Early Recovery after Bariatric Surgery

Alfonso Torquati, MD, MSCI, FACS

Associate Professor and Chief

Division of Metabolic and Bariatric Surgery

KEY PROBLEM

Bariatric Surgery

Treat severe obesity

Cure obesity related comorbidity

Associated with significant perioperative morbidity

Prolong convalescence

Impair surgical recovery

Enhanced Recovery After Surgery (ERAS) protocols

Multiple evidence-based perioperative care interventions to optimise and standardise perioperative care

Reduce morbidity and length of stay (LOS) in other types of surgery

Comparably less evidence in bariatric surgery

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What is ERAS?

AKA Fast-track or ERP

Developed by Kehlet in Denmark in colonic

surgery

Gradually has gained world-wide acceptance

Originally described in Open Surgery but same

advantages seem to apply for Laparoscopy

ERAS Results

Type of Operation Duration of stay

Carotid endarterectomy 1-2 days

Lung lobectomy 1-2 days

Prostatectomy 1-2 days

Colectomy 1-3 days

Aortic Aneurysm 3-4 days

What is ERAS?

Patient Information

• At the clinic

• Ward visit

Carbohydrate drinks

4 night before surgery if having bowel prep

2 morning of the surgery

No mechanical bowel preparation

Enema morning of surgery for L) sided cases

Patients admitted on the morning of surgery

Pre-op

Thoracic Epidural Analgesia

Incision choice

Transverse for R) sided

Mid-line or Laparoscopic for L) sided

Avoidance of Drains and NGT post-operatively

Limited Intra-Operative fluid therapy

Aiming to max of 1.5-2 L

Goal Directed

Surgery

Cessation of IVF

unless clinically indicated

Pressors for epidural hypotension

Regular pre-emptive antiemetics

ondansetron as first line

On arrival to the ward Patient sits up

Starts drinking protein drinks (Resource/Fortisip etc)

After surgery

Day 1 IDC removed in the morning

8 hrs of enforced mobilisation

Resumes normal diet

Pre-emptive oral analgesia is started Paracetamol and NSAIDs

Avoid Opioids

Day 2

Epidural infusion is stopped in the morning

Epidural Catheter is removed at 1400 if pain controlled,

and timed with Clexane dose

Day 3/4 - discharge criteria:

Return of GI function

Able to eat and drink without discomfort

Passing flatus, or moved a B/M

Pain controlled with oral analgesia

Adequate home support

Discharge date is an important target for

patients and staff but flexibility is vital

Length of hospital stay (days)

Experimental group= Enhanced Recovery After Surgery (ERAS) Control = Traditional Care (TC)

Complications

Experimental group= Enhanced Recovery After Surgery (ERAS)

Control = Traditional Care (TC)

Readmissions (days)

Experimental group= Enhanced Recovery After Surgery (ERAS)

Control = Traditional Care (TC)

Mortality

Experimental group= Enhanced Recovery After Surgery (ERAS)

Control = Traditional Care (TC)

ERAS in Bariatrics

Randomised Controlled Trial

2 Arms

ERAS vs. Standard Perioperative Care

Population

Patients undergoing laparoscopic sleeve gastrectomy (LSG) for weight loss

Eligibility Criteria

Procedure at Manukau Surgery Centre (MSC)

Consenting surgeon

Exclusion Criteria

Not at MSC

Redo procedure

Intervention and Control

Perioperative care as per Bariatric Specific ERAS protocol

VS.

Standard perioperative care

Outcomes

Primary outcome was initial median length of hospital stay (LOS)

Powered to detect a reduction in median LOS from 3 (current figure) to 1 (target from the literature)

:0.05; β:0.8; Sample Size = 56 (28 in each arm)

Follow up time

30 day follow up

Further analysis planned for longer term follow up on weight loss data

Results

71 randomised 11 post randomization exclusions

60 patients included in analysis 31 ERAS group

29 Non ERAS group

Baseline Characteristics

ERAS (31) Non ERAS (29) p value

Mean Age 44.3 43.6 0.66

Female Gender (%)

23 (74) 24 (83) 0.54

Planned Admit to PCU (%)

8 (26) 1 (3) 0.027

Baseline Characteristics

ERAS (31) Non ERAS (29) p value

Mean Weight (kg)

132 133.6 0.78

Mean BMI (kg/m2)

46.2 46.7 0.80

Mean Excess Weight (kg)

66.9 67.8 0.85

Baseline Characteristics

ASA ERAS (31) Non ERAS (29) p value

ASA 1 1 0 1.00

ASA 2

18 18 0.80

ASA 3 12 11 1.00

Complications (Cx)

ERAS (31) Non-ERAS (29) p value

Total Cx (%) 9 (30) 7 (24) 0.77

Major Cx (%) 5 (16.1) 4 (13.7) 1.00

Leak (%) 2 (6.4) 2 (6.8) 1.00

Bleed (%) 3 (9.7) 2 (6.8) 1.00

Length of Stay (LOS)

ERAS (31) Non ERAS (29) p value

Initial LOS (median)

1 2 <0.001

Readmissions (%)

5 (18) 5 (18) 1.00

Conclusion

ERAS is possible in a New Zealand public hospital.

