Less pain and earlier discharge after implementation of a multidisciplinary enhanced recovery after surgery (ERAS) protocol for laparoscopic sleeve gastrectomy

  • Daniel B. Jones
  • Mohamad Rassoul A. Abu-Nuwar
  • Cindy M. Ku
  • Leigh-Ann S. Berk
  • Linda S. Trainor
  • Stephanie B. JonesEmail author



Laparoscopic sleeve gastrectomy (LSG) may be complicated by postoperative pain, nausea, and vomiting, with consequent increases in length of stay (LOS), decreased patient satisfaction, and higher costs. While enhanced recovery after surgery (ERAS) protocols have been in circulation for many years, there is no standard ERAS protocol for bariatric surgery.


Data were collected prospectively and compared to a historical control. All patients undergoing LSG, ages 18 to 75, were included in the pathway; those with preoperative chronic opioid use were excluded from our results. Statistical analysis was performed using t-statistics and chi-squared test. Ninety patients undergoing LSG, performed by a single surgeon, were included in our ERAS group from November 26, 2018, to April 30, 2019, and were compared to a historical control of 570 patients who underwent LSG over the previous 5 years (pre-ERAS). Measured outcomes included discharge opioid prescriptions issued, hospital length of stay, 30-day readmissions, reoperations, morbidity, and mortality.


Ten (11%) ERAS patients vs 100% of pre-ERAS patients received opioid prescriptions upon, or after, discharge (p < 0.001). The ERAS group LOS decreased to 1.36 days vs 2.40 days in the pre-ERAS group (p < 0.001). 30-day readmission rates were 0% for ERAS patients vs 3.09% for pre-ERAS patients (p = 0.149). 30-day reoperation rates were 0% for ERAS patients vs 0.54% for pre-ERAS patients (p = 1). Thirty-day morbidity rates were 3.33% (3) for ERAS patients vs 3.27% for pre-ERAS patients (p = 1); there was no 30-day mortality in either group.


ERAS for LSG results in a clinical and statistically significant reduction in postoperative opioid use and LOS, without increasing 30-day readmissions, reoperations, morbidity, or mortality.


ERAS Sleeve gastrectomy PONV Length of stay Pain management TAP block 



We would like to thank Aaron Fleishman of the FIRST program at BIDMC for his continuous assistance in this project. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Compliance with ethical standards


Dr. Daniel Jones is on the advisory board for Allurion gastric balloon systems and PatientApps Inc. These data were presented in part at the 2019 European Association for Endoscopic Surgery Annual Congress, Sevilla, Spain. Drs. Mohamad Rassoul Abu-Nuwar, Cindy Ku, Stephanie Jones & Ms. Leigh-Ann Berk, and Linda Trainor have no conflicts of interest or financial ties to disclose.


