intervals occurred on 12 separate days over a 1-month period (February-March 2023). We observed post-CABG patients and HCPs involved in delivering direct care. Data were gathered on the clinical care, timing, delivery mode, and education content.

RESULTS

Ten post-CABG patients and nine HCPs were observed. Postoperative care delivered by HCPs focussed on clinical care tasks and patient education activities. Patients participated in education focussed on respiratory exercises, wound care, anticoagulant therapy, and thromboembolic deterrent education. HCPs discussed pain management with two patients.

CONCLUSION

Education was the primary strategy delivered by HCPs to CABG patients during the postoperative care pathway and phase 1 CR; however, many patients were overwhelmed by the complicated information they received. Opportunities exist to improve the postoperative care pathway with phase 1 CR delivery by developing patient-centred education interventions.

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.

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

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

Fully ambulatory robotic single anastomosis duodeno-ileal bypass (SADI): 40 consecutive patients in a single tertiary bariatric center

BACKGROUND

Single Anastomosis Duodeno-Ileal bypass (SADI) is becoming a key option as a revision procedure after laparoscopic sleeve gastrectomy (LSG). However, its safety as an ambulatory procedure (length of stay < 12 h) has not been widely described.

METHODS

A prospective bariatric study of 40 patients undergoing SADI robotic surgery after LSG with same day discharge (SDD), was undertaken in April 2021. Strict inclusion and exclusion criteria were applied and the enhanced recovery after bariatric surgery protocol was followed. Anesthesia and robotic procedures were standardized. Early follow-up (30 days) analyzed postoperative (PO) outcomes.

RESULTS

Forty patients (37 F/3 M, mean age: 40.3yo), with a mean pre-operative BMI = 40.5 kg/m2 were operated. Median time after LSG was 54 months (21-146). Preoperative comorbidities included: hypertension (n = 3), obstructive sleep apnea (n = 2) and type 2 diabetes (n = 1). Mean total operative time was 128 min (100-180) (mean robotic time: 66 min (42-85)), including patient setup. All patients were discharged home at least 6 h after surgery. There were four minor complications (10%) and two major complications (5%) in the first 30 days postoperative (one intrabdominal abscess PO day-20 (radiological drainage and antibiotic therapy) and one peritonitis due to duodenal leak PO day-1 (treated surgically)). There were six emergency department visits (15%), readmission rate was 5% (n = 2) and reintervention rate was 2.5% (n = 1) There was no mortality and no unplanned overnight hospitalization.

CONCLUSIONS

Robotic SADI can be safe for SDD, with appropriate patient selection, in a high-volume center.

Patient's Preference for Same-Day Discharge or Hospitalization After Bariatric Surgery

PURPOSE

Enhanced Recovery After Bariatric Surgery protocols have proven to be effective in reducing complication rates and length of stay. Guidelines do not include a recommendation on the length of hospital stay whereas same-day discharge is currently widely investigated on safety and feasibility. However, none of these studies takes patient preferences into account. The study aimed to reveal the patient's preference for outpatient surgery (OS) in patients who underwent primary bariatric surgery.

MATERIALS AND METHODS

A single-center preference-based randomized trial was performed between March and December of 2021. Adult patients planned for primary bariatric surgery were able to choose their care pathway, either OS with remote heart and respiratory rate monitoring by a wearable data logger or standard care with at least one-night hospitalization.

RESULTS

Out of the 202 patients, nearly everyone (98.5%) had a preference. Of 199 patients, 99 (49.7%) chose inpatient surgery. Of the 100 with a preference for OS, 23 stayed in the hospital due to medical reasons and 12 patients changed their preference. Based on both initial preference and changed preference, there were no differences between sex, age, body mass index, and co-morbidities such as diabetes mellitus, hypertension, and atrial fibrillation, nor in the use of anticoagulants or type of surgery.

CONCLUSION

Patients seemed to have a strong preference for their stay after a bariatric procedure. The preference is equally divided between outpatient and inpatient surgery and is not influenced by any patient characteristics.

