An enhanced recovery program for bariatric surgical patients significantly reduces perioperative opioid consumption and postoperative nausea

doi:10.1016/j.soard.2018.02.010

Surgery for Obesity and Related Diseases

Volume 14, Issue 6, June 2018, Pages 849-856

https://doi.org/10.1016/j.soard.2018.02.010 Get rights and content

Abstract

Background

Patients frequently remain in the hospital after bariatric surgery due to pain, nausea, and inability to tolerate oral intake. Enhanced recovery after surgery (ERAS) concepts address these perioperative complications and therefore improve length of stay for bariatric surgery patients.

Objectives

To determine if ERAS concepts increase the proportion of patients discharged on postoperative day 1. Secondary objectives included mean length of stay, perioperative opioid use, emergency department visits, and readmissions.

Setting

A large metropolitan university tertiary hospital.

Methods

A quantitative before and after study was conducted for patients undergoing bariatric surgical patients. Data were collected surrounding length of stay, perioperative opioid consumption, antiemetic therapy requirements postoperatively, multimodal analgesia compliance, emergency department visits, and hospital readmission rates. Wilcoxon rank-sum and χ² test were used to compare continuous and categorical variables, respectively. A secondary analysis was performed using Aligned Rank Transformation and Cochran-Mantel-Haenszel χ² tests to account for an increase in sleeve gastrectomies in the intervention group.

Results

The 2 groups had clinically similar baseline characteristics. Comparison group (N = 366) and ERAS group (N = 715) patients underwent a primary bariatric surgery procedure. There was an increase in the number of patients undergoing a laparoscopic sleeve gastrectomy in the intervention group. After accounting for this increase, the percentage of patients discharged on postoperative day 1 was unchanged (79.8% non-ERAS versus 83.1% ERAS, P = .52). ERAS length of stay was statistically significantly lower for gastric bypass (P<.001) and robotic gastric bypass (P = .01). Perioperative opioid consumption was reduced (41.0 versus 16.2 morphine equivalents, P<0.001), and fewer ERAS patients required postoperative antiemetics (68.8% versus 46.2%, P<.001). Emergency department visits at 7 days were reduced (6.0% versus 3.2%, P = .04), but hospital readmission rates were unchanged.

Conclusions

Implementing ERAS did not reduce the percentage of patients discharged on postoperative day 1 in a bariatric surgery program with historically low length of stay, but it led to significant reductions in perioperative opioid use, decreases in postoperative nausea, and early emergency room visits.

Graphical abstract

Section snippets

Methods

After approval from our institutional review board, with a waiver of informed consent, we performed a quantitative, observational (before and after) process improvement study for patients undergoing primary bariatric operations requiring an inpatient stay at our institution for the year preceding the ERAS protocol implementation (January 1, 2014 through January 25, 2015) and for 21 months after implementation (January 26, 2015 through October 31, 2016).

Patients>18 years of age undergoing

Results

The comparison group included 366 patients and the ERAS group included 715 patients. Baseline characteristics were clinically similar between the 2 groups. However, there was noted to be an increase in the number of sleeve gastrectomies in the intervention group (31.7% versus 38.5%, P<.001; Table 1). Nine patients were excluded in the comparison group: 8 cases were revisional foregut procedures and 1 for a traumatic intubation that prolonged the hospital stay due to airway precautions. In the

Discussion

Quality initiatives employing ERAS principles have been successful in several surgical populations over the past 2 decades [5], [7], [9], [22]. Based on a manual chart review of long stay patients before ERAS implementation, pain, PONV, and dehydration are the primary reasons for patients remaining in the hospital after bariatric surgery or being readmitted after discharge. Thus, this population would appear to be a good target population for application of ERAS principles, and successful

Conclusions

We performed a quantitative, observational (before and after) process improvement study in metabolic and bariatric surgery that did not affect the primary outcome of increasing the proportion of discharges on POD1. However, introduction of ERAS was able to achieve improvements in patient-centered outcomes, such as reductions in postoperative nausea, opioid consumption, and early emergency room visits. Future research will need to assess whether these gains can be sustained or improved upon in a

Disclosures

The authors have no commercial associations that might be a conflict of interest in relation to this article.

