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Initial result of unselective implementation of
enhanced recovery after surgery in a low-volume
bariatric unit: a feasibility and safety study
Hung Chieh Lo ( carshcat@yahoo.com.tw )
Taipei Municipal Wanfang Hospital https://orcid.org/0000-0001-6079-8657
Wen-Kuan Chiu
Taipei Municipal Wan-Fang Hospital
Yu-Chi Chiu
Taipei Municipal Wan-Fang Hospital
An-Chih Hsu
Taipei Municipal Wan-Fang Hospital
Yu-Ting Tai
Taipei Municipal Wan-Fang Hospital
Research article
Keywords: obesity, enhanced recovery, bariatric
DOI: https://doi.org/10.21203/rs.3.rs-48389/v2
License: This work is licensed under a Creative Commons Attribution 4.0 International License.
Read Full License
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Abstract
Background
The feasibility and safety of unselectively applying an enhanced recovery after surgery (ERAS) protocol in
a low-volume bariatric unit were determined.
Methods
We retrospectively reviewed all patients undergoing bariatric surgeries under a single surgeon between
January 2015 and December 2018. Our ERAS protocol initiated in January 2017 with all patients enrolled
unselectively. For those receiving non-primary procedures or with BMI<32.5 kg/m2 were excluded from
this analysis. Demographic features and all 30-day outcome measures, including operation time, length
of stay (LOS), ER visits, readmissions, reoperations were collected and compared between the ERAS
(2017–2018) and control (2015-2016) groups.
Results
One hundred eighty-four consecutive patients underwent bariatric surgeries during the study period. Of
those fullling the inclusion criteria, 62 (40.8%) were treated before and 90 (59.2%) were treated after
ERAS implementation. No differences in baseline demographics were found between the groups except
ERAS group had more Roux-en-Y gastric bypass procedures (58.9% vs. 12.9%). A markedly reduced
operation time (101 min vs. 147 min; p<0.001) and shortened LOS (2.6 days vs. 3.3 days; p<0.001) were
observed, with signicantly more ERAS patients achieving POD1 discharge (45.6% vs. 1.6%; p<0.001).
There were no signicant differences in terms of ER visits (2.2% vs. 8%), readmissions (1.1% vs. 4.8%) or
total complication rates between the groups (5.5% vs. 9.7%).
Conclusion
Unselective ERAS implementation in low-volume units is feasible and safe, with signicantly reduced
operation times and a shortened LOS without increased complications.
Background
While obesity is being recognized as a global epidemic[1], the commensurate rising prevalence of obesity
and multiple comorbidities, such as hypertension (HTN), type II diabetes mellitus (DM), obstructive sleep
apnea (OSA), dyslipidemia, etc., resulting in mounting pressure to offer proper treatment for this
worldwide health hazard[2]. Interventions such as diet, exercise and intensive medical therapy generally
fail to achieve durable effectiveness[3]. Instead, bariatric surgeries currently serve as a standard solution
to settle this problem because of their well-recognized long-term effectiveness for weight reduction and
comorbidity remission[4]. However, to widespread introduction of such a relatively complex treatment is
not without risks [5]. Conventionally, cumulative surgical experience or high-volume practice generally
yields superior outcomes[6]. However, it takes a long time to build up adequate experience and achieve
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this goal. Therefore, for low-volume practices, it is important to utilize alternative measures that are able
to maintain safety proles and facilitate quality improvement.
Clinical pathways such as enhanced recovery after surgery (ERAS) concept and alike, which consists of
multimodal recommendations, has successfully been shown to be a valuable modality to attenuate
perioperative stress and achieve faster convalescence for various surgical disciplines[7]. Systemic
reviews and meta-analyses demonstrate that ERAS concepts could optimize perioperative care with
improved results for bariatric surgeries[8]. Only technique prociency is generally believed to be a
prerequisite to conduct such a practice[9]. In addition, there are no clear patient selection or exclusion
criteria. For instance, individuals with an age beyond the regular limits (e.g., <18 or >60 years); super
obese ; American Society of Anesthesiologists class >3[10]; organ failure such as chronic kidney disease
or congestive heart failure, etc.[11], are traditionally deemed unsuitable for ERAS enrollment. In contrast,
other clinicians have considered that the presence of multiple comorbidities should not preclude patients
from beneting from such protocols[12]. In summary, because of the aforementioned factors, the
literature remains scarce with respect to the feasibility and results to conduct such a plan in a low-volume
practice. The primary aim of this study was to verify ecacy of ERAS in a low volume setting. All 30
days’ adverse events are carefully audit and served as the secondary outcome measures. By means of an
unselective approach, our goal was to increase its generalizability.
