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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

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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 fulfilling 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 significantly more ERAS patients achieving POD1 discharge (45.6% vs. 1.6%; p<0.001). There were no significant 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 significantly reduced operation times and a shortened LOS without increased complications.
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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 ( )
Taipei Municipal Wanfang Hospital
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
License: This work is licensed under a Creative Commons Attribution 4.0 International License.
Read Full License
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The feasibility and safety of unselectively applying an enhanced recovery after surgery (ERAS) protocol in
a low-volume bariatric unit were determined.
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.
One hundred eighty-four consecutive patients underwent bariatric surgeries during the study period. Of
those fullling 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 signicantly more ERAS patients achieving POD1 discharge (45.6% vs. 1.6%; p<0.001).
There were no signicant 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%).
Unselective ERAS implementation in low-volume units is feasible and safe, with signicantly reduced
operation times and a shortened LOS without increased complications.
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 proles 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 prociency 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 beneting 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 ecacy 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.
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 stratied 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 ecacy and risks based on literature at the time. Affected by growing concern regarding
long-term sequelae, such as anemia and bile reux after one-anastomosis gastric bypass (OAGB), as the
study progressed[14-16]; we modied our approach to preferably suggesting Roux-en-Y gastric bypass
(RYGB) for younger patients (<40 yrs.) and those with gastroesophageal reux 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 benets of the surgery as per
surgical consent. Premedication was also provided for ERAS patients. Both groups received
thromboprophylaxis according to the individual risk prole. Routine nasogastric tube, abdominal
drainage, or urinary catheter placement were discontinued after ERAS implementation.
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 dened 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 classication
(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 signicance were two-sided with a level of signicance of 0.05.
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 signicant 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
signicant (p=0.095).
The mean operation time was signicantly 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 signicance. 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 identied, 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
classied as having major complications. This specic 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 identied, 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.
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 ecient 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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signicantly 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 signicantly 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 signicantly 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 reect clinician prociency 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 stratication among these studies. On the other hand, a noticeable
tendency toward an increase in adverse outcomes was found in several studies that were specically
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
signicantly 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 signicance. 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 signicant 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 signicantly 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 benets both procedures in current study. Another interesting nding in our study was
OAGB (n=53) took signicant 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 -identied factors that affect the operation
Our study shows that ERAS can be safely performed unselectively under low-volume setting and provided
with benecial effects usually reported from high-volume, specialized centers.
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 surgeons work; we believe
biases from major technique progress and aws of individual practice can be avoided.
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Our study veries 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 benecial effect and long-term
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 classication; SD, standard deviation;
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
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.
Page 10/16
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.
Not applicable
1. Stevens GA, Singh GM, Lu Y, Danaei G, Lin JK, Finucane MM, Bahalim AN, McIntire RK, Gutierrez HR,
Cowan M
et al
: National, regional, and global trends in adult overweight and obesity prevalences.
Popul Health Metr
2012, 10(1):22.
2. Angrisani L, Santonicola A, Iovino P, Vitiello A, Higa K, Himpens J, Buchwald H, Scopinaro N: IFSO
Worldwide Survey 2016: Primary, Endoluminal, and Revisional Procedures.
Obes Surg
3. Schauer PR, Bhatt DL, Kirwan JP, Wolski K, Aminian A, Brethauer SA, Navaneethan SD, Singh RP,
Pothier CE, Nissen SE
et al
: Bariatric Surgery versus Intensive Medical Therapy for Diabetes - 5-Year
N Engl J Med
2017, 376(7):641-651.
4. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K: Bariatric surgery:
a systematic review and meta-analysis.
2004, 292(14):1724-1737.
5. Ashraan H, Darzi A, Athanasiou T: Bariatric surgery - can we afford to do it or deny doing it?
Frontline Gastroenterol
2011, 2(2):82-89.
6. Zevin B, Aggarwal R, Grantcharov TP: Volume-outcome association in bariatric surgery: a systematic
Ann Surg
2012, 256(1):60-71.
7. Visioni A, Shah R, Gabriel E, Attwood K, Kukar M, Nurkin S: Enhanced Recovery After Surgery for
Noncolorectal Surgery?: A Systematic Review and Meta-analysis of Major Abdominal Surgery.
2018, 267(1):57-65.