  1. 1.
    Sjöström L, Narbro K, Sjöström CD, Karason K, Larsson B, Wedel H et al (2007) Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 357:741–752Google Scholar
  2. 2.
    Estimate of Bariatric Surgery Numbers, 2011–2017 | American Society for Metabolic and Bariatric Surgery, 2019.; [Accessed 3 May 2019].
  3. 3.
    Fletcher R, Deal R, Kubasiak J, Torquati A, Omotosho P (2018) Predictors of increased length of hospital stay following laparoscopic sleeve gastrectomy from the National Surgical Quality Improvement Program. J Gastrointest Surg 22:274–278CrossRefGoogle Scholar
  4. 4.
    Dogan K, Kraaij L, Aarts E, Koehestanie P, Hammink E, van Laarhoven CJ et al (2015) Fast-track bariatric surgery improves perioperative care and logistics compared to conventional care. Obes Surg 25(1):28–35CrossRefGoogle Scholar
  5. 5.
    Carmichael J, Keller D, Baldini G, Bordeianou L, Weiss E, Lee L et al (2017) Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of colon and rectal surgeons and Society of American gastrointestinal and endoscopic surgeons. Dis Colon Rectum 60(8):761–784CrossRefGoogle Scholar
  6. 6.
    Jiang X, Orton M, Feng R, Hossain E, Malhotra NR, Zager EL et al (2017) Chronic opioid usage in surgical patients in a large academic center. Ann Surg 265(4):722–727CrossRefGoogle Scholar
  7. 7.
    Awad S, Carter S, Purkayastha S, Hakky S, Moorthy K, Cousins J et al (2014) Enhanced recovery after bariatric surgery (ERABS): clinical outcomes from a tertiary referral bariatric centre. Obes Surg 24(5):753–758CrossRefGoogle Scholar
  8. 8.
    Bakker N, Cakir H, Doodeman HJ, Houdijk AP (2015) Eight years of experience with enhanced recovery after surgery in patients with colon cancer: impact of measures to improve adherence. Surgery 157:1130–1136CrossRefGoogle Scholar
  9. 9.
    Thorell A, MacCormick AD, Reynolds N, Roulin D, Demartines N, et al (2016) Guidelines for perioperative care in bariatric surgery: enhanced recovery after surgery (ERAS) society recommendations. World J Surg 40(9):2065–2083CrossRefGoogle Scholar
  10. 10.
    Maessen J, Dejong CHC, Hausel J, Nygren J, Lassen K, Andersen J et al (2007) A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg 94:224–231CrossRefGoogle Scholar
  11. 11.
    Telem D, Gould J, Pesta C, Powers K, Majid S, Greenberg JA et al (2017) American Society for metabolic and bariatric surgery: care pathway for laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 13(5):742–749CrossRefGoogle Scholar
  12. 12.
    Auer C, Laferton J, Shedden-Mora M, Salzmann S, Moosdorf R, Rief W (2017) Optimizing preoperative expectations leads to a shorter length of hospital stay in CABG patients: further results of the randomized controlled PSY-HEART trial. J Psychosom Res 97:82–89CrossRefGoogle Scholar
  13. 13.
    Devine EC, Cook TD (1983) A meta-analytic analysis of effects of psychoeducational interventions on length of postsurgical hospital stay. Nurs Res 32:267–274CrossRefGoogle Scholar
  14. 14.
    Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO (2011) Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med 124:144–154CrossRefGoogle Scholar
  15. 15.
    Anderin C, Gustafsson UO, Heijbel N, Thorell A (2015) Weight loss before bariatric surgery and postoperative complications: data from the Scandinavian Obesity Registry (SOReg). Ann Surg 261:909–913CrossRefGoogle Scholar
  16. 16.
    Ljungqvist O, Jonathan E (2012) Rhoads Lecture 2011: Insulin resistance and enhanced recovery after surgery. J Parenter Enter Nutr 36(4):389–398CrossRefGoogle Scholar
  17. 17.
    Feldheiser A, Aziz O, Baldini G, Cox BP, Fearon KC, Feldman LS et al (2016) Enhanced recovery after surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand 60(3):289–334CrossRefGoogle Scholar
  18. 18.
    Brady M, Ness V, O’Rourke K, Randhawa N, Stuart P (2009) Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev. CrossRefPubMedGoogle Scholar
  19. 19.
    Benevides ML, Oliveira SS, de Aguilar-Nascimento JE (2013) The combination of haloperidol, dexamethasone, and ondansetron for prevention of postoperative nausea and vomiting in laparoscopic sleeve gastrectomy: a randomized double-blind trial. Obes Surg 23:1389–1396CrossRefGoogle Scholar
  20. 20.
    Apfel C, Zhang K, George E, Shi S, Jalota L, Hornuss C et al (2010) Transdermal scopolamine for the prevention of postoperative nausea and vomiting: a systematic review and meta-analysis. Clin Ther 32(12):1987–2002CrossRefGoogle Scholar
  21