Revisional bariatric surgery for gastroesophageal reflux disease: characterizing patient and procedural factors and 30-day outcomes for a retrospective cohort of 4412 patients

INTRODUCTION

Gastroesophageal reflux disease (GERD) is a well-established potential consequence of bariatric surgery and can require revisional surgery. Our understanding of the population requiring revision is limited. In this study, we aim to characterize patients requiring revisional surgery for GERD to understand their perioperative risks and identify strategies to improve their outcomes.

METHODS

Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry, a retrospective cohort of patients who required revisional surgery for GERD in 2020 was identified. Multivariable logistic regression modelling was used to assess correlations between baseline characteristics and morbidity.

RESULTS

4412 patients required revisional surgery for GERD, encompassing 24% of all conversion procedures. In most cases, patients underwent sleeve gastrectomy (SG) as their original surgery (n = 3535, 80.1%). The revisional surgery for most patients was a Roux-en-Y gastric bypass (RYGB) (n = 3722, 84.4%). Major complications occurred in 527 patients (11.9%) and 10 patients (0.23%) died within 30 days of revisional surgery. Major complications included anastomotic leak in 31 patients (0.70%) and gastrointestinal bleeding in 38 patients (0.86%). Multivariable analyses revealed that operative length, pre-operative antacid use, and RYGB were predictors of major complications.

CONCLUSION

GERD is the second most common indication for revisional surgery in patients who have undergone bariatric surgery. Patients who underwent SG as their initial procedure were the primary group who required revisional surgery for GERD; most underwent revision via RYGB. Further inquiry is needed to tailor operative approaches and pre-operative optimization for revisional surgery patients.

Mid-term Results of an ERAS Program of Bariatric Surgery in a Tertiary Referral Center

BACKGROUND

To identify preoperative risk factors for discharge failure beyond postoperative day two (POD-2) in bariatric surgery ERAS program in a tertiary referral center.

METHODS

all consecutive patients who underwent laparoscopic bariatric treated in accordance with ERAS protocol between January 2017 and December 2019 were included. Two groups were identified, failure of early discharge (> POD-2) (ERAS-F) and success of early discharge (≤ POD-2) (ERAS-S). Overall postoperative morbidity, unplanned readmission rates were analyzed at POD-30 and POD-90, respectively. Multivariate logistic regression was performed to determine the independent risk factors for LOS > 2 days (ERAS-F).

RESULTS

A total of 697 consecutive patients were included, 148 (21.2%) in ERAS-F group and 549 (78.8%) in ERAS-S group. All postoperative complications at POD 90, whether medical or surgical were significantly more frequent in ERAS-F group than in ERAS-S group. Neither readmission nor unplanned consultations rates at POD 90 were significantly different between both groups. History of psychiatric disorder (p = 0.01), insulin-dependent diabetes (p < 0.0001), use of anticoagulants medicine (p < 0.00001), distance to the referral center > 100 km (p = 0.006), gallbladder lithiasis (p = 0.02), and planned additional procedures (p = 0.01) were independent risk factors for delayed discharge beyond POD-2.

CONCLUSIONS

One in five patients with bariatric surgery failed to discharge earlier despite the ERAS program. Knowledge of these preoperative risk factors would allow us to identify patients who need more recovery time and a tailored approach to the ERAS protocol.

Comparison of the Effects of Special Care Enhanced Recovery and Conventional Recovery Methods after Mini Omega Gastric Bypass

Background

Bariatric surgery is a surgical procedure for patients with extreme obesity. Enhanced Recovery after Surgery (ERAS) is a method that provides special peri- and post-operation care. Here, we aimed to compare the effects of ERAS and standard recovery cares.

Materials and Methods

This is a randomized clinical trial that was performed in 2020-2021 in Isfahan on 108 candidates for mini gastric bypass. Patients were then randomly divided into two equal groups receiving ERAS and standard recovery protocols. Patients were examined and visited after one month regarding the average number of hospitalization days, the average days required to return to normal activity or work, occurrence of pulmonary thromboemboli (PTE) and the rate of readmission.

