Postoperative Care and Functional Recovery After Laparoscopic Sleeve Gastrectomy vs. Laparoscopic Roux-en-Y Gastric Bypass Among Patients Under ERAS Protocol

Data concerning bariatric patients treated for morbid obesity in one academic center were prospectively gathered. Recommendations of the Metabolic and Bariatric Surgery Section of the Polish Surgical Society were used as indication for surgery, that is body mass index (BMI) ≥ 35 kg/m² with obesity-related comorbidities or BMI ≥ 40 kg/m² [11, 12]. Inclusion criteria for this study were informed consent to participate in the study, meeting the eligibility criteria for bariatric treatment, either for LSG or LRYGB. We excluded patients with insufficient data (Fig. 1). Study was designed and described according to all STROBE checklist points for observational studies [13].

Data collection was performed by authors, who were also directly involved in treatment process. Database included demographic characteristics and factors related to the surgery. Features describing patient profile included age, sex, maximal preoperative BMI, BMI on a day of operation, American Society of Anesthesiologist​s (ASA) class, and main comorbidities (cardiovascular diseases, arterial hypertension, obstructive sleep apnea syndrome, diabetes mellitus type 2). Perioperative variables were type of procedure, operative time, intraoperative adverse events, postoperative complications, length of hospital stay (LOS), readmissions, reoperations, fever, postoperative nausea and vomiting, stool passage after surgery during the hospitalization, diuretics management, painkillers management, and data concerning postoperative fluid management (intravenous fluid administration, oral fluid intake, and diuresis) during the operation day and first three consecutive postoperative days. Patients were divided into two groups: LSG and LRYGB. An intraoperative adverse event was defined as any iatrogenic harmful event occurring during operation, which had not derived from standard LSG or LRYGB technique. We defined postoperative complications as adverse events occurring within 1 year of the procedure. Rhabdomyolysis was defined as elevated levels of creatinine phosphokinase (CPK > 1000 IU/l) with coexisting increase of myoglobin level. Gastrointestinal leakage was defined as leakage from the GI tract clinically diagnosed and confirmed with radiological examination. Postoperative hemorrhage was defined as a significant drop in hemoglobin count with either clinically demonstrated hemorrhage requiring reoperation or need of erythrocyte transfusion. LOS was defined as period from admission to discharge, based on number of nights spent in hospital. All patients were admitted to hospital 1 day prior to surgery, so if the patient would be discharged on the day of surgery, his LOS would be 1 day.

In order to minimize bias, patients were treated in accordance with enhanced recovery after surgery (ERAS) pathway, including preoperative, intraoperative, and postoperative interventions [6, 14, 15]. During the preoperative period, patients were appropriately counseled. The health status of all patients was assessed with particular emphasis on incidence of type 2 diabetes mellitus, hypertension, obstructive sleep apnea, and gastroesophageal reflux disease (GERD). Incidence of GERD was assessed during history taking by a direct question and questions concerning taking proton-pump inhibitors. Preoperative consultations included also routine endoscopy of the upper gastrointestinal tract with assessment of hiatal hernia and esophageal, gastric, or duodenal mucosa pathology. In case of a large hiatal hernia with inflammatory lesions in esophageal mucosa, patients were treated with pantoprazole and qualified for LRYGB. If hiatal hernia did not coexist with inflammatory lesions in esophageal mucosa or clinical symptoms of GERD requiring pharmacotherapy, we suggested LSG with possible simultaneous cruroplasty in case of large gap in the diaphragm. Final decision was made by patients. During endoscopy, gastric mucosa tissue biopsy sample was obtained to perform rapid urease test for Helicobacter pylori infection (Campylobacter-like organism (CLO) test). In case of positive result of CLO test, eradication was conducted accordingly to guidelines from the Polish Society of Gastroenterology for the diagnosis and treatment of Helicobacter pylori infection [16]. Nutritional intervention included high-protein and high-carbohydrate drinks. General anesthesia, obligatory in laparoscopic surgery, was conducted accordingly to the optimized bariatric anesthetic protocol with the use of multimodal analgesics. Patients undergoing LRYGB and LSG did not require standard usage of the nasogastric tubes and intra-abdominal drains. Postoperative pain management did not include standard usage of opioids. Enoxaparin used for antithrombotic prophylaxis was administered for 14 consecutive postoperative days. All patients received routinely pantoprazole (40 mg/day) for 30 consecutive postoperative days or longer in case of postoperative incidence of GERD symptoms. After surgery, patients were mobilized and had enteral feeding introduced early. Our target is to not use intravenous fluids in postoperative period routinely. Fluids were given only if we observed absence of sufficient functional recovery: vomiting, insufficient oral fluid intake (less than 500 ml until 4:00 pm), insufficient diuresis, or biochemical symptoms of rhabdomyolysis expressed by the high blood level of myoglobin, CPK, and low GFR (glomerular filtration rate). Every bariatric patient in our center is scheduled to have three follow-up appointments: 2 weeks after discharge, 1 month after discharge, and 3 months after discharge.

