Enhanced Recovery After Bariatric Surgery Research Articles

Laparoscopic-Guided Transversus Abdominis Plane (TAP) Block Combined with Port-Site Infiltration (PSI) for Laparoscopic Sleeve Gastrectomy in an ERABS Pathway: A Randomized, Prospective, Double-Blind, Placebo-Controlled Trial.

Patients undergoing laparoscopic sleeve gastrectomy (LSG) commonly experience moderate to severe postoperative pain. We conducted a randomized, prospective double-blind placebo-controlled study to evaluate the analgesic effect of laparoscopic-guided TAP (LG-TAP) block after LSG in a high-volume bariatric center, applying an enhanced recovery after bariatric surgery (ERABS) pathway. One hundred ten patients were randomly allocated to receive LG-TAP block with local anesthetic (LA) or saline solution (placebo), both combined with port-site infiltration with LA (LA-PSI). Primary outcome was pain score measured in post-anesthesia care unit (PACU) and at 6, 12, and 24 h after surgery. Secondary outcomes included postoperative nausea and/or vomiting (PONV), analgesic requirement, time to walking, time to flatus, length of hospital stay (LOS), and surgical complications. No significant differences were observed between LG-TAP and placebo groups in postoperative analgesia, with a median (IQR) NRS of 2 (4.75-0) vs. 2 (5.25-0) in PACU, 5.5 (7-3) vs. 6 (7-4) at 6 h, 2 (6-0) vs. 3 (5.25-1.75) at 12 h, and 2 (3.75-0) vs. 1 (2-0) at 24 h; all p > 0.05. A significant difference was found in PONV in PACU (LG-TAP, 46%; placebo, 25%, p-value, 0.019) and at 6 h postoperatively (LG-TAP, 69%, placebo, 41%, p-value, 0.003). No differences were observed as regards other secondary outcomes. Our results suggest that LG-TAP block is not related to more effective postoperative analgesia compared to placebo when LA-PSI is performed.

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

The aim of this study isto evaluate the effects of an adapted protocol of enhanced recovery after bariatric surgery (ERABS) on outcomes. This is asingle-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 ± 7.37kg/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.

Praktické klinické doporučení pro perioperační péči v bariatrické chirurgii 2023: adaptace doporučení společnosti ERAS (Enhanced Recovery After Surgery) s konsenzuálním hlasováním pracovní skupiny Společné sekce bariatricko-metabolické chirurgie České chirurgické společnosti a České obezitologické společnosti

Summary: Introduction: Bariatric surgery is the most effective treatment for the morbid obesity. It results in sustained weight loss as well as pronounced effects on obesity-related comorbidities. In the last twenty years the number of procedures performed worldwide increased. Therefore, the effort to establish a consensus in perioperative care based on best evidence in this issue is evident. Methods: Working Group of Joint Section of Bariatric and Metabolic Surgery of Czech Surgery Society and Czech Obesitology Society reached practical recommendations for ERAS (Enhanced Recovery After Surgery) in perioperative care in bariatric surgery. It issued from ERAS recommendations published in 2021. Working group adopted the original text, consequently adapted and in particular cases affixed its commentary. The electronic voting of all members of working group was the final phase, by which the strength of consensus of particular elements was expressed. Results: The Czech working group reached the consensus with recommendations ERABS (Enhanced Recovery After Bariatric Surgery) in the most elements. For some interventions of ERAS protocol for bariatric surgery the quality of evidence is low. Therefore, evidence-based practices may need to be extrapolated from other surgeries. Conclusion: The recommendation is appointed for clinical practice in bariatric surgery with protocol ERAS based on updated evidence and recommendations. It is based on recent and comprehensive ERAS recommendation, which was adopted and adapted by the Czech working group of Joint Section of Bariatric and Metabolic Surgery of Czech Surgery Society and Czech Obesitology Society. The Czech version contents some supplementations and specifications in commentaries. Original article was published in Rozhledy v chirurgii [1]. Key words: bariatric and metabolic surgery – Enhanced Recovery After Surgery – practical clinical recommendations

Perioperative Nutritional Management in Enhanced Recovery after Bariatric Surgery.