Methods
Data were retrieved retrospectively from a prospectively maintained database between January 2015 and
December 2018 and all procedures performed in this study were in accordance with the ethical standards
in the 1964 Declaration of Helsinki and its later amendments. The local institutional review board
approved this study. The requirement to obtain formal consent was waived for this kind of study. All
patients met the regional criteria[13]and were enrolled unselectively. Those who underwent non-primary
surgery or for metabolic purpose that had a body mass index (BMI) of <32.5 kg/m2 were excluded from
this analysis. The periods analyzed were two years before and after the implementation of the ERAS
protocol. Patients were stratied into control (2015-2016) or ERAS groups (2017-2018) based on case
sequence. Procedure selection was conducted through a shared decision-making process after full
clearance of ecacy and risks based on literature at the time. Affected by growing concern regarding
long-term sequelae, such as anemia and bile reux after one-anastomosis gastric bypass (OAGB), as the
study progressed[14-16]; we modied our approach to preferably suggesting Roux-en-Y gastric bypass
(RYGB) for younger patients (<40 yrs.) and those with gastroesophageal reux disease or DM in ERAS
group despite the lack of established guidelines to support such practice. Preoperative routine
evaluations included blood tests, chest radiographs, electrocardiograms, echocardiograms, abdominal
ultrasound and upper gastrointestinal endoscopy.
ERAS protocol
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A pragmatic ERAS protocol in accordance with the available guidelines at that time that utilized basic
and essential changes was fully initiated in January 2017[17]. Interventions consisted of proper
preoperative education and preparations, intraoperative care, and early ambulation and oral intake
postoperatively. Table 1 highlights the differences between this protocol and the previous standard of
care. Before admission, patients underwent thorough instruction with emphasis on clear expectations
and goals in addition to general information regarding the risks and benets of the surgery as per
surgical consent. Premedication was also provided for ERAS patients. Both groups received
thromboprophylaxis according to the individual risk prole. Routine nasogastric tube, abdominal
drainage, or urinary catheter placement were discontinued after ERAS implementation.
Anesthesia
A standard regimen for general anesthesia was given after full preoxygenation in the ramped position. In
the interim, positive end-expiratory pressure was utilized to prevent the formation of atelectasis, with
concerted efforts focused on maintaining normothermia, euglycemia, and euvolemia. Apart from
standard care, bolus dexamethasone (10 mg) and droperidol (0.625 mg) were introduced for
postoperative nausea and vomiting (PONV) prophylaxis in the ERAS group. As per the multimodal
analgesic regimen, a particular emphasis was placed on the total elimination of opioid medication and its
equivalent usage under the aid of laparoscopically guided transversus abdominis plane (TAP) block.
Additionally, an optimal muscle tension monitor (train of four) was utilized to facilitate deep
neuromuscular blockage plus sugammadex (2-4 mg/kg) administration for its reversal. Postoperatively,
ERAS patients treated with routine and on-demand multimodal analgesics and antiemetic agents (i.e.,
Dynastat, acetaminophen, ondansetron). The clinical pathway included avoidance of uid overload
(<2L/day) and rigorous early ambulation.
Liquid diet was commenced on the rst postoperative day in the ERAS group with no further need for a
swallow study. Discharge criteria included no surgical complications, no fever, stationary hemodynamic
parameters, a negative routine laboratory survey, tolerable oral uid intake and no need for further IV
analgesics; this status was granted on POD1 or POD2 in the ERAS group. Each patient received a printed
instructional handout when discharged.