Surgical techniques for LSG and LRYGB were standardized [17]. Veress needle was used to achieve pneumoperitoneum (15 mmHg). Routine procedure required insertion of four trocars during LSG and five trocars during LRYGB. A sealer/divider or ultrasonic shears were used for a dissection and coagulation (LigaSure Atlas™, Covidien or SonoSurg™, Olympus). A 34-French gastric bougie inserted into the stomach along the lesser curvature was used to calibrate the gastric sleeve. Gastrectomy started 4–5 cm proximal to the pylorus with continuously applied linear staplers, starting with two firings of 60 mm, Ethicon Echelon EndoFlex with gold cartridges (3.8 mm open stapler height, 1.8 mm closed stapler height), then continued with blue cartridges (3.6 mm open stapler height, 1.5 mm closed stapler height) straight to the angle of His. Stapler line was reinforced by a running 3-0 PDS suture. Resected portion of the stomach was removed from the peritoneal cavity through the left flank trocar site during LSG. LRYGB required creation of a pouch by one horizontal 45-mm stapler followed by vertical stapling toward the angle of His, until the pouch was totally separated from the rest of the stomach. Gastrojejunal anastomosis was created with a linear stapler Ethicon Echelon EndoFlex (45 mm, with blue cartridges, open staple height 3.5 mm, closed staple height 1.5 mm) with hand-sewn closure of the remaining defect (3/0 Vicryl, Ethicon). The length of alimentary and enzymatic limb was standardized in all patients, respectively, 150 and 100 cm. Jejunojejunal anastomosis was created using a linear stapler Ethicon Echelon EndoFlex (45 mm, with white cartridge, open staple height 2.5 mm, closed staple height 1 mm). Petersen’s defect was not routinely closed as prevention for internal hernias. A routine 10/12 mm port sites closure was performed to prevent herniation.

Our primary endpoints were factors determining the influence of the type of bariatric procedure on postoperative functional recovery:

Secondary endpoint was analysis of operative outcomes influenced by the type of bariatric procedure:

All data were analyzed with Statistica version 12.0 PL (StatSoft Inc., Tulsa, OK, USA). The results are presented as mean standard deviation (SD), median and interquartile range (IQR), and odds ratio (OR) with 95% confidence intervals (CI) when appropriate. The study of categorical variables used the chi-square test of independence. Shapiro-Wilk test was used to check for normal distribution of data, and the Student t test was used for normally distributed quantitative data. For non-normally distributed quantitative variables, the Mann-Whitney U test was used. Influence of the type of bariatric procedure on postoperative complications, gastrointestinal leakage, gastrointestinal stricture, postoperative hemorrhage, wound infection, pneumonia, reoperation, readmission, fever, PONV, stool passage, extra pain killer management, diuretics management, and incidence of intravenous fluid administration during the operation day and first to third postoperative day rates was analyzed in univariate logistic regression models. p value < 0.05 was considered statistically significant. Statistical power analysis was performed with power and sample size calculator for odds ratio: equality available from: http://​powerandsamplesi​ze.​com/​Calculators based on method by Chow et al. [18].

Five hundred eighty patients were treated for morbid obesity at tertiary referral academic institution from April 2009 to November 2016. Five hundred seventy-four patients met inclusion criteria and underwent LSG or LRYGB (362 females, 212 males, mean age 42.77 ± 11 years). Three hundred sixty-four (63.41%) patients underwent LSG (245 females, 119 males, mean age 40.88 ± 11.1 years) and 210 (36.59%) patients underwent LRYGB (117 females, 93 males, mean age 46.06 ± 10.08 years) (Fig. 1). Median maximal preoperative BMI and BMI on a day of operation were significantly higher in LRYGB group. Higher ASA classes were more often present in LRYGB group. Patients in LRYGB group presented significantly greater rates of comorbidities, including cardiovascular diseases (CVD), arterial hypertension (HTN), and diabetes mellitus (DM). Rates of obstructive sleep apnea (RD) were similar in bath groups (Table 1).

The limitations of the present study are typical for non-randomized design and relatively small group. Influence of the type of procedure on excess weight loss and improvement of obesity-related comorbidities after bariatric treatment was not analyzed.