Obesity is a crucial health problem because it leads to several chronic diseases with an increased risk of mortality and it is very hard to reverse with conventional treatment including changes in lifestyle and pharmacotherapy. Bariatric surgery (BS), comprising a range of various surgical procedures that modify the digestive tract favouring weight loss, is considered the most effective medical intervention to counteract severe obesity, especially in the presence of metabolic comorbidities. The Enhanced Recovery After Bariatric Surgery (ERABS) protocols include a set of recommendations that can be applied before and after BS. The primary aim of ERABS protocols is to facilitate and expedite the recovery process while enhancing the overall effectiveness of bariatric procedures. ERABS protocols include indications about preoperative fasting as well as on how to feed the patient on the day of the intervention, and how to nourish and hydrate in the days after BS. This narrative review examines the application, the feasibility and the efficacy of ERABS protocols applied to the field of nutrition. We found that ERABS protocols, in particular not fasting the patient before the surgery, are often not correctly applied for reasons that are not evidence-based. Furthermore, we identified some gaps in the research about some practises that could be implemented in the presence of additional evidence.

Clinical practice guidelines for perioperative care in bariatric surgery 2023: Adapted ERAS (enhanced recovery after surgery) guidelines with consensual voting of the working group of the Joint Bariatric and Metabolic Surgery Section of the Czech Surgery….

Currently, bariatric surgery is the most effective treatment for the morbid obesity. It provides sustained weight loss as well as demonstrated positive effects on obesity-related comorbidities. The number of procedures performed worldwide has seen a sharp increase in the past twenty years. Therefore, an effort has been developed to establish a consensus in perioperative care based on best evidence. The working group of the Joint Bariatric and Metabolic Surgery Section of the Czech Surgery Society and Czech Society of Obesitology prepared clinical practice guidelines for the ERAS (enhanced recovery after surgery) concept in perioperative care in bariatric surgery. The working group based its guidelines on ERAS guidelines published in 2021. The working group adopted the original text and then adapted the text and added its comments to specific items as appropriate. Electronic voting of all members of the working group was the final phase, by which the strength of consensus was expressed with respect to individual elements of the guidelines. The Czech working group reached a consensus with ERABS (enhanced recovery after bariatric surgery) guidelines for most elements. The quality of evidence is low for some interventions of the ERAS protocol for bariatric surgery. Therefore, extrapolation from other surgeries and fields is needed for evidence-based practice. The guidelines are intended for clinical practice in bariatric surgery with the ERAS protocol based on updated evidence and guidelines. It is based on recent and comprehensive ERAS guidelines adopted and adapted by the Czech working group of the Joint Bariatric and Metabolic Surgery Section of the Czech Surgery Society and Czech Society of Obesitology. Some supplementations and specifications are reflected in comments added to the Czech version.

Complications in Patients Undergoing Laparoscopic Bariatric Surgery in an ERABS-optimized, High-Volume, Single Center During 2020 and 2021