8. Malczak P, Pisarska M, Piotr M, Wysocki M, Budzynski A, Pedziwiatr M: Enhanced Recovery after
Bariatric Surgery: Systematic Review and Meta-Analysis.
Obes Surg
2017, 27(1):226-235.
9. Dogan K, Kraaij L, Aarts EO, Koehestanie P, Hammink E, van Laarhoven CJ, Aufenacker TJ, Janssen
IM, Berends FJ: Fast-track bariatric surgery improves perioperative care and logistics compared to
conventional care.
Obes Surg
2015, 25(1):28-35.
10. Gondal AB, Hsu CH, Serrot F, Rodriguez-Restrepo A, Hurbon AN, Galvani C, Ghaderi I: Enhanced
Recovery in Bariatric Surgery: A Study of Short-Term Outcomes and Compliance.
Obes Surg
Page 11/16
11. Jonsson A, Lin E, Patel L, Patel AD, Stetler JL, Prayor-Patterson H, Singh A, Srinivasan JK, Sweeney
JF, Davis SS, Jr.: Barriers to Enhanced Recovery after Surgery after Laparoscopic Sleeve
J Am Coll Surg
2018, 226(4):605-613.
12. Awad S, Carter S, Purkayastha S, Hakky S, Moorthy K, Cousins J, Ahmed AR: Enhanced recovery after
bariatric surgery (ERABS): clinical outcomes from a tertiary referral bariatric centre.
Obes Surg
13. Kasama K, Mui W, Lee WJ, Lakdawala M, Naitoh T, Seki Y, Sasaki A, Wakabayashi G, Sasaki I,
Kawamura I
et al
: IFSO-APC consensus statements 2011.
Obes Surg
2012, 22(5):677-684.
14. Jammu GS, Sharma R: A 7-Year Clinical Audit of 1107 Cases Comparing Sleeve Gastrectomy, Roux-
En-Y Gastric Bypass, and Mini-Gastric Bypass, to Determine an Effective and Safe Bariatric and
Metabolic Procedure.
Obes Surg
2016, 26(5):926-932.
15. Kular KS, Manchanda N, Rutledge R: A 6-year experience with 1,054 mini-gastric bypasses-rst study
from Indian subcontinent.
Obes Surg
2014, 24(9):1430-1435.
16. Luque-de-Leon E, Carbajo MA: Conversion of One-Anastomosis Gastric Bypass (OAGB) Is Rarely
Needed if Standard Operative Techniques Are Performed.
Obes Surg
2016, 26(7):1588-1591.
17. Thorell A, MacCormick AD, Awad S, Reynolds N, Roulin D, Demartines N, Vignaud M, Alvarez A, Singh
PM, Lobo DN: Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After
Surgery (ERAS) Society Recommendations.
World J Surg
2016, 40(9):2065-2083.
18. Dindo D, Demartines N, Clavien PA: Classication of surgical complications: a new proposal with
evaluation in a cohort of 6336 patients and results of a survey.
Ann Surg
2004, 240(2):205-213.
19. Kehlet H: Multimodal approach to control postoperative pathophysiology and rehabilitation.
Br J
1997, 78(5):606-617.
20. Ahmed OS, Rogers AC, Bolger JC, Mastrosimone A, Robb WB: Meta-Analysis of Enhanced Recovery
Protocols in Bariatric Surgery.
J Gastrointest Surg
2018, 22(6):964-972.
21. Singh PM, Panwar R, Borle A, Goudra B, Trikha A, van Wagensveld BA, Sinha A: Eciency and Safety
Effects of Applying ERAS Protocols to Bariatric Surgery: a Systematic Review with Meta-Analysis
and Trial Sequential Analysis of Evidence.
Obes Surg
2017, 27(2):489-501.
22. Elliott JA, Patel VM, Kirresh A, Ashraan H, Le Roux CW, Olbers T, Athanasiou T, Zacharakis E: Fast-
track laparoscopic bariatric surgery: a systematic review.
Updates Surg
2013, 65(2):85-94.
23. Rebibo L, Dhahri A, Badaoui R, Hubert V, Lorne E, Regimbeau JM: Laparoscopic sleeve gastrectomy
as day-case surgery: a case-matched study.
Surg Obes Relat Dis
2019, 15(4):534-545.
24. Rickey J, Gersin K, Yang W, Stefanidis D, Kuwada T: Early discharge in the bariatric population does
not increase post-discharge resource utilization.
Surg Endosc
2017, 31(2):618-624.
25. Inaba CS, Koh CY, Sujatha-Bhaskar S, Zhang L, Nguyen NT: Same-Day Discharge after Laparoscopic
Roux-en-Y Gastric Bypass: An Analysis of the Metabolic and Bariatric Surgery Accreditation and
Quality Improvement Program Database.
J Am Coll Surg
2018, 226(5):868-873.
Page 12/16
26. Morton JM, Winegar D, Blackstone R, Wolfe B: Is ambulatory laparoscopic Roux-en-Y gastric bypass
associated with higher adverse events?
Ann Surg
2014, 259(2):286-292.
27. McCarty TM, Arnold DT, Lamont JP, Fisher TL, Kuhn JA: Optimizing outcomes in bariatric surgery:
outpatient laparoscopic gastric bypass.
Ann Surg
2005, 242(4):494-498; discussion 498-501.
28. Jacobsen HJ, Bergland A, Raeder J, Gislason HG: High-volume bariatric surgery in a single center:
safety, quality, cost-ecacy and teaching aspects in 2,000 consecutive cases.
Obes Surg
29. Hahl T, Peromaa-Haavisto P, Tarkiainen P, Knutar O, Victorzon M: Outcome of Laparoscopic Gastric
Bypass (LRYGB) with a Program for Enhanced Recovery After Surgery (ERAS).
Obes Surg
30. Sasse KC, Ganser JH, Kozar MD, Watson RW, 2nd, Lim DC, McGinley L, Smith CJ, Bovee V, Beh J:
Outpatient weight loss surgery: initiating a gastric bypass and gastric banding ambulatory weight
loss surgery center.
2009, 13(1):50-55.
31. Fares LG, 2nd, Reeder RC, Bock J, Batezel V: 23-hour stay outcomes for laparoscopic Roux-en-Y
gastric bypass in a small, teaching community hospital.
Am Surg
2008, 74(12):1206-1210.
32. Lam J, Suzuki T, Bernstein D, Zhao B, Maeda C, Pham T, Sandler BJ, Jacobsen GR, Cheverie JN,
Horgan S: An ERAS protocol for bariatric surgery: is it safe to discharge on post-operative day 1?
Surg Endosc
2019, 33(2):580-586.
33. Geubbels N, Bruin SC, Acherman YI, van de Laar AW, Hoen MB, de Brauw LM: Fast track care for
gastric bypass patients decreases length of stay without increasing complications in an unselected
patient cohort.
Obes Surg
2014, 24(3):390-396.
34. Mannaerts GH, van Mil SR, Stepaniak PS, Dunkelgrun M, de Quelerij M, Verbrugge SJ, Zengerink HF,
Biter LU: Results of Implementing an Enhanced Recovery After Bariatric Surgery (ERABS) Protocol.
Obes Surg
2016, 26(2):303-312.
35. Bamgbade OA, Adeogun BO, Abbas K: Fast-track laparoscopic gastric bypass surgery: outcomes and
lessons from a bariatric surgery service in the United Kingdom.
Obes Surg
2012, 22(3):398-402.
Table 1.󰁅Highlighted differences comparing󰁅the󰁅ERAS protocol to standard care
Page 13/16
Phase of care󰁅 ERAS Standard care
expectations and goals routine surgical consent
LMW heparin
PPI and IV acetaminophen
LMW heparin
During the
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󰁅
On demand
PPI, metoclopramide
Dynastat, ondansetron󰁅
IV acetaminophen
PPI, metoclopramide
Patient care head elevated 45 degrees
lung recruitment therapy󰁅
avoidance of fluid
󰁅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 after󰁅the󰁅ERAS protocol
Page 14/16
Variables ERAS
Type of procedures, n (%)󰁅
󰁅SG 󰁅
53 (58.9)
36 (40.0)
1 (1.10)
󰁅 󰁅 󰁅 󰁅 󰁅󰁅
8 (12.9)
53 (85.5)
1 (1.60)
< 0.001
Age (years), range 󰁅
Female gender, n (%) 45 (50) 30 (48.4) 0.847
BMI󰁅(kg/m2), range 39.6±7.6
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
Table 3.󰁅Surgical perspectives and outcomes
Page 15/16
Variables ERAS
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 (CDIIIa)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-day󰁅complications and󰁅reinterventions
Page 16/16
n = 5
n = 6
treated by
ade I 󰁅 1 transient liver
supportive treatment
1 󰁅 abdominal wall
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
ER; readmission󰁅
for image guide drainage
ade IIIb
󰁅 1 anastomosis
ER; readmission for dilatation under
general anesthesia
1 󰁅 aborted index
reoperation 4 months later
ERAS, enhanced recovery after surgery; ER, emergency room; GI, gastrointestinal
LOS, length of stay
ResearchGate has not been able to resolve any citations for this publication.
Full-text available
Introduction The implementation of Enhanced Recovery After Surgery (ERAS) guidelines has been widely studied among various surgical specialties. We aimed at comparing the perioperative outcomes and compliance with ERAS protocol in bariatric surgery at our center. Methods An observational review of a prospectively maintained database was performed. Patients who underwent primary bariatric surgery (gastric bypass or sleeve gastrectomy) between January 2011 and June 2018 were included. Patients were divided into pre- and post-ERAS groups. Data including basic demographic information, length of hospital stay, 30-day perioperative complications, and readmission rates were collected. Compliance with elements of ERAS was assessed using a combination of chart review and a prospectively implemented checklist. P < 0.05 was chosen to be statistically significant. Results A total of 435 patients were included: 239 patients in the pre-ERAS group and 196 patients in the post-ERAS group. There were no statistical differences in baseline demographics and major comorbidities between the 2 groups. The post-ERAS group had shorter length of hospital stay (2.23 vs 1.23, p < 0.001) and lower rates of 30-day postoperative morbidity (8.7 vs 4%, p = .04). There was no significant difference between the 2 groups with respect to readmissions rates. There was no mortality in either group. Overall compliance rates with ERAS elements were 85%; compliance increased significantly with the implementation of a checklist (p < 0.001). Conclusions Implementation of ERAS program for bariatric surgery is safe and feasible. It reduces hospital stay and postoperative morbidity. Easy to implement strategies such as checklists should be encouraged in bariatric programs to aid in implementation and compliance with ERAS elements for perioperative care.
Full-text available
Background Laparoscopic sleeve gastrectomy is the most commonly performed bariatric surgery in the world. Enhanced recovery after surgery (ERAS) protocols have been shown to reduce complications and decrease length of stay for various types of surgeries. In this study, we propose an ERAS protocol for laparoscopic sleeve gastrectomy and compare the clinical outcomes with patients who received standard care. Methods We performed a single-institution retrospective analysis in patients who underwent laparoscopic sleeve gastrectomy from February 2015 to December 2017. Patients were stratified into standard care and ERAS protocol groups. The ERAS protocol consisted of goal-directed patient education, specific pre- and post-op multi-modal medication regimen, early ambulation, and early oral intake. Patients were discharged on their first post-operative day if they met appropriate post-surgical milestones. The primary outcomes were length of stay, 7- and 30-day readmission rates, and complication rates. Secondary outcomes included anti-emetic and pain medication utilization, post-operative emesis episodes per day, post-operative pain scores, and mortality. Results We included 214 consecutive patients who underwent sleeve gastrectomy, 130 were in the ERAS group and 84 were in the standard care group. Median hospital stay was significantly shorter in the ERAS group compared to the standard care group (1 vs. 2 days; p < 0.001). There were no differences in 7- or 30-day readmission rates (1.5 vs. 1.2%; p = 0.838, 2.3 vs. 2.4%; p = 0.966) or post-operative complications (6.2 vs. 3.6%; p = 0.410). The ERAS group also had decreased median intra-operative opioid consumption and self-reported pain scores on post-operative day 1 (27.5 MME vs. 27.4 MME; p = 0.044, 3.3 vs. 3.9; p = 0.046). Mortality rate was 0% overall. Conclusion A cost-effective ERAS protocol for laparoscopic sleeve gastrectomy results in shorter length of stay, without increase in peri-operative morbidity or readmission rates.
Full-text available
Application of the enhanced recovery after surgery (ERAS) to the bariatric surgical procedures is at its early stages with little consolidated evidence. This meta-analysis evaluates present literature and indicates pathways for development of evidence-based standardized ERAS protocols for bariatric surgery. Comparative trials between ERAS and conventional bariatric surgery published till June 2016 were searched in the medical database. Comparisons were made for length of stay (LOS), readmission, complications (major/minor), and reoperation rates. Trial sequential analysis (TSA) for the strength of meta-analysis was performed for the primary outcome LOS. Five subgroups with a total of 394 and 471 patients in ERAS and conventional group respectively were included. LOS was shorter in ERAS group by 1.56 ± 0.18 days (random-effects, p < 0.001, I (2) = 93.07 %). The sample size in ERAS was well past the "information size" variable which was calculated to be 189 as per the TSA for power 85%. MH odds ratio [1.41 (95% CI 1.13 to1.76)] was higher for minor complications in the ERAS group (fixed effects, I (2) = 0, p < 0.001). Superiority/inferiority of ERAS could not be established for major or overall complications, readmission, and anastomotic leak rates. No publication bias was found in the included trials (Egger's test, X-intercept = 6.14, p = 0.66). Evaluation based on Cochrane collaboration recommendations suggested that all the five included trials had a high risk of methodological bias. ERAS protocols for bariatric procedures allow faster return to home for patients. The present bariatric ERAS protocols have high heterogeneity and would benefit from standardization. Minor complication rates increase with implementation of ERAS, however without any significant effect on overall patient morbidity. Further randomized trials comparing ERAS with conventional care are required to consolidate these findings.
Full-text available
Enhanced recovery after surgery (ERAS) protocol is well established in many surgical disciplines and leads to a decrease in the length of hospital stay and morbidity. Multimodal protocols have also been introduced to bariatric surgery. This review aims to evaluate the current literature on ERAS in obesity surgery and to conduct a meta-analysis of primary and secondary outcomes. MEDLINE, Embase, Scopus and Cochrane Library were searched for eligible studies. Key journals were hand-searched. We analysed data up to May 2016. Eligible studies had to contain four described ERAS protocol elements. The primary outcome was the length of hospital stay; the secondary outcomes included overall morbidity, specific complications, mortality, readmissions and costs. Random effect meta-analyses were undertaken. The initial search yielded 1151 articles. Thorough evaluation resulted in 11 papers, which were analysed. The meta-analysis of the length of stay presented a significant reduction standard mean difference (Std. MD) = -2.39 (-3.89, -0.89), p = 0.002. The analysis of overall morbidity, specific complications and Clavien-Dindo classification showed no significant variations among the study groups. ERAS protocol in bariatric surgery leads to the reduction of the length of hospital stay while maintaining no or low influence on morbidity.
Full-text available
Introduction There is a trend toward shorter-stay bariatric surgery. However, reducing LOS may increase complications and post-discharge resource utilization. Our goal was to compare outcomes before and after implementation of short-stay bariatric surgery. Methods and procedures A retrospective chart review of a single-surgeon series of laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass (LRYGB). The two cohorts “target discharge POD 1” and “target discharge POD 2” were analyzed for on time discharges (feasibility) and complications. Patients who were successfully discharged in each cohort were further analyzed for post-discharge resource utilization. Results Early discharge was initiated in November of 2014 with 107 patients identified in this group. An additional 107 patients from those immediately preceding represented the target DC POD 2 group. The target DC POD 2 patients had a significantly higher percentage of patients who met their target LOS. The SD group (overall and LRYGB) had a significantly higher rate of hospital readmissions; this was the only significant difference in primary outcomes between the two groups. There was no difference in mortality, leaks or reoperation. Conclusions This study suggests that short-stay bariatric surgery is feasible and safe. Reducing the LOS from 2 to 1 day did not significantly increase the rate of hospital readmissions, ED visits or patient calls to our office. Further research is necessary to determine whether LOS can be further abbreviated to allow outpatient LSG and LRYGB.
Background: Few series have demonstrated the feasibility of laparoscopic sleeve gastrectomy (SG) as day-case surgery (DCS). Objective: Compare the outcomes and healthcare costs of SG performed as DCS or as an inpatient procedure. Setting: University Hospital, France, public practice. Methods: This was a prospective, nonrandomized study of 250 consecutive patients undergoing day-case SG from May 2011 to June 2017. Each patient in the DCS group (n = 250) was manually paired by sex, age, body mass index, preoperative co-morbidities, and year of surgery with 1 patient undergoing SG as an inpatient procedure (SG control group, n = 250). Patients in the SG control group were excluded from DCS on the basis of DCS criteria. The primary endpoint of this study was the clinical and economic impact of performing SG as DCS compared with inpatient management. The secondary endpoints were related to DCS, DCS satisfaction rate, comparison of outcomes and costs between DCS and inpatient procedures, and the changing modalities of SG as DCS in our institution (by comparing the first 100 patients to the last 150 patients). Results: A total of 1573 patients underwent SG during the period, 250 patients underwent SG as DCS (15.9%) and 554 patients were excluded on the basis of DCS criteria. No postoperative deaths, 19 overnight admissions (7.6%), 16 unscheduled consultations (6.4%), and 12 unscheduled hospitalizations (4.8%) were observed in the DCS group. No significant differences were observed in postoperative complications. Readmission was higher in the DCS group (5.6% versus 4%; P < .001), while the length of rehospitalization was shorter in the DCS group (5.8 versus 10.8 d; P < .001). Overall cost and cost per patient were significantly lower in the DCS group (P < .001). Conclusion: Day-case SG on selected patients was not associated with increased morbidity and mortality rates and was cost-effective due to the low cost of management of postoperative complications.
Background: Enhanced recovery after surgery (ERAS) guidelines, fast-track protocols, and alternative clinical pathways have been widely promoted in a variety of disciplines leading to improved outcomes in post-operative morbidity and length of stay (LOS). This meta-analysis assesses the implications of standardized management protocols in bariatric surgery. Methods: The PRISMA guidelines were adhered to. Databases were searched with the application of pre-defined inclusion and exclusion criteria. Results were reported as mean differences or pooled odds ratios (OR) with 95% confidence intervals (95% CI). Individual protocols and surgical approaches were assessed through subgroup analysis, and sensitivity analysis of methodological quality was performed. Results: A total of 1536 studies were screened; 13 studies were eventually included for meta-analysis involving a total of 6172 patients. Standardized perioperative techniques were associated with a savings of 19.5 min in operative time (p < 0.01), as well as a LOS which was shortened by 1.5 days (p < 0.01). Pooled post-operative morbidity rates also favored enhanced recovery care protocols (OR 0.7%, 95% CI 0.6-0.9%, p < 0.01). Conclusion: Bariatric surgery involves a complex cohort of patients who require high-quality evidence-based care to improve outcomes. Consensus guidelines on the feasibility of ERAS and alternative clinical pathways are required in the setting of bariatric surgery.
Background: Enhanced recovery (ERAS) protocols lead to expedited discharges and decreased cost. Bariatric centers have adopted such programs for safely discharging patients after sleeve gastrectomy (LSG) on the first postoperative day (POD1). Despite pathways, some bariatric patients cannot be discharged on POD1. Methods: Retrospective review of patients undergoing LSG, between 2013 through 2016, in a center of excellence utilizing a standardized enhanced recovery pathway. Patient variables and perioperative factors were analyzed, including multivariate regressions, for predictors of early discharge. Results: 573 patients underwent LSG (83% female, mean age of 46.3 ± 11.7 years and body mass index of 46.0 ± 6.6 kg/m2). Mean hospital stay was 1.7 days ± 1.0 SD. Early discharge occurred in 38.2% of patients. Independently, early operating room (OR) start times and treated obstructive sleep apnea were associated with earlier discharge (<0.05). In contrast, preoperative opioid use, history of psychiatric illness, chronic kidney disease, and revision cases delayed discharge (p<0.05). Age, gender, ASA class, diabetes, CHF, hypertension, distance to home, and insurance status were not significant. On regression modeling, early OR start time and treated obstructive sleep apnea (OSA) reduced length of stay (LOS) (p<0.05), while Creatinine >1.5, EF<50%, and increased case duration increased LOS (p<0.05). Fifteen patients were readmitted within 30 days (2.6%). Conclusion: Several clinical and operative factors impact early discharge after LSG. Knowing factors that enhance ERAS success as well as the causes and corrections for failed implementation allow teams to optimally direct care pathway resources.
Objective: To evaluate the impact of enhanced recovery after surgery (ERAS) protocols across noncolorectal abdominal surgical procedures. Background: ERAS programs have been studied extensively in colorectal surgery and adopted at many centers. Several studies testing such protocols have shown promising results in improving postoperative outcomes across various surgical procedures. However, surgeons performing major abdominal procedures have been slower to adopt these ERAS protocols. Methods: A systematic review was performed using "enhanced recovery after surgery" or "fast track" as search terms and excluded studies of colorectal procedures. Primary endpoints for the meta-analysis include length of stay (LOS) and complication rate. Secondary endpoints were time to first flatus, readmission rate, and costs. Results: A total of 39 studies (6511 patients) met inclusion and exclusion criteria. Among them 14 studies were randomized trials, and the remaining 25 studies were cohort studies. Meta-analysis showed a decrease in LOS of 2.5 days (95% confidence interval, CI: 1.8-3.2, P < 0.001) and a complication rate of 0.70 (95% CI: 0.56-0.86, P = 0.001) for patient treated in ERAS programs. There was also a significant reduction in time to first flatus of 0.8 days (95% CI: 0.4-1.1, P < 0.001) and cost reduction of $5109.10 (95% CI: $4365.80-$5852.40, P < 0.001). There was no significant increase in readmission rate (OR 1.03, 95% CI: 0.84-1.26, P = 0.80) in our analysis. Conclusions: ERAS protocols decreased length of stay and cost by not increasing complications or readmission rates. This study adds to the evidence that ERAS protocols are safe to implement and are beneficial to surgical patients and the healthcare system across multiple abdominal procedures.
Background Long-term results from randomized, controlled trials that compare medical therapy with surgical therapy in patients with type 2 diabetes are limited. Methods We assessed outcomes 5 years after 150 patients who had type 2 diabetes and a body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) of 27 to 43 were randomly assigned to receive intensive medical therapy alone or intensive medical therapy plus Roux-en-Y gastric bypass or sleeve gastrectomy. The primary outcome was a glycated hemoglobin level of 6.0% or less with or without the use of diabetes medications. Results Of the 150 patients who underwent randomization, 1 patient died during the 5-year follow-up period; 134 of the remaining 149 patients (90%) completed 5 years of follow-up. At baseline, the mean (±SD) age of the 134 patients was 49±8 years, 66% were women, the mean glycated hemoglobin level was 9.2±1.5%, and the mean BMI was 37±3.5. At 5 years, the criterion for the primary end point was met by 2 of 38 patients (5%) who received medical therapy alone, as compared with 14 of 49 patients (29%) who underwent gastric bypass (unadjusted P=0.01, adjusted P=0.03, P=0.08 in the intention-to-treat analysis) and 11 of 47 patients (23%) who underwent sleeve gastrectomy (unadjusted P=0.03, adjusted P=0.07, P=0.17 in the intention-to-treat analysis). Patients who underwent surgical procedures had a greater mean percentage reduction from baseline in glycated hemoglobin level than did patients who received medical therapy alone (2.1% vs. 0.3%, P=0.003). At 5 years, changes from baseline observed in the gastric-bypass and sleeve-gastrectomy groups were superior to the changes seen in the medical-therapy group with respect to body weight (−23%, −19%, and −5% in the gastric-bypass, sleeve-gastrectomy, and medical-therapy groups, respectively), triglyceride level (−40%, −29%, and −8%), high-density lipoprotein cholesterol level (32%, 30%, and 7%), use of insulin (−35%, −34%, and −13%), and quality-of-life measures (general health score increases of 17, 16, and 0.3; scores on the RAND 36-Item Health Survey ranged from 0 to 100, with higher scores indicating better health) (P<0.05 for all comparisons). No major late surgical complications were reported except for one reoperation. Conclusions Five-year outcome data showed that, among patients with type 2 diabetes and a BMI of 27 to 43, bariatric surgery plus intensive medical therapy was more effective than intensive medical therapy alone in decreasing, or in some cases resolving, hyperglycemia. (Funded by Ethicon Endo-Surgery and others; STAMPEDE number, NCT00432809.)