Results

Patients that received ERAS had significantly lower frequencies of nausea and vomiting (P = 0.032). Patients that received ERAS had significantly lower hospitalization duration (P < 0.001) compared to controls. No other significant differences were observed between two groups regarding surgery complication, re-admission rate and occurrence of PTE (P > 0.99 for all).

Conclusion

Patients that received ERAS protocol after gastric bypass had significantly lower hospitalization duration and lower incidence of nausea and vomiting. They also had similar post-operative outcomes compared to the standard protocol.

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.

Does Liposomal Bupivacaine Decrease Postoperative Opioid Use in Conjunction with an Enhanced Recovery After Bariatric Surgery Pathway? A Prospective, Double-blind, Randomized Controlled Trial

BACKGROUND

Minimization of opiate use is an important focus in the setting of the severe national opioid crisis. This study evaluated the role of liposomal bupivacaine (LB) in decreasing postoperative opioid use before and after implementation of a bariatric enhanced recovery after surgery (ERAS) program.

METHODS

We performed an IRB-approved, prospective, double-blind, randomized controlled trial of LB versus plain bupivacaine (PB) in patients undergoing elective, minimally invasive, weight loss surgery at a comprehensive metabolic and bariatric surgery program from November 2017 to December 2019. Primary outcomes were postoperative morphine milligram equivalents per day (MME/day) and average subjective inpatient pain level. Secondary outcomes were length of hospital stay (LOS) and adverse events (AEs).

RESULTS

Of the 100 patients enrolled, 78 were randomly assigned to LB (42) or PB (36). Thirty-four received the ERAS protocol, and 44 did not. The mean MME/day use did not differ significantly by the bupivacaine group [median, IQR PB: 20.3 (40.95); LB: 33.0 (42.9); p = .314], but it did differ by the ERAS group [median, IQR no ERAS 33.2 (47.1), ERAS 24.0 (34.0); p = .049]. Length of stay, inpatient pain score, and AEs did not differ significantly by either the bupivacaine or the ERAS group.

CONCLUSIONS

In our study, liposomal bupivacaine did not significantly decrease postoperative opioid use either before implementation of ERAS or as part of an enhanced recovery after surgery program for minimally invasive bariatric surgery procedures.

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

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

Enhanced recovery after bariatric surgery: an Italian consensus statement

Background

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

Methods

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

Results

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

Conclusions

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

Re-Do Surgery after Sleeve Gastrectomy: A Single Center Comparison between Roux-en-Y Gastric Bypass and One Anastomosis Gastric Bypass

Introduction: According to the high rate of patients requiring a Re-Do surgery after a primary Sleeve Gastrectomy, due to failure on weight loss, this study proposes a comparison between RYGB and OAGB as a secondary intervention for morbidly obese patients. Methods: A retrospective review of patients who underwent revisional surgery to convert SG to RYGB or OAGB at our institution from November 2011 to November 2019 was performed. Results: A subset of sixty-three patients with previous SG underwent revisional surgery due to failure of the primary intervention. The OAGB group (n = 17) had a mean BMI at the time of the sleeve of 62 kg/m2 and a mean BMI of 50.7 kg/m2, the length of the Omega was 139.35 cm. The RYGB (n = 46) group showed a mean BMI of 47 kg/m2 at the time of the sleeve and a BMI of 34.8 kg/m2 at the time of the revision. The RYGB was performed according to the 70/120 cm standard for all the patients. One patient also had a revision from secondary OAGB to RYGB due to persistent biliary reflux, in this case the biliary branch was settled at 150 cm and the alimentary at 50 cm. Conclusions: The outcomes in the OAGB group showed a 29%WL and a 47%EWL (out of a 17%WL and 28%EWL at the time of the sleeve), on the other side the RYGB group reached a 33%WL and 72%EWL (out of a 25%WL and a 54%EWL at the time of the sleeve). According to our data we assume that RYGB is more effective in terms of weight loss as a revisional surgery after sleeve

Effect of Intravenous Infusion of Lidocaine Compared with Ultrasound-Guided Transverse Abdominal Plane Block on the Quality of Postoperative Recovery in Patients Undergoing Laparoscopic Bariatric Surgery

Purpose

To investigate the effect of intravenous infusion of lidocaine compared with ultrasound-guided transverse abdominal plane (TAP) block on the quality of postoperative recovery and analgesic effect in patients undergoing bariatric surgery.

