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

Shifting paradigms: protocol implementation to reduce length of stay for bariatric surgery following the pandemic at a high volume bariatric center

BACKGROUND

With the Covid-19 pandemic reducing the capacity to perform elective bariatric surgical cases, a multidisciplinary approach to reducing length of stay has been essential to continue providing this service. In conjunction with the use of our local ERAS protocols, same day discharge (SDD) and early next day discharge (NDD) for bariatric surgery is becoming more of a reality.

OBJECTIVES

To evaluate the effectiveness of our new protocols targeted at reducing length of stay (LOS) for our bariatric surgery patients during the pandemic. Secondary outcomes included comparisons of readmission and complications compared to baseline data.

METHODS

The MBSAQIP data set was analyzed identifying patients who underwent laparoscopic roux-en- Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (SG) from April to November 2021. Mean LOS and complication rates including re-admission in this baseline group were documented. This was compared to a cohort who underwent the surgeries between December 2021 and February 2022 under our new protocols for early discharge.

RESULTS

195 patients underwent bariatric surgery in the baseline group and 87 patients in the early discharge cohort were included. There was a statistically significant decrease in mean LOS comparing baseline group (34.5 h) and next day PACU discharges (25 h) with P = 0.004. No increase in complication rate from the early discharge cohort against the baseline group. (P = 0.014).

CONCLUSION

SDD and NDD in carefully selected bariatric surgery patients is feasible with good outcomes. With ERAS protocols as a foundation and a multidisciplinary approach, this can be achieved in spite of pressures placed on bariatric units by the pandemic.

Do sleeve gastrectomy and Roux-en-Y gastric bypass have different venous thromboembolism risk factors? Creation of 30-day Bariatric Hypercoagulation Score

BACKGROUND

Venous thromboembolism (VTE) is a major cause of morbidity and mortality after bariatric surgery, most often occurring after discharge within 30 days after surgery.

OBJECTIVES

To determine the risk factors associated with VTE after either sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) and to develop a Bariatric Hypercoagulation Score (BHS) to predict 30-day adverse postoperative outcomes.

SETTING

University hospital.

METHODS

Using 2015-2018 data from the Metabolic and Bariatric Surgery Quality Improvement Program, a BHS was created by performing a logistic regression of "venous thromboembolism." The variables with the highest odds ratio (OR) were selected for the SG and RYGB groups. Then, the 30-day outcomes of low-risk (0-1), average-risk (2-3), and high-risk (≥4) BHS were compared.

RESULTS

Similar risk factors for VTE were found in both the SG and RYGB groups; the highest OR was shown by history of deep vein thrombosis (SG: 3.54, RYGB: 3.05). Other related factors in both groups were history of pulmonary embolism, prolonged length of stay, Black race, and male sex. Conversely, unique risk factors such as dialysis (OR 1.81) was found in the SG group; meanwhile, prolonged operative time (OR 1.50) and age >60 years (OR 1.28) were for the RYGB group. When comparing the 30-day outcomes, BHS ≥4 had a significantly higher rate of complications (P < .001).

CONCLUSIONS

SG and RYGB have some risk factors in common for VTE; however, dialysis was associated only with SG, and prolonged operative time and age >60 years were associated only with RYGB. BHS ≥4 showed higher 30-day adverse outcomes. The VTE-correlated variables require special consideration when assessing patients undergoing SG and RYGB.

Development of the "OS-SEV90 Score" to Predict Severe Postoperative Complications at 90 Days Following Bariatric Surgery

BACKGROUND

Bariatric surgery may be associated with severe postoperative complications (SPC). Factors associated with the risk of SPC have not been fully investigated.

OBJECTIVES

This study aimed to identify preoperative risk factors of SPC within 90 days and to develop a risk prediction model based on these factors.

METHODS

We conducted a retrospective single-center cohort study based on a prospectively maintained database of obese patients undergoing laparoscopic bariatric surgery from October 2005 to May 2019. All SPC occurring up to the 90th postoperative day were recorded according to the Dindo-Clavien classification. Associations between potential risk factors and SPC were analyzed using a logistic regression model, and the risk prediction ("OS-SEV90 score") was computed. Based on the OS-SEV90 score, the patients were grouped into 3 categories of risk: low, intermediate, and high.

RESULTS

Among 1963 consecutive patients, no patient died and 82 (4.2%) experienced SPC within 90 days. History of gastric or esophageal surgery (adjusted odds ratio (aOR) 3.040, 95% confidence interval; CI 1.78-5.20, p< 0.0001), past of thromboembolic event aOR 2.26, 95%; CI 1.12-4.55, p = 0.0225), and surgery performed by a junior surgeon (aOR 1.99, 95%; CI 1.26-3.13, p = 0.003) were all independently associated with risk for SPC, adjusting for ASA physical status system (ASA) score ≥ 3, severe OSA, psychiatric disease, asthma, a history of abdominal surgery, alcohol, cardiac disease, and dyslipidemia. "the OS-SEV90 score" based on these factors was constructed to classify patients into 3 risk groups: low (≤2), intermediate (3-4), and high (≥5). According to "the OS-SEV90 score," SPC increased significantly from 2.9% in the low-risk group, 7.7% in the intermediate-risk group, and 23.3% in the high-risk group.

CONCLUSIONS

A predictive model of SPC within 90 days "the OS-SEV90 score" has been developed using 9 baseline risk factors. The use of the OS-SEV90 score may help the multidisciplinary team to identify the specific risk of each patient and inform them about and optimize the comorbidities before the surgery. Further studies are warranted to validate this score in a new independent cohort before using it in clinical practice.

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

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

Can the Caprini score predict thromboembolism and guide pharmacologic prophylaxis after primary joint arthroplasty?

Aims

Venous thromboembolism (VTE) has a 30-day mortality rate of between 10 and 30%. The Caprini score is a VTE risk assessment model, which assigns points to 20 past medical history and current health factors. We hypothesized that the Caprini score could predict VTE incidence and recommend prophylaxis following total joint arthroplasty.

Patients and methods

We performed a retrospective review of prospectively collected institutional data identifying Caprini scores on 2155 primary hip (n = 840) and knee (n = 1315) arthroplasties. Surgeons were blinded to Caprini scores when prescribing VTE prophylaxis. Patients were separated into prophylaxis groups receiving Aspirin (81 mg BID or 325 mg BID) or other (Rivaroxaban, Warfarin, Enoxaparin, Apixaban, Dabigatran, Heparin). Univariate, multivariate, and Cohen's effect size analyses assessed the predictive power of the Caprini score on VTE incidence.

Results

The mean Caprini score was 9.49 (5-25). A majority, 83% (1792) of patients were in the Aspirin group, and 17% (363) in the other group. Other prophylaxis patients had statistically significantly higher Caprini scores (10 vs. 9, p < 0.0001). Twenty-five (1.2%) patients developed VTE. Controlling for prophylaxis, higher Caprini scores increased VTE risk, but this wasn't statistically significant (p = 0.16). Multivariate analysis showed a non-significant effect for patients with BMIs >40 or Caprini scores ≥11 to predict VTE incidence in the Aspirin or other prophylaxis groups (p = 0.52 and p = 0.15 respectively). Cohen's effect size was small, comparing Caprini scores in patients who had and had not had a VTE in both Aspirin and other prophylaxis groups (Cohen's d = 0.25 and d = 0.16 respectively).

Conclusion

Surgeons rely on stronger pharmacologic prophylaxis for a select high risk group of their primary lower extremity total joint arthroplasty patients. When controlling for prophylaxis, the Caprini score had a small effect size and did not have the predictive power necessary to guide treatment.