Surgical technique
All surgical procedures were conducted laparoscopically. RYGB was performed by constructing a 30-mL
vertical gastric pouch over a 32 Fr. calibrating tube, followed by an average 100-cm antecolic alimentary,
100-cm biliary limb; linear stapled gastrojejunostomy, jejuno-jejunostomy and suture closure of
mesenteric defects via non-absorbable suture.
For OAGB, the technique involved rst stapling via Crow’s foot and subsequent multiple rings alongside
a Fr. 32 calibration tube with stapled gastrojejunostomy. The average length of the biliary limb was 200
cm. Laparoscopic sleeve gastrectomy (SG) involved multiple rings of the proper linear stapler 4-6 cm
from the pylorus along a Fr. 32 calibration tube.
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Data collection and statistical analysis
Demographic features, including age, gender, BMI, type of operation and history of common comorbid
conditions, e.g., HTN, DM, and dyslipidemia, together with all relevant outcome measures, including
operating times, length of stay (LOS), emergency room (ER) visits, readmissions, reoperations, and any
30-day complications, such as unplanned procedures/interventions and mortality, were collected and
analyzed between groups. Prolonged stay was dened as an LOS over 3 days. Any adverse events
including outside facility ER visits were obtained by inquiring directly from all our patients. Postoperative
thirty-day complications were recorded and graded according to the Clavien–Dindo classication
(CD)[18], and CD grade ≥ IIIa was considered a major complication. Statistical analyses were performed
using Statistical Package for the Social Sciences software version 20.0 (SPSS, Inc., Chicago, Illinois,
USA). Data are reported as the mean ± standard deviation (SD) or as counts and percentages when
appropriate. Chi-square tests or Fisher’s exact tests were used to compare two categorical variables. Tests
for statistical signicance were two-sided with a level of signicance of 0.05.
Results
From Jan 2015 to Dec 2018, a total of one hundred and eighty-four consecutive patients underwent
bariatric surgery at our hospital. In the ERAS group, 26 patients receiving metabolic surgery with
BMI<32.5 kg/m2 and another four patients who underwent revision surgeries were excluded. Among the
control group, two patients for metabolic purpose with BMI<32.5 kg/m2 were excluded, leaving a total of
152 patients enrolled in this study. Of these patients, 90 (59.2%) were in the ERAS group, and 62 (40.8%)
were in the control group.
Patient characteristics are outlined in Table 2. No signicant differences were found between patients
who underwent surgery before and after implementation of the ERAS protocol with respect to age
(38.7±11.2 yrs. vs. 39.4±11.3 yrs.; p=0.707), female gender (30 (48.4%) vs. 45 (50%); p=0.847),
preoperative BMI (41.2±7.8 kg/m2 vs. 39.6±7.6 kg/m2; p=0.209) or incidence of common comorbidities
such as DM, HTN, and dyslipidemia. RYGB accounted for fewer operations in the control group (8 (12.9%)
and 53 (58.9%), respectively), whereas OAGB was more often performed (53 (85.5%) vs. 36 (40%);
p<0.001). There were four concomitant procedures in the ERAS group, including two with partial
gastrectomy for benign lesions and two with fundus resection for obscured surgical elds, while none of
these procedures were performed in the control group. However, this difference was not statistically
signicant (p=0.095).
The mean operation time was signicantly reduced (101 ± 42.2 min vs. 147 ± 40.2 min; p < 0.001), and
the LOS was markedly shortened in the ERAS group compared to the control group (2.6 ± 0.7 days vs. 3.3
± 0.8 days; p < 0.001), as shown in Table 3. Forty-one out of ninety patients (45.6%) in the ERAS group
were successfully discharged on POD1 compared with a meager one out of 62 patients (1.6%) in the
control group (p < 0.001). Fewer patients in the ERAS group had an LOS more than 3 days (6 (6.7%) vs. 13
(20.1%); p = 0.013). Moreover, there was a trend of reduction in 30-day ER visits (2 (2.2%) vs. 5 (8%);
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p=0.093), readmissions (1 (1.1%) vs. 3 (4.8%); p=0.161), overall complications (5 (5.5%) vs. 6 (9.7%);
p=0.360), and unplanned procedures or interventions (1 (1.1%) vs. 2 (3.2%); p=0.360) in the ERAS group,
although none of these differences reached statistical signicance. The incidence of major (CD ≥ IIIa) (1
(1.1%) vs. 2 (3.2%); p=0.360) or minor (4 (4.4%) vs. 4 (6.4%); p = 0.343) complications was not different
between the groups. There was no anastomotic leakage, open conversion or mortality reported in either
group throughout the study.