PurposeComplication rates after fast-track optimization in bariatric surgery are varying. The aim of this study was to identify short-term complications in patients undergoing laparoscopic sleeve gastrectomy (SG) in an ERABS (enhanced recovery after bariatric surgery) optimized setup.Materials and MethodsThis study is an observational analysis of a consecutive cohort of 1600 patients undergoing SG at an ERABS-optimized, private hospital during 2020 and 2021. Primary outcomes were length of stay, mortality, readmissions, reoperations, and complications according to the Clavien-Dindo classification (CDC) within postoperative day (POD) 30 and 90. Secondary outcomes were weight loss and quality of life (QoL) according to Moorehead-Ardelt questionnaires during the first postoperative year.ResultsPrimary outcomes: 99.1% of patients were discharged within POD 1. The 90-day mortality rate was zero. There were 1% readmissions and 1.2% reoperations within POD 30. Total 30-day complication rate was 4.6%, where 3.4% accounted for CDC grades ≤ II, and 1.3% accounted for CDC grade III. There were zero grade IV–V complications. Secondary outcomes: One year after surgery, weight loss was substantial (p < 0.001), with an excess weight loss of 71.9%, and QoL had significantly increased (p < 0.001).ConclusionThis study demonstrates that the use of an ERABS protocol in bariatric surgery does not compromise neither safety nor efficacy. Complication rates were low, and weight loss was significant. This study thus provides strong arguments that ERABS programs are beneficial in bariatric surgery.Graphical

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

Enhanced recovery after bariatric surgery pathways are associated with improved postoperative outcomes. This study aims to assess efficacy and safety of three novel protocol contributions (transversus abdominis plane blocks, ketamine and fosaprepitant), as well as their impact on length of stay (LOS) and on postoperative complications. Effectiveness and safety were retrospectively investigated in patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) over a 6-year period in a single institution. Group 1 patients were not exposed to any of our suggested interventions, whereas Group 2 were exposed to all of three. Between January 2015 and August 2021, 1480 patients underwent primary SG (77.6%) or RYGB (22.4%); of those, 1132 (76.5%) and 348 (23.5%) were in Groups 1 and 2, respectively. Mean BMI and age were 45.87 versus 43.65kg/m2 and 45.53 versus 44.99years in groups 1 and 2, respectively. Suggested interventions were associated with lower operative times (84.79 ± 24.21 vs. 80.78 ± 32.8min, p = 0.025). In Group 2, the mean LOS decreased in 0.18day (1.79 ± 1.04 vs. 1.60 ± 0.90; p = 0.004). Overall complication rates were 8% and 8.6% for groups 1 and 2, respectively; readmission rates were 5.7% (64 pts) vs. 7.2% (25 pts), p > 0.05. Reoperations were less prevalent in Group 2 (1.5% vs. 1.1%; p = 0.79). Focus on optimized pain management, allied to a superior PONV control, may be relevant contributors for a lower LOS without negative impacts in complications rates.

Effect of intraperitoneal local anesthesia on enhanced recovery outcomes after bariatric surgery: a randomized controlled pilot study.

Background:Patients with extreme obesity are at high risk for adverse perioperative events, especially when opioid-centric analgesic protocols are used, and perioperative pain management interventions in bariatric surgery could improve safety, outcomes and satisfaction. We aimed to evaluate the impact of intraperitoneal local anesthesia (IPLA) on enhanced recovery after bariatric surgery (ERABS) outcomes.Methods:We conducted a prospective double-blind randomized controlled pilot study in adherence to an a priori peer-reviewed protocol. Patients undergoing laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) with an established ERABS protocol between July 2014 and February 2015 were randomly allocated to receive either IPLA with 0.2% ropivacaine (intervention group) or normal saline (control group). We measured pain scores, analgesic consumption and adverse effects. Functional prehabilitation outcomes, including peak expiratory flow (PEF) and the Six Minute Walk Test (6MWT) and Quality of Recovery Survey-40 (QoR-40) scores, were assessed before surgery, and 1 day and 7 days postoperatively.Results:One hundred patients were randomly allocated to the study groups, of whom 92 completed the study, 46 in each group. There were no statistically significant differences between the 2 groups in baseline characteristics or any primary or secondary outcomes. Pain scores and analgesic consumption were low in both groups. There were no adverse events. Significant declines in PEF and 6MWT and QoR-40 scores were noted on postoperative day 1 in both groups; the values returned to baseline on postoperative day 7 in both groups.Conclusion:Intraperitoneal local anesthesia with ropivacaine did not reduce postoperative pain or analgesic consumption when administered intraoperatively to patients undergoing LRYGB. Standardization of the ERABS protocol benefited patients, with functional prehabilitation outcomes returning to baseline postoperatively. Trial registration: ClinicalTrials.gov no. NCT 02154763

Postoperative nausea and vomiting in bariatric surgery: a position statement endorsed by the ASMBS and the ISPCOP.