Patients and Methods

Ninety-nine ASA II-III patients scheduled for elective laparoscopic bariatric surgery were randomized into the lidocaine group (group L), transverse abdominal plane block group (group T), and control group (group C). Group L: a loading dose of 1.5 mg/kg lidocaine was given at induction, followed by 2 mg·kg-1·h-1 maintenance until the end of surgery. Group T: ultrasound-guided bilateral administration of 0.25% ropivacaine in the transverse abdominal plane was given after induction of general anesthesia. Group C: no additional treatment was performed. Quality of recovery-40 (QoR-40) was assessed at 24 h after surgery. Consumption of propofol and remifentanil, visual analog scale (VAS) pain scores at rest at 0, 6, 12, and 24 h postoperatively, time to return of intestinal function, use of remedial analgesics within 24 h after surgery, adverse reactions were recorded.

Results

Compared with Group C, Group L and Group T had higher QoR-40 scores at 24 h postoperatively, and the difference was statistically significant (P=0.002 and P=0.003, respectively). However, there was no difference between Group L and Group T (P=0.128). In addition, compared with those of Group T and Group C, VAS scores at 12 h and 24 h postoperatively were lower in Group L (P <0.0166).

Conclusion

Both intravenous infusion of lidocaine and ultrasound-guided TAP block provided good postoperative recovery and postoperative analgesia for patients with bariatric surgery, and intravenous infusion of lidocaine provided better analgesia at 12 h and 24 h postoperatively compared with TAP block.

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.

Racial disparity in causes for readmission following bariatric surgery

BACKGROUND

Readmission after bariatric surgery is not cost-effective and is a preventable quality metric within standardized practices. However, reasons for readmission among racial/ethnic bariatric cohorts are less explored and understood.

OBJECTIVE

Our study objective was designed to compare reasons for readmission among racial/ethnic cohorts of bariatric patients.

SETTING

Academic hospital.

METHODS

We performed a retrospective analysis of the 2015-2018 MBSAQIP databases to identify Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) cases. Regression analyses determined predictors of all-cause and bariatric-related readmissions. Reasons for readmission were compared between racial/ethnic cohorts using propensity score matching.

RESULTS

More than 550 000 RYGB and SG cases were analyzed. The readmission rate was 3%-4%. Black race, RYGB, robot-assisted approach, and numerous co-morbidities were independently associated with readmission (P <.05). In RYGB cases, black (versus white) patients were at decreased odds of leak-related (P < .001) and cardiovascular-related (P < .001) readmissions but at increased odds of readmissions related to renal complications (P < .001). Hispanic (versus white) patients had a higher likelihood of venous thromboembolism-related readmissions (P < .001). In SG cases, black (versus white) patients had a similar lower likelihood of readmission related to leaks or cardiovascular complications but higher odds of readmission related to renal complications (P < .001). Hispanic (versus black) patients had a higher likelihood of leak-related readmissions (P < .001).

CONCLUSION

Readmission reasons after bariatric surgery vary by race/ethnicity. Perioperative pathways to mitigate complications, including readmissions, should consider these disparate findings.

Efficacy of intraoperative intravenous lidocaine for postoperative analgesia following bariatric surgery: a meta-analysis of randomized controlled studies

BACKGROUND

The impact of intravenous lidocaine in adults undergoing laparoscopic bariatric surgeries (LBS) remains unclear.