Five patients in the ERAS group experienced 30-day complications, with details described in Table 4. Of
these, four minor complications were identied, including a patient with focal abdominal wall hematoma.
Two other patients visited the ER after discharge; one for self-limited abdominal pain and another patient
with hematemesis who visited the ER at an outside hospital and was arranged to be readmitted. The
fourth patient had gastrointestinal bleeding that required a total of 4 days of in-hospital observation.
Last, one particular patient who had to abort the index operation due to an obscured surgical eld was
classied as having major complications. This specic patient underwent a second surgical attempt four
months later uneventfully after vigorous diet control.
In the control group, six patients experienced complications. Among these were four minor complications,
including one case of transient liver dysfunction. The other three patients visited the ER, with one
presenting mild fever and another reporting self-limited abdominal pain. The third patient had PONV and
was readmitted for hydration. Two major complications were identied, namely, one patient was
readmitted through the ER for an intra-abdominal hematoma that required image-guided drainage;
another patient of anastomosis stenosis that required readmission via the ER for balloon dilatation under
general anesthesia, which comprised the second unplanned intervention.
Discussion
Our analysis demonstrates that unselective implementation of ERAS protocol can be safe in a low
volume unit and realize its advantage by a marked decrease in operation time, shortened LOS and with
more patients securely discharge on POD1 without an increase in complications.
Since the concept of a multimodal approach to control postoperative pathophysiology and improve
recovery was rst introduced in 1997[19], relevant protocols have evolved. The rationale is to hasten
convalescence by reducing perioperative stress. From then onwards, guidelines have been established
regarding recommendations for integral ERAS components in bariatric eld[17]. Recently, several
systemic reviews and meta-analyses have demonstrated the superiority of enhanced recovery protocols
in terms of carrying out more ecient surgical procedures, lessening the length of hospitalization and
effectively reducing overall morbidities compared with standard care[8,20,21]. That being said, to
generally implement the ERAS regimen remains questionable since this approach is not without
risks[9,22]. For instance, Rebibo et al. reported a cohort with a 40% increase in the readmission rate
(from 4% to 5.6%)[23]and others observed an increase in the ER visit rate[24]. Using the Metabolic and
Bariatric Surgery Accreditation and Quality Improvement Program data set, Inaba et al. found a
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signicantly higher morbidity (3.76% vs. 1.54%) and mortality rate (0.94% vs. 0.05%) when comparing
same-day discharge to POD1 discharge[25]. Similarly, Morton et al. discovered that an LOS of ≤1 day
was associated with a signicantly increased risk of 30-day mortality (OR 2.02) for RYGB patients[26]. In
fact, ERAS be implemented under the setting of specialized high-volume centers is frequently deemed a
prerequisite to conduct these projects safely[9]. For example, McCarty et al. proposed that 84% of
patients can be discharged within 23 hours postoperatively with a readmission rate as low as 1.7% for
2000 consecutive RYGB patients[27]. Similarly, Jacobsen et al. published an ERAS cohort based on a
single high-volume center with a signicantly shortened hospital stay (from 3 days to 2 days), an early
complication rate as low as 2.8% and a readmission rate of only 1.9%[28]. In this regard, it seems
reckless to conduct ERAS in a non-accredited low volume unit with fewer than 50 perennial cases.