Despite extensive research regarding risk factors and treatment regimens, postoperative nausea and vomiting (PONV) has remained a challenge affecting up to 40% of the general surgical population, underlining the complex nature of this adverse outcome [1]. In addition to the criteria described by Apfel et al. [1], contributing risk factors may be anesthesia, patient, or procedure related. Compared with the general surgical population, patients undergoing bariatric surgical procedures experience a much higher incidence of PONV, and current enhanced recovery after bariatric surgery (ERABS) guidelines suggest intraoperative prophylaxis but provide little guidance for postoperatively administered prophylaxis or treatment [2].

Impact of Enhanced Recovery After Bariatric Surgery (ERABS) Protocol in Reducing Length of Stay and Hospitalization Costs: the Experience of a Philanthropic Hospital in Brazil.

The global prevalence of obesity and increase in bariatric surgeries are burdening the healthcare system. Enhanced recovery postoperative protocols are associated with a reduction in hospitalization costs and length of stay (LOS) and may be an alternative to reduce public health expenses. To assess the impact of implementing a customized Enhanced Recovery After Bariatric Surgery (ERABS) protocol on hospitalization costs (HC), LOS, and complication rates. Santa Marcelina Hospital, São Paulo, Brazil. A retrospective electronic health record analysis of patients who underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy and who were cared for within a clinical pathway (CP) protocol (Jan. 2016-Aug. 2018) or after implementation of an ERABS protocol (Aug. 2018-Jun. 2019). The LOS, HC, and complication, readmission, and reoperation rates were compared between the two groups. Eighty-two patients were included in the study (CP, 56, 87.5% women; ERABS, 26, 92.3% women). Hospital LOS and total HC decreased significantly by 32.5% and 15.2%, respectively (both, p < 0.05), after implementation of ERABS. There were no significant differences in 30-day readmission, complication, or reoperation rates. The implementation of a standardized enhanced recovery program resulted in reduced LOS and HC without an increase in perioperative morbidity. The ERABS protocol is cost-effective and can help ease the healthcare burden.

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.

Enhanced recovery after bariatric surgery: Implementation of program and clinical outcomes from a bariatric surgery and metabolic diseases reference center.

Enhanced recovery after bariatric surgery (ERABS) protocols involve a series of multimodal perioperative procedures based on evidence designed to reduce physiological stress, improve recovery, and reduce costs on medical attention by decreasing length of hospital stay (length of stay [LOS]). The objective of the study was to report the viability and results of the ERABS application in a reference bariatric center. A prospective, observational, and descriptive study on bariatric procedures conducted over 12 months in the ERABS context which includes pre-procedure, intraprocedure, and post-procedure measures. The collected data include demographic data, comorbidity, morbimortality, LOS, and readmission to hospital. Sixty-four patients within a median of 38.8 ± 9.5 years and 44.1 ± 6.20 kg/m2 BMI underwent surgery. Fifty-five (85.93%) were Roux-en-Y gastric bypass (RYGB) cases and 9 (14.06%) were sleeve gastrectomy (SG). Related comorbidities were hypertension 37%, diabetes 34%, dyslipidemia 23%, and obstructive sleep apnea 21%. Two (3.12%) patients developed post-operative morbidity (respiratory and thromboembolic complications). LOS for RYGB was 1.16 ± 0.97 and 1 ± 0 days for SG. The successful discharge rate on the 1st day after procedure was 96% and 100%, respectively. Readmission to hospital within a 30-day period presented itself on 4 patients (6.25%). Applying ERABS protocols is feasible, safe, morbidity low, LOS acceptable, and a low readmission rate within 30 days.