References (36)

K.K. Varadhan et al.
Enhanced recovery after surgery: the future of improving surgical care
Crit Care Clin
(2010)
K.J. Coleman et al.
Three-year weight outcomes from a bariatric surgery registry in a large integrated healthcare system
Surg Obes Relat Dis
(2014)
N.J. Batdorf et al.
Enhanced recovery after surgery in microvascular breast reconstruction
J Plast Reconstr Aesthet Surg
(2015)
E.J. DeMaria et al.
Baseline data from American Society for Metabolic and Bariatric Surgery-designated Bariatric Surgery Centers of Excellence using the Bariatric Outcomes Longitudinal Database
Surg Obes Relat Dis
(2010)
M. Barreca et al.
Is there a role for enhanced recovery after laparoscopic bariatric surgery? Preliminary results from a specialist obesity treatment center
Surg Obes Relat Dis
(2016)
W.C. King et al.
Use of prescribed opioids before and after bariatric surgery: prospective evidence from a US multicenter cohort study
Surg Obes Relat Dis
(2017)
G. Ribaric et al.
Diabetes and weight in comparative studies of bariatric surgery vs conventional medical therapy: a systematic review and meta-analysis
Obes Surg
(2014)
R.A. Karlnoski et al.
Reduced postoperative pain and complications after a modified multidisciplinary approach for bariatric surgery
Open Obes J
(2013)
Y.K. Choi et al.
Efficacy and safety of patient-controlled analgesia for morbidly obese patients following gastric bypass surgery
Obes Surg
(2000)
B. Tufanogullari et al.
Dexmedetomidine infusion during laparoscopic bariatric surgery: the effect on recovery outcome variables
Anesth Analg
(2008)

T.E. Miller et al.

Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol

Anesth Analg

(2014)

K. Mortensen et al.

Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Society (ERAS®) Society recommendations

Br J Surg

(2014)

Cerantola Y, Valerio M, Persson B, et al. Guidelines for perioperative care after radical cystectomy for bladder...

K. Lassen et al.

Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations

World J Surg

(2013)

S. Awad et al.

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

Obes Surg

(2014)

D.P. Lemanu et al.

Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy

Br J Surg

(2013)

P. Malczak et al.

Enhanced recovery after bariatric surgery: systematic review and meta-analysis

Obes Surg

(2017)

P.M. Singh et al.

Efficiency 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)

Cited by (49)

Utilization of an Enhanced Recovery After Surgery (ERAS) protocol for pediatric metabolic and bariatric surgery
2023, Journal of Pediatric Surgery
Citation Excerpt :
Notably, only one patient in the protocol group required an opioid script after discharge [15]. In a quality improvement initiative reported by King et al., both utilization of anti-nausea medications and opioid consumption was significantly reduced after implementation of an ERAS protocol that included pre-operative gabapentin and acetaminophen, bilateral rectus sheath blocks, and dexamethasone for prophylactic nausea control [14]. All of these interventions have been implemented in our ERAS protocol, leading to a significant decrease in opioid consumption.
Enhanced recovery after surgery (ERAS) protocols for pediatric metabolic and bariatric surgery are limited. In 2018, an ERAS protocol for patients undergoing robotically assisted vertical sleeve gastrectomy (r-VSG) was instituted. This study's aim was to compare outcomes before and after ERAS initiation.
A single institution retrospective review of patients undergoing r-VSG from July 2015 to July 2021 was performed. The multimodal ERAS protocol focused on limiting post-operative nausea and narcotic utilization. Subjects were categorized into non-ERAS (July 2015–July 2018) and ERAS (August 2018–July 2021) groups. In-hospital and 30-day outcomes were compared.
110 subjects (94 females) with a median age of 17.6 years (range 12.5–22.0 years) were included (60 non-ERAS, 50 ERAS). Demographics were similar except for a higher proportion of females in the non-ERAS group (97% vs 72%, p < 0.001). A significant decrease in narcotic use (p < 0.001) and higher utilization of acetaminophen (p < 0.001) and ketorolac (p < 0.001) was observed in the ERAS group. Additionally, median time to oral intake, a proxy for postoperative nausea and vomiting [2:00 h (1:15, 2:30) vs. 3:22 h (2:03, 6:15), p < 0.001] and hospital length of stay (LOS) [1.25 days (1.14, 1.34) vs. 2.16 days (1.48, 2.42), p < 0.001] were shorter in the ERAS group. Eleven subjects (10%; ERAS = 5, non-ERAS = 6) experienced post-discharge dehydration, prompting readmission 8 times for 7 (6%) individuals.
Utilization of ERAS led to a significant decrease narcotic utilization, time to first oral intake, and hospital LOS with no change in adverse events following pediatric metabolic and bariatric surgery. Larger studies, including comparative analysis of health care utilization, should be carried out.
III.
Treatment Study.
Comment on: Dexmedetomidine reduces postoperative pain and speeds recovery after bariatric surgery: a meta-analysis of randomized controlled trials
2022, Surgery for Obesity and Related Diseases
Postoperative nausea and vomiting in bariatric surgery: a position statement endorsed by the ASMBS and the ISPCOP
2021, Surgery for Obesity and Related Diseases
The influence of preoperative carbohydrate loading on postoperative outcomes in bariatric surgery patients: a randomized, controlled trial
2021, Surgery for Obesity and Related Diseases
Citation Excerpt :
After the implementation of their ERAS protocol, there was decreased morbidity and major complication rates postoperatively. Another study by King et al. implemented a new ERAS protocol that also incorporated preoperative carbohydrate drinks by having patients consume Gatorade drinks the night before and morning of surgery [12]. They found decreased perioperative opioid use and early emergency department visits.
Preoperative carbohydrate loading is a component of Enhanced Recovery After Surgery (ERAS) protocols, but there is limited literature in bariatric surgery patients.
The objective of this study was to characterize the impact of preoperative carbohydrate loading on postoperative bariatric surgery outcomes.
University Hospital.
Patients undergoing a primary minimally invasive Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between 2018 and 2020 were randomized to standard management or intervention. Standard management patients were nothing by mouth (NPO) after midnight prior to surgery. Intervention patients consumed 2 carbohydrate drinks: 1 the night before and another 3 hours prior to surgery. Primary outcomes analyzed included postoperative nausea and vomiting (PONV), length of stay, and overall complications.
In total, 134 patients were analyzed: 64 intervention (47.8%) and 70 (52.2%) standard. In the end, 7% and 15% of patients were lost to follow-up at 6-weeks and 3-months, respectively. There was no statistically significant difference in length of stay (2.0 ± 1.2 vs 2.1 ± .9 d; P = .65) or postoperative outcomes between the 2 groups. There were no episodes of aspiration among the intervention group. Among RYGB patients, intervention patients had a shorter duration of nausea compared with standard patients. There was no significant difference in glycemic control among patients with and without diabetes.
Preoperative carbohydrate drinks can be administered to bariatric surgery patients without significant risks. Carbohydrate loading preoperatively can decrease the duration of PONV in RYGB patients. Carbohydrate drinks can be safely included in bariatric ERAS protocols for patients with and without diabetes, although the benefits remain unknown.
Clinical significance of diabetes control before metabolic surgery
2021, Surgery for Obesity and Related Diseases
Even though observational studies have suggested that poor preoperative diabetes control increases risk after major abdominal surgery, it is unclear whether this effect is seen in metabolic surgery patients.
To determine whether poor preoperative diabetes control is associated with worse outcomes in patients with obesity and diabetes undergoing metabolic surgery.
Metabolic and Bariatric Surgery Quality Improvement Project (MBSAQIP) database.
Using the MBSAQIP 2017 and 2018 database and preoperative glycated hemoglobin (HbA1C) as a diabetes control surrogate, we examined the association between diabetes control and major outcomes of primary laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) in patients with diabetes and obesity. Multivariate logistic regression modeling examined five 30-day postoperative outcomes: composite serious complications (composite of 10 adverse events), composite infection (composite of 7 infectious complications), length of stay >5 days, reoperation, and readmission. Models were adjusted for multiple covariates.
In total, 26,674 patients with HbA1C data available within 30 days before metabolic surgery were included in the primary analysis and 35,884 patients with HbA1C data within 90 days before surgery were included in the sensitivity analysis. The mean body mass index (BMI) and preoperative HbA1C were 45.6 ± 8.2 kg/m² and 8.2 ± 2.7%, respectively. The incidence of 30-day postoperative infections and serious complications were 1.62% and 1.35%, respectively. Neither primary analysis nor sensitivity analysis demonstrated any association between higher HbA1C and worsening of 5 primary outcomes of interest. The odds ratio of an overall effect for SG was 1.01 (95% CI .98–1.03; P = .58) and for RYGB was .99 (95% CI .96–1.02; P = .41).
Suboptimal preoperative diabetes control is not associated with increased adverse events and should not delay metabolic surgery, as metabolic surgery is generally a safe procedure and intrinsically improves diabetes control.
Does ERAS impact outcomes of laparoscopic sleeve gastrectomy in adolescents?
2020, Surgery for Obesity and Related Diseases
Citation Excerpt :
The median value of opioid volume used in the ERAS group was nearly half of the value used in the conventional group (11.2 versus 20 morphine equivalents intraoperatively, 10 versus 21.5 morphine equivalents postoperatively). The significant reduction in perioperative opioid consumption after ERAS in bariatric surgery was demonstrated in a few other studies as well [17,24–26], with decrease in postoperative pain scores in 2 of them [17,26]. The current opioid epidemic in the United States is related with the use and abuse of diverted prescription opioid medications.
Enhanced recovery after surgery (ERAS) protocols have been successfully implemented in several surgical fields; however, the application of ERAS in the pediatric population is still limited.
The aim was to determine if implementation of an ERAS protocol can improve outcomes of laparoscopic sleeve gastrectomy (LSG) in adolescents.
University Hospital, United States.
A retrospective analysis of 112 adolescent patients who underwent LSG from February 2011 to July 2019 was conducted. An ERAS protocol was instituted in June 2016. Conventional care patients (n = 51) were compared with ERAS patients (n = 61). Comparisons were made using Χ² tests or Fisher’s exact for categoric data and Wilcoxon-rank sum tests for continuous data. Multiple linear regression was used to adjust length of stay for patient characteristics.
The 2 cohorts were similar in age, sex, race, number of co-morbidities, and preoperative body mass index. The volume of intraoperative fluid, intraoperative and postoperative opioids were significantly reduced in the ERAS group (P < .0001). The number of ERAS elements received per patient increased from a median of 9 to 15 (P < .0001). ERAS group had more discharges on postoperative day 1 (48% versus 6 %, respectively). Length of stay was significantly lower in the ERAS group (2.34 versus 2.04 median d, respectively). Difference was still significant after adjusting for age, sex, race/ethnicity, payor status, American Society of Anesthesiologists score, preoperative body mass index, and the duration of surgery (P < .0001). There were no differences in postoperative complications and 30-day readmissions.
An LSG ERAS protocol is associated with significant reduction in perioperative opioid use and length of stay with no increase in complications or readmission rates.

View all citing articles on Scopus

^☆: Supported by the Foundation for Anesthesia Education and Research Health Services Research Grant and the Anesthesia Quality Institute (J.P.W.).

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Original articleAn enhanced recovery program for bariatric surgical patients significantly reduces perioperative opioid consumption and postoperative nausea☆

Abstract

Background

Objectives

Setting

Methods

Results

Conclusions

Graphical abstract

Section snippets

Methods

Results

Discussion

Conclusions

Disclosures

Crit Care Clin

Surg Obes Relat Dis

J Plast Reconstr Aesthet Surg

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Diabetes and weight in comparative studies of bariatric surgery vs conventional medical therapy: a systematic review and meta-analysis

Obes Surg

Reduced postoperative pain and complications after a modified multidisciplinary approach for bariatric surgery

Open Obes J

Efficacy and safety of patient-controlled analgesia for morbidly obese patients following gastric bypass surgery

Obes Surg

Dexmedetomidine infusion during laparoscopic bariatric surgery: the effect on recovery outcome variables

Anesth Analg

Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol

Anesth Analg

Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Society (ERAS®) Society recommendations

Br J Surg

Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations

World J Surg

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

Obes Surg

Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy

Br J Surg

Enhanced recovery after bariatric surgery: systematic review and meta-analysis

Obes Surg

Efficiency and safety effects of applying ERAS protocols to bariatric surgery: a systematic review with meta-analysis and trial sequential analysis of evidence

Obes Surg

Original article
An enhanced recovery program for bariatric surgical patients significantly reduces perioperative opioid consumption and postoperative nausea☆