Moreover, unlike our study background, a vast accumulating experience can usually be found when
referring to preceding research that has been conducted with low case numbers. Hahl et al. analyzed data
from 318 patients who underwent RYGB during a 4-year period with excellent results showing a mean
LOS of only 1.3 days and 83% of patients discharged on POD1[29]. Notably, their accumulative
experience at that time was already far more than ve hundred cases. Similar to our study, Awad et al.
introduce a series of 226 cases that comprised various bariatric procedures. With a low 30-day
complication rate of only 4.4% and a readmission rate of 2.7%[12]; however, this particular study were
conducted at a regional high-volume tertiary referral center. Therefore, whether these superior outcomes
merely reect clinician prociency remains unclear. Some other studies were notably undertaken via
independent patient-selection or procedure-selection process. Such as Sasse et al. presented a 38 RYGB
case series with a 100% POD1 discharge rate and a low 30-day complication rate of only 2.6%[30].
However, their study group represented fewer than 3% of their total RYGB cases as a result of stringent
patient selection. Likewise, Fares et al. accomplished a high POD1 discharge rate of up to 94.8% from a
consecutive 96 RYGB case series in a small, teaching community hospital with only 5.2%
complications[31]. Nevertheless, the study group comprised 55% of patients selected from a total
caseload of 173. Lam et al. reported their recent work which yielding remarkable results in terms of 83.1%
of patients achieving POD1 discharge with a 1.5% readmission rate whereas they selected 130 out of 240
total cases in their research, and all subjects were receiving SG[32]. Even so, there was no coherent
criterion for subject selection and risk stratication among these studies. On the other hand, a noticeable
tendency toward an increase in adverse outcomes was found in several studies that were specically
endorsed with an unselective approach. For example, Geubbels et al. followed a cohort of 360 unselected
RYGB patients and found an increasing early complication rate (from 17.3% to 18.3%) and an increasing
readmission rate (from 4.8% to 8.1%) after ERAS conduction[33]. Similarly, Mannaerts et al. reported a
signicantly higher minor complication rate (20.7% vs. 16.1%) and a higher ER visit rate (16.8% vs.
12.5%)[34]. By unselective approach, our series comprised various susceptible groups; for example, 5
(5.6%) patients were aged >65 yrs. (range, 65-74 yrs.), 4 (4.4%) patients had a BMI of >50 kg/m2 (range,
52.5-73.7 kg/m2), and two other patients had a wheelchair-bound status. Unlike the aforementioned
studies, a tendency of decreasing 30-day ER visits (2 (2.2%) vs. 5 (8%)), readmissions (1 (1.1%) vs. 3
(4.8%)), 30-day complication rates (5 (5.5%) vs. 6 (9.7%)) was found via our ERAS regimen despite none
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of these values reaching statistical signicance. Compared to an LOS ranging from 1 day to 2.9 days,
readmission rates between 1.7% and 8.1%, early complication rates between 2.8% and 18.3%, and
mortality rates of up to 0.7% across former, high-volume studies[12,27-29,35], a total LOS of 2.6 days
was accomplished in our series and fall in line with these valuable large studies.
Further analysis and comparing patients discharged on POD1 with those discharged later, there was no
statistically signicant increase in ER visits (1/41 (2.4%) vs. 1/49 (2%)), readmissions (1 /41 (2.4%) vs. 0)
or overall complication rates (1/41 (2.4%) vs. 4/49 (8.2%)). Therefore, our initial result did not come at the
expense of patient safety.
It is clear that a major difference in procedures was noted between groups, with signicantly more
patients who underwent RYGB in the ERAS group. Subgroups analysis revealed similar trend of
advantages after ERAS implementation in terms of operation time (RYGB, 128 min vs. 104 min; OAGB,
150 min vs.99 min), LOS (RYGB, 3.4 days vs. 2.5 days; OAGB, 3.3 days vs. 2.8 days) and accomplishment
of POD1 discharge (RYGB, 0% vs. 54.7%; OAGB, 1.9% vs. 33.3%) with no increment of complications.