OBJECTIVES

This study aimed at investigating the effect of intravenous lidocaine on postoperative opioid consumption and recovery following LBS.

SETTING

Meta-analysis.

METHODS

We searched databases including MEDLINE, Embase, Google Scholar, and the Cochrane Library for randomized controlled trials that evaluated the use of intravenous lidocaine compared to placebo only prior to May 2021. The primary outcome was 24-hour postoperative opioid consumption, while secondary outcomes included pain score, quality of recovery (QOR)-40 score, length of hospital stay (LOS), and postoperative nausea/vomiting (PONV).

RESULTS

Seven trials (496 participants) were included. Intraoperative intravenous lidocaine significantly reduced 24-hour equivalent morphine consumption (mean difference [MD]: -11.97 mg; 95% confidence interval [CI]: -23.12 to -.83), pain score at 1 to 3 hours (MD: -.77; 95% CI: -1.5 to -.04), and LOS (MD: -8.93 hr; 95% CI: -13.41 to -4.44) without positive impact on 24-hour pain score and PONV. There was also an increase in time to first opioid requirement (MD: 20.23 min; 95% CI: 11.76-28.7) and QOR-40 score (MD: 24.38; 95% CI: 5.57-43.18). However, sensitivity analysis demonstrated evidence supporting the beneficial effect of lidocaine only for time to first opioid requirement and QOR-40. The associations of intraoperative intravenous lidocaine with reductions in morphine consumption, pain score at 1 to 3 hours, and LOS after LBS were also weak.

CONCLUSION

Intraoperative intravenous lidocaine during LBS prolonged time to first opioid requirement and improved quality of recovery postoperatively without 24-hour pain or nausea/vomiting benefits. Due to the small number of trials, larger studies are warranted to verify our findings.

Intraoperative Monitoring of the Obese Patient Undergoing Surgery: A Narrative Review

With the increasing prevalence of obesity in the population, anaesthetists must confidently manage both the pathophysiological and technical challenges presented in bariatric and non-bariatric surgery. The intraoperative period represents an important opportunity to optimise and mitigate risk. However, there is little formal guidance on what intraoperative monitoring techniques should be used in this population. This narrative review collates the existing evidence for intraoperative monitoring devices in the obese patients. Although a number of non-invasive blood pressure monitors have been tested, an invasive arterial line remains the most reliable monitor if accurate, continuous monitoring is required. Goal-directed fluid therapy is recommended by clinical practice guidelines, but the methods tested to assess this had guarded applicability to the obese population. Transcutaneous carbon dioxide (CO₂) monitoring may offer additional benefit to standard capnography in this population. Individually titrated positive end expiratory pressure (PEEP) and recruitment manoeuvres improved intraoperative mechanics but yielded no benefit in the immediate postoperative period. Depth of anaesthesia monitoring appears to be beneficial in the perioperative period regarding recovery times and complications. Objective confirmation of reversal of neuromuscular blockade continues to be a central tenet of anaesthesia practice, particularly relevant to this group who have been characterised as an "at risk" extubation group. Where deep neuromuscular blockade is used, continuous neuromuscular blockade is suggested. Both obesity and the intraoperative context represent somewhat unstable search terms, as the clinical implications of the obesity phenotype are not uniform, and the type and urgency of surgery have significant impact on the intraoperative setting. This renders the generation of summary conclusions around what intraoperative monitoring techniques are suitable in this population highly challenging.

Advanced endoscopic gastrointestinal techniques for the bariatric patient: implications for the anesthesia provider

PURPOSE OF REVIEW

The incidence of obesity and the use of endoscopy have risen concurrently throughout the 21st century. Bariatric patients may present to the endoscopy suite for primary treatments as well as preoperatively and postoperatively from bariatric surgery. However, over the past 10 years, endoscopic bariatric and metabolic therapies (EBMTs) have emerged as viable alternatives to more invasive surgical approaches for weight loss.