ERAS is safe in a New Zealand Hospital

ERAS enhances recovery in a New Zealand Hospital

ERAS is cost-effective in a New Zealand Hospital

ERAS is more than just Colorectal Surgery

3-3c_HRT1215-Session_LEMANU_CMDHB_NZ

Enhanced Recovery After Laparoscopic Sleeve

Gastrectomy: A Randomised Controlled Trial

Presenter: Daniel Peter Lemanu

1. South Auckland Clinical School, School of Medicine, Faculty of Medical and

Health Sciences, University of Auckland, NEW ZEALAND

2. Middlemore Hospital, Counties Manukau District Health Board, NEW ZEALAND

Innovation

HRT1215 – Innovation Awards

Sydney

11th and 12th Oct 2012

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AIM OF THIS INNOVATION

Aim:

To investigate whether a bariatric specific ERAS protocol was effective at improving recovery after LSG

A randomised controlled trial was conducted to investigate the efficacy and safety of an ERAS protocol

Exposure arm (EG): Perioperative care according to ERAS

Control arm (CG): Standard perioperative care

Matched propensity scores used to generate an historical control group (HCG) to account for potential cross over as a result of inadequate blinding

Primary outcome: Reduction in LOS from 3 days to 1 day requiring 38 patients in each arm

Other outcomes: Postoperative complications, readmission rates, postoperative fatigue, protocol compliance, perioperative costs

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BASELINE DATA

All procedures performed at the Manukau Surgery

Centre, Auckland, New Zealand

400 patients had LSG between 2006 and 2010

Primary outcome: Reduction in LOS from 3 days to 1

day

Other outcomes: Postoperative complications,

readmission rates, perioperative costs ($NZ)

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KEY CHANGES IMPLEMENTED

Exposure Group Control Group

Preoperative

Standardised education

Routine advice Formal goal setting

Tour of the ward

Intraoperative

Clear oral fluids up to 2 hours pre surgery

Care as per individual anaesthetist and

surgeon

CHO loading

8mg IV dexamethasone

Standardised anaesthesia

Intraperitoneal local anaesthetic

Avoidance of prophylactic drains and NGTs

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KEY CHANGES IMPLEMENTED

Exposure Group Control Group

Postoperative

Early instigation of oral fluid intake

Care as per surgeon

Mobilisation 2h after return to ward

Multimodal analgesia and antiemesis

Standardised thromboprophylaxis

Day 1 and week 1 phone call

Discharge Criteria

Adequate pain relief with non opioid agents Wound satisfactory

No postoperative complications HR<90, T ≤ 37.6, RR ≤ 20

Uneventful technical procedure Ambulatory

Oral intake ≥ 1L of water/24h Tolerating bariatric free oral fluids

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OUTCOMES SO FAR

Exposure

(n=40)

Control

(n=38)

Historic

(n=38) p

LOS Index

Admission

(IQR)

1 day

(1-2)a

2 days

(0)b

3 days

(2-4) <0.001

Readmission 8 8 8 0.991

LOS Total

(IQR)

1 day

(1-3)a

2 days

(1-2)b

3 days

(2-4) <0.001

aSignficantly reduced in ERAS group compared to both non-ERAS and historical group

bSignifcantly reduced in non-ERAS group compared to historical group

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OUTCOMES SO FAR

Exposure

(n=40)

Control

(n=38)

Historic

(n=38) p

Total

Complications 10 8 15 0.172

Major

Complications 5 5 6 0.906

Cost per

patient (SD)

$14,836.13

(13,092)a

$15,566.06

(14,920)b

$27,700.08

(26,976) 0.005

aSignificant reduction in the Exposure Group when compared to the Historical Group

bSignificant reduction in the Control Group when compared to the Historical Group

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LESSONS LEARNT

A bariatric specific ERAS protocol reduced LOS after

surgery and was cost effective without increasing

perioperative morbidity

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