Implementing enhanced recovery after bariatric surgery protocol: a retrospective study

Differences between the pre-ERABS and ERABS period in continuous data were analyzed using unpaired Student t test, and differences in categorical data were analyzed using the chi-squared test. A p value <0.05 was considered statistically significant.

Patients received low-molecular-weight heparin 5,000 IU subcutaneously on the evening before surgery. Without premedication, patients without compression stockings walked to the operating room, and then receive a balanced crystalloid solution via a peripheral venous catheter. General anesthesia was induced with sufentanil 10 µg and remifentanil 0.5 µg/kg, followed by continuous infusion at 0.1 µg/kg/min, with propofol 1.5–2 mg/kg and rocuronium 0.6 mg/kg before orotracheal intubation. Doses of these anesthetics were decided based on ideal body weight. The lungs were ventilated to maintain end-tidal carbon dioxide tension between 32 and 35 mmHg with a positive end-expiratory pressure of 3–10 cmH₂O. Anesthesia was maintained with desflurane 0.8–1.0 × minimum alveolar concentration, with a mixture of air and oxygen with an oxygen concentration of 50–60 % to maintain the bispectral index between 40 and 60. At the beginning of surgery, dexamethasone 8 mg and metamizole 2.5 g were administered as an antiemetic and analgesic, respectively. Following anastomosis of the intestinal organs, ondansetron 8 mg and oxycodone 10 mg were administered intravenously.

A maximum of 1,000 ml of balanced crystalloid solution was administered during surgery. Both desflurane and remifentanil were discontinued at a pre-defined point according to the type of surgery. On completion of surgery, a combination of atropine and neostigmine, or sugammadex alone was administered for reversal of neuromuscular blockade. The endotracheal tube was removed after confirming the TOF ratio >90 %, SpO₂ >92 %, PaO₂ >60 mmHg, adequate ventilation, stable blood pressure and heart rate, usually within 5 min after surgery. The patients were moved to their bed unaided by medical personnel and were transferred to the PACU.

On the PACU, patients received dexamethasone 8 mg and ondansetron 8 mg. The level of pain was evaluated using a visual analog scale. Patients who leave the PACU are transported to the surgical ward after confirming PACU discharge criteria—(1) respond to verbal stimuli, and (2) respiratory rate 10–20/min, SpO2 >95 % (at room air), and heart rate 60–90 bpm. Patients are encouraged to leave their bed and move around independently by the nurses to minimize the risk of venous thrombosis, and are discharged as soon as satisfying the following conditions, without complications during anesthesia and surgery—(1) heart rate <100 bpm, (2) respiratory rate <20/min, (3) body temperature <38 °C, (4) VAS <4/10 with acetaminophen 4 g daily, (5) recovery of full mobility, being able to independently perform basic activities, and (6) C-reactive protein <100 mg/l or decrease compared with the first postoperative measurements and the number of leucocytes <20,000/µl. On the surgical ward, patients were administered a daily dose of acetaminophen 4 g or tramadol 150 mg, and additional paracetamol 150 mg or diclofenac 150 mg followed by dexamethasone 8 mg, metoclopramide 30 mg, ondansetron 12 mg and pantoprazole 80 mg. The patients were required to visit our hospital 1, 4 and 12 months after discharge for follow-up.

A total of 374 patients were included in this study—228 underwent surgery following the pre-ERABS protocol and 146 following the ERABS protocol. Of the 374 patients, 186, 144, 31 and 13 underwent gastric bypass, sleeve gastrectomy, gastric band and revisional surgery, respectively. There were no differences in baseline demographic or co-morbidity data between the two groups of patients (Table 1). The length of stay in the hospital was significantly shortened from 3.7 (95 % CI 3.1–4.7) days to 2.1 (95 % CI 1.6–2.6) days (p < 0.001) following the ERABS protocol compared to the pre-ERABS protocol. Procedure (surgical) times were shortened by 15 (7) min and 12 (5) min for gastric bypass and gastric sleeve surgery, respectively (P < 0.001 for both), by introducing the ERABS protocol. Induction times were reduced from 15.2 (95 % CI 14.3–16.1) min to 12.5 (95 % CI 11.7–13.3) min (P < 0.001). Turnover times shortened significantly from 38 (95 % CI 44–32) min to 11 (95 % CI 8–14) min. The incidence of re-operations, readmissions and complications within 30 days after discharge did not change after implementation of the ERABS protocol (Table 2). The reduction in the length of stay in hospital can be explained by the change in the anesthesia protocol; this ensured that the patient became mobile as soon as possible following the surgical procedure, quickly regaining full mobility, including oral food intake. The procedure time decreased by shortening the induction time and surgical time but also as a result of introducing the ‘working with a fixed team’ concept. A dedicated group of surgeons, anesthesiologist and circulating nurses worked together. Instead of operating on two to four patients per day on several days of the week with different anesthesiologist and nurses, the team now works together all day for 2 days per week. This contributes to team cohesion and may increase the team work and safety climate and productivity [9, 10]. In conclusion, our study confirms that the use of ERABS makes it possible to create centers which are able to process a large number of bariatric cases and at the same time maintain the quality as well as efficiency of surgery, while ensuring the highest safety standards [11, 12].