Reducing complication rates and hospital readmissions while revising the enhanced recovery after bariatric surgery (ERABS) protocol.

To optimize the postoperative phase following bariatric surgery, the enhanced recovery after bariatric surgery pathway (ERABS) has been developed. The aim of ERABS is to create a care path that is as safe, efficient and patient-friendly as possible. Continuous evaluation and optimization of ERABS are important to ensure a safe treatment path and may result in better outcomes. The objective of this study was to compare the clinical outcomes of patients undergoing bariatric surgery over 2014-2017, during which the ERABS protocol was continuously evaluated and optimized. This is a retrospective cohort study. Data were collected from patients undergoing a primary Roux-en-Y gastric bypass or sleeve gastrectomy between January 2014 and December 2017. Outcomes were early complications, unplanned hospital revisits, readmissions, duration of surgery and length of hospital stay. 2889 patients underwent a primary bariatric procedure in a single center. There was a significant decrease in minor complications over the years from 7.0 to 1.9% (p < 0.001). Hospital revisit rates decreased after 2015 (p < 0.001). Readmission rates decreased over time (p < 0.001). The mean duration of surgery decreased from 52 (in 2014) to 41 (in 2017) minutes (p < 0.001). Median length of hospital stay decreased from 1.8 to 1.5days in 2015 (p = 0.002) and remained stable since. An improvement of the ERABS protocol was associated with a decrease in minor complication rates, number of unplanned hospital revisits and readmission rates after primary bariatric procedures.

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

Background: With the creation of a new bariatric center in Abu Dhabi, United Arab Emirates (UAE) and the organization of this bariatric department according to the international guidelines, a new activity of bariatric surgery started in January 2015. The surgeon had 20 years of experience in this field and he had performed over 5000 major laparoscopic bariatric procedures before starting this new bariatric program. The concept of enhanced recovery after bariatric surgery (ERABS) was applied from the beginning of the program. We decided to analyze the first 2 years of ERAS activity after having split them in two different periods: the 1st year of activity included restrictive procedures and the 2nd year associated malabsorptive surgeries. Materials and Methods: The results of the use of a fast-track program could be measured by different parameters like operative time, length of hospital stay, rate of complications, and rate of readmission and reoperation. Results: Between January and December 2015, 116 patients underwent a bariatric procedure. The mean age was 34.6 years (16-61) and average body mass index (BMI) was 41.7 kg/sqm (32-72.2). Sixty percent of patients were women and 37% of patients had at least one comorbidity (diabetes type 2, high blood pressure, hyperlipidemia, or sleep apnea). Ninety-four percent of the procedures were laparoscopic sleeve gastrectomy (LSG), 2.6% were laparoscopic Roux-en-Y gastric bypass, and 3.4% band removal. The mean operative time was 20 minutes for an LSG (14-45 minutes) and the average hospital stay was 1.2 days (standard deviation [SD]: 0.9-3.3). The rate of complications was 1.7% with 1 postoperative hematoma drained by CT scan on day 14 after the surgery and 1 relative stenosis endoscopically dilated on postoperative day 45. No reoperation was done. No leak was observed. At 1 year, the mean excess weight loss (EWL) was 64% (47-124) in 89 patients with a 76% rate of follow-up. For the 2nd year of activity in 2016, 142 patients went in the program. The mean age was 32.7 years (17-64) and average BMI was 42.3 kg/sqm (31-68). Seventy-two percent were women and 41% of the patients had one comorbidity or more. The majority of surgeries performed were LSG for 83.1% of the patients. RYGB was realized in 4.2% of cases, resleeve gastrectomy in 4.2%, and band removal in 1.4%. Some malabsorptive surgeries were performed as well, such as one anastomosis gastric bypass for 3 patients (4.2%), and single anastomosis duodeno-ilelal in 2 cases (2.8%). The average hospital stay was 1.5 days (SD: 0.9-3.5). No complication was observed. No reoperation was done. Two patients (1.4%) came back to the hospital on postoperative day 2 and 8 after a LSG for one or several episodes of vomiting without further complication. At 1 year, the mean EWL was 68% (49-154) in 98 patients with a 69% rate of follow-up. Conclusions: This new program of bariatric surgery in two steps using fast-track protocols, respecting international guidelines and with an experienced surgeon showed on its 1st year of implementation a 1.7% rate of readmission on 116 patients without reoperation or major complication and a hospital stay of 1.2 days. For the 2nd year of implementation with the inclusion of malabsorptive procedures only 2 patients (1.4%) were readmitted for a short episode of vomiting and the hospital stay was 1.5 days.