RECENT FINDINGS

The United States Food and Drug Administration (FDA) has approved several different gastric EBMTs including aspiration therapy, intragastric balloons, and endoscopic suturing. Other small intestine EBMTs including duodenal mucosal resurfacing, endoluminal magnetic partial jejunal diversion, and Duodenal-Jejunal Bypass Liner are not yet FDA approved, but are actively being investigated.

SUMMARY

Obesity causes anatomic and physiologic changes to every aspect of the human body. All EBMTs have specific nuances with important implications for the anesthesiologist. By considering both patient and procedural factors, the anesthesiologist will be able to perform a safe and effective anesthetic.

Does Laparoscopic Sleeve Gastrectomy lead to Barrett's esophagus, 5-year esophagogastroduodenoscopy findings: A retrospective cohort study

Introduction

Laparoscopic Sleeve Gastrectomy (LSG) is one of the most prevalent approaches to tackle obesity and its co-morbidities. The main complication following the LSG is Gastro-esophageal reflux disease (GERD), with most patients developing worsening symptoms of GERD, and a small number progressing to Barrett's esophagus. This retrospective analysis aims to assess the rate of GERD pre- and post- LSG as well as the rate of progression to Barrett's.

Methods

Data was collected from 1639 patients. 92 patients fit our inclusion criteria. Data was then analyzed and summarized against similar literature.

Results

Of 64 (69.6%) patients who had normal EGD findings pre-LSG, only 28 patients (30.4%) had the same results 5 years post-LSG (p= < 0.05). The number of patients who had Grade A GERD almost quadrupled post-LSG, increasing from 3 patients (3.3%) to 14 (15.2%). Patients with esophagitis/gastritis/duodenitis increased from 20 (21.7%) to 32 patients (34.8%). Patients with hiatal hernias increased from 4 (4.4%) to 10 patients (10.9%). The most significant result is that 2 out of 92 patients developed Barrett's Esophagus (2.2%), while 7 other patients developed further serious complications.

Conclusion

LSG is a very effective and safe bariatric procedure. However, the major downslide is that it can lead to the aggravation of GERD symptoms. This paper and the included literature demonstrate that LSG does lead to a substantial increase in the rate of GERD, however, the percentages of Barrett's Esophagus are markedly low. Performing an EGD pre- and post- LSG is an important protocol that aids in the diagnosis and management of LSG related GERD.

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The main complication post-LSG is Gastro-esophageal reflux disease (GERD), with some progressing to Barrett’s esophagus.

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We assessed Esophagogastroduodenoscopy (EGD) results pre-LSG and 5 yrs post-op to determine the development of Barrett’s.

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This paper and the included literature demonstrate that LSG does lead to the development of Barrett’s Esophagus.

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Performing an EGD pre- and post-LSG is an important protocol that aids in the diagnosis and management of LSG related GERD.

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.

How can lean thinking improve ERAS program in bariatric surgery?

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Bariatric surgery and the COVID-19 pandemic: SICOB recommendations on how to perform surgery during the outbreak and when to resume the activities in phase 2 of lockdown

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its related disease, coronavirus disease 2019 (COVID-19), has been rapidly spreading all over the world and is responsible for the current pandemic. The current pandemic has found the Italian national health system unprepared to provide an appropriate and prompt response, heavily affecting surgical activities. Based on the limited data available in the literature and personal experiences, the Società Italiana di Chirurgia dell'OBesità e Malattie Metaboliche (SICOB) provides recommendations regarding the triage of bariatric surgical procedures during the COVID-19 pandemic defining a dedicated path for surgery in morbidly obese patients with known or suspected COVID-19 who may require emergency operations. Finally, the current paper delineates a strategy to resume outpatient visits and elective bariatric surgery once the acute phase of the pandemic is over. Models developed during the COVID-19 crisis should be integrated into hospital practices for future use in similar scenarios. Surgeons are presented with a golden opportunity to embrace systemic change and to drive their professional future.

Perioperative Exercise Therapy in Bariatric Surgery: Improving Patient Outcomes

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