Though there were lacks of comparison study regarding impact of ERAS for individual procedure, the
index protocol benets both procedures in current study. Another interesting nding in our study was
OAGB (n=53) took signicant longer op time than RYGB (n=8) in control group. In addition to the research
sample is too small, our results can be partially explained by differences in the demographic
characteristics between groups with RYGB comprising younger patients (31.3 yrs. vs. 39.8 yrs.) with a
lower BMI (37.5 kg/m2 vs. 42.0 kg/m2) for these are well -identied factors that affect the operation
time.
Our study shows that ERAS can be safely performed unselectively under low-volume setting and provided
with benecial effects usually reported from high-volume, specialized centers.
Limitations
Our analysis has several limitations that should be taken into consideration.
First, inherent to its retrospective nature, quality measures such as pain score, nausea episodes, etc.,
cannot be thoroughly collected. In addition, we report only 30-day morbidities, thus leaving long-term
complications unreported. However, the strengths of this study reside in the efforts to capture of all
complications since no patients dropped out within 30 days postoperatively.
Second, the marked improvement can be interpreted to be caused by the increase in expertise rather than
the positive impact of the ERAS protocol. Nevertheless, like all preceding studies conducted across two
time frames, it is hard to total eliminate time bias. Having said that, consider current study was based on
such a small sample size within a short period and comprised only a single surgeon’s work; we believe
biases from major technique progress and aws of individual practice can be avoided.
Conclusion
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Our study veries the safety and feasibility of conducting the ERAS protocol over a wide spectrum of
patients in the context of mixed procedures under a low volume setting. Given the small study population,
more relevant data and follow-up are required to elucidate the continual benecial effect and long-term
results.
List Of Abbreviations
ERAS, enhanced recovery after surgery; LOS, length of stay; HTN, hypertension;
DM, diabetes mellitus; OSA, obstructive sleep apnea;
BMI, body mass index; PONV, postoperative nausea and vomiting;
RYGB, Roux-en Y gastric bypass; OAGB, one anastomosis gastric bypass;
SG, laparoscopic sleeve gastrectomy; LOS, length of stay; ER, emergency room;
CD, Clavien-Dindo classication; SD, standard deviation;
Declarations
Ethical approvaland consent to participate
All procedures performed in studies involving human participants were in accordance with the ethical
standards of institutional and/or national research committees and with the 1964 Declaration of Helsinki
and its later amendments or comparable ethical standards. The research project was approved by local
Institutional Review Board.Informed consent was waived because no data regarding the cases were
disclosed.
Consent for publication
Written informed consent for publication was waived because no clinical details and/or clinical images
regarding the cases were disclosed.
Availability of data and materials
The datasets generated during and/or analyzed during the current study are not publicly available due to
restrictions from local Institutional Review Board but are available from the corresponding author on
reasonable request and with permission from the local Institutional Review Board.
Competing interests
The authors declare that they have no competing interests.
Funding
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The study was not sponsored and funded by any funding.
Authors' contributions
HC designed the study, performed the surgical procedures, followed the patients, and participated in the
data analysis and writing of the manuscript. WK contributed to the data analysis. YC, AC and YT
participated in patient anesthesia. The authors read and approved the nal manuscript.
Acknowledgments
Not applicable
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Tables
Table 1.Highlighted differences comparingtheERAS protocol to standard care
Page 13/16
Phase of care ERAS Standard care
Preadmission
education
expectations and goals routine surgical consent
Medications
scheduled
Premedication
LMW heparin
PPI and IV acetaminophen
LMW heparin
During the
operation
Anesthesia
intermittent pneumatic
compression device
no Foley catheter
no abdominal drain
PONV prophylaxis
TAP block
elimination of opioid use
muscle tension monitoring
reversal with Sugammadex
intermittent pneumatic compression device
routine Foley catheterization and
abdominal drainage
standard anesthesia
Postoperative
Medications
scheduled
On demand
PPI, metoclopramide
Dynastat, ondansetron
IV acetaminophen
PPI, metoclopramide
Patient care head elevated 45 degrees
lung recruitment therapy
avoidance of fluid
overloading
rigorous early ambulation
routine lab survey on POD1
head elevated 45 degrees
lung recruitment therapy
liberal use of IV fluids
urinary catheter and abdominal drain
removed on POD1 or POD2
routine lab survey on POD1
Diet clear liquids on POD1
clear liquids on POD1 after a swallow test
Discharge if
criteria met
granted on POD1 or POD2 no such regulations
ERAS, enhanced recovery after surgery; LMW, low molecular weight
PPI, proton pump inhibitor; IV, intravenous;
PONV, postoperative nausea vomiting; TAP, transversus abdominis plane;
Lab, laboratory; POD, postoperative day
Table 2.Characteristics of patients before and aftertheERAS protocol
Page 14/16
Variables ERAS
(N=90)
control
(N=62)
p-value
Type of procedures, n (%)
RYGB
OAGB
SG
53 (58.9)
36 (40.0)
1 (1.10)
8 (12.9)
53 (85.5)
1 (1.60)
< 0.001
Age (years), range
39.4±11.3
(19-74)
38.7±11.2
(21-64)
0.707
Female gender, n (%) 45 (50) 30 (48.4) 0.847
BMI(kg/m2), range 39.6±7.6
(32.5-73.7)
41.2±7.8 (32.5-64.1) 0.209
Comorbidity, n (%)
Diabetes mellitus 27 (30.0) 20 (32.3) 0.764
Hypertension 40 (44.4) 27 (43.5) 0.913
Dyslipidemia 52 (57.8) 33 (53.2) 0.576
Concomitant procedure, n (%) 4 (4.40) 0 0.095
Partial gastrectomy 2
Fundus resection 2
ERAS, enhanced recovery after surgery; RYGB,Roux-en-Y gastric bypass
OAGB,one-anastomosis gastric bypass; SG, sleeve gastrectomy
BMI,body mass index
Data are expressed as the means ± standard deviation (range) or as numbers and
percentages
Table 3.Surgical perspectives and outcomes
Page 15/16
Variables ERAS
(N=90)
control
(N=62)
P-value
OP time(minutes) 101±42.2 147±40.2 < 0.001
LOS (days), range 2.6±0.7 (1-5) 3.3±0.8 (2-6) < 0.001
POD1 discharge, n (%) 41 (45.6) 1 (1.6) < 0.001
LOS >3 days, n (%) 6 (6.7) 13 (20.1) 0.013
30-day ER visits, n (%) 2 (2.2) 5 (8) 0.093
30-day readmissions, n (%) 1 (1.1) 3 (4.8) 0.161
30-day complications, n (%) 5 (5.5) 6 (9.7) 0.360
Major (CDIIIa)1, n (%) 1 (1.1) 2 (3.2) 0.360
Minor, n (%) 4 (4.4) 4 (6.4) 0.343
Unplanned procedures or interventions, n (%) 1 (1.1) 2 (3.2) 0.360
30-day Reoperations 0 0
30-day Mortality 0 0
ERAS, enhanced recovery after surgery; OP, operation; LOS, length of stay
POD, postoperative day; ER, emergency room;
1 Clavien–Dindo classification[18]
Table 4.Details of 30-daycomplications andreinterventions
Page 16/16
avien–
ndo
ssification
ERAS
n = 5
control
n = 6
complications
reported
treated by
ade I 1 transient liver
dysfunction
supportive treatment
1 abdominal wall
hematoma
supportive treatment
1 fever ER; medical treatment
1 1 abdominal pain ER / ER; medical treatment
ade II 1 nausea/vomiting ER; readmission
for hydration
1 hematemesis ER; readmission
for medical treatment
1 GI bleeding
LOS 4 days;
medical treatment
(no transfusion)
ade IIIa 1 intra-abdominal
hematoma
ER; readmission
for image guide drainage
ade IIIb
ajor)
1 anastomosis
stenosis
ER; readmission for dilatation under
general anesthesia
1 aborted index
operation
reoperation 4 months later
ERAS, enhanced recovery after surgery; ER, emergency room; GI, gastrointestinal
LOS, length of stay