A110 Efficacy of liposomal bupivacaine versus bupivacaine in port site injections on postoperative pain within enhanced recovery after bariatric surgery (ERABS) program; A Randomized Clinical Trial

Use of liposomal bupivacaine (Exparel®) in surgery is reported with decreased postoperative opioid requirements. The efficacy of liposomal bupivacaine versus standard bupivacaine injections at laparoscopic port sites during bariatric surgery is unknown.

A111 Impact of Enhanced Recovery After Bariatric Surgery (ERAS) on Patient Experience, Surgical Outcomes and Healthcare Costs: Electronic Medical Records (EMR) and Highmark Health claims data analysis

A111 Impact of Enhanced Recovery After Bariatric Surgery (ERAS) on Patient Experience, Surgical Outcomes and Healthcare Costs: Electronic Medical Records (EMR) and Highmark Health claims data analysis

Reduction of opioid use after implementation of enhanced recovery after bariatric surgery (ERABS).

Enhanced recovery after surgery (ERAS) protocols have been extensively proven in lower gastrointestinal surgery to decrease postoperative physiologic stress and length of stay (LOS). ERAS in bariatric surgery (ERABS) varies immensely from each program with inconsistent results with a predominant goal of reducing LOS. Our focus in implementing enhanced recovery after bariatric surgery (ERABS) protocols is aimed at reducing postoperative pain and opioid use. This is a retrospective review of patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (VSG) at a single high-volume center from June 2016 to October 2017. Patients on previous standard protocol were categorized into "Pre-Liposomal Bupivacaine (LB) group." After routine use of Exparel™, patients were grouped into "LB group." After ERABS protocol was initiated, patients were categorized into "ERABS/LB group." Postoperative opioids were converted to morphine equivalents units (MEU); pain scores, LOS, and 30-day outcomes were analyzed using combination of t test and Mann-Whitney U. A total of 1340 patients were included in the study: 304 patients in pre-LB group; 754 patients in LB group, and 282 patients in ERABS/LB group. Total hospital opioid use was 58.6 MEU in pre-LB, 40.8 MEU in LB, and 23.8 MEU in ERABS/LB (p = 0.01). ERABS/LB group found a 59.5% decline in MEU requirements compared to pre-LB (p < 0.001) and 44.9% of patients did not require any additional narcotics on the floor compared to 0% in pre-LB group (p < 0.001). ERABS/LB LOS was an average of 1.48days compared to 1.54days in pre-LB group (p = 0.03) with an overall decrease of 3.74% in readmission rates (p = 0.03). Implementation of ERABS significantly reduced postoperative opioid use, LOS, and readmissions. With ERABS, a more profound effect was observed than simply adding Exparel™ to preexisting protocols. Almost half of these patients did not require narcotics while recovering on the surgical floor. More studies are required to assess the true effect of ERABS without use of Exparel™.

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

BackgroundThe growing demand for bariatric surgery has been accompanied by an expensive technological evolution and the need to contain healthcare costs and to increase the quality of care. The enhanced recovery after surgery (ERAS) protocols applied to the bariatric setting can be the answer to all these different issues. ObjectivesFeasibility and safety of ERAS protocol in a single, high-volume bariatric center. SettingHumanitas Research Hospital, Rozzano MI, Italy. MethodsOur ERAS bariatric protocol is based on the following 3 steps: (1) preoperative: optimization of all co-morbidities, counseling patients and family with information and education, and shortening fasting times (clear fluids up to 2 hr and solids up to 4 hr before induction of anesthesia); (2) intraoperative: premedication, parallel team work, awake patient positioning, standardized multimodal anesthesia and analgesia, noninvasive monitoring, video-laryngoscopy in reverse Trendelenburg position, short-acting anesthetic agents, and standardized laparoscopic surgery avoiding the nasogastric tube, catheter, and drain; and (3) postoperative: analgesia, early mobilization, early oral fluid, thromboprophylaxis, discharge planning, and follow-up telephone call. Clinical pathways were established and outcomes were retrospectively collected. ResultsComparison between conventional care and ERAS protocol reveals a reduction of the length of hospital stay (from 4.7 to 2.1 d) and a low morbidity rate. From July 2015 to July 2018, a total of 2400 consecutive patients underwent primary or revisional bariatric surgery (2122 sleeve gastrectomies and 278 Roux-en-Y gastric bypasses [RYGB]). Mean body mass index was 44.9 kg/m2, mean age was 41.9 years, and the male to female ratio was 1:2.5. Total mean operative time was 85 minutes, with a surgical time of 65 minutes and an anesthesiologic/patient induction time of 4 minutes. Early complication rate was 3.5% with no perioperative mortality. Mean hospital stay was 2.1 days and the rate of readmission was .9%. ConclusionsThis study demonstrates that our ERAS protocol is safe, feasible, and efficient. Patient preparation and multidisciplinary/parallel team work are crucial points.

Enhanced recovery after bariatric surgery (ERABS): Analysis of outcomes from a tertiary referral centre

Enhanced recovery after bariatric surgery (ERABS): Analysis of outcomes from a tertiary referral centre

Implementation of enhanced recovery programs for bariatric surgery. Results from the Francophone large-scale database

BackgroundThe feasibility, safety, and efficacy of programs for enhanced recovery after bariatric surgery (ERABS) are now well established. However, data concerning their large-scale implementation remain insufficient. ObjectivesThe objective of the present study was to review the multicenter implementation of ERABS SettingThis retrospective analysis of a prospective database was conducted in 15 Groupe francophone de Rehabilitation Améliorée après ChirurgiE centers from data from March 2014 to January 2017. MethodsThe Francophone working Group for Enhanced Recovery After Surgery (Groupe francophone de Rehabilitation Améliorée après ChirurgiE) edited and released protocols of ERABS for its members. Compliance with ERABS, lengths of hospital stay, and postoperative morbidity were obtained from the Groupe francophone de Rehabilitation Améliorée après ChirurgiE–audit database. ResultsIn this study, 1667 patients were included. Procedures were sleeve gastrectomy (n = 1011), gastric bypass (n = 300), or mini-bypass (n = 356). Mean body mass index was 41.8 ± 8.3 kg/m2. Global morbidity was 2.57%, and surgery-related morbidity was 1.67% (mostly anastomotic leakages and hemorrhage). Mean length of hospital stay was 2.4 ± 3.6 days. Overall compliance was 79.6%. Among the 23 elements of the ERABS program, 14 were applied in>70% of instances, 6 in between 50% and 70%, and 3 in<50%. The elements least often applied were limb intermittent pneumatic compression during surgery (23.3%), multimodal analgesia (49.5%), and optimal perioperative fluid management (43.8%). ConclusionThis study shows that even if the overall compliance was good, the large-scale implementation of ERABS can still be improved, as several elements remain insufficiently applied. This finding highlights the importance of thorough, continuous training in addition to the need for repeated audits by centers involved in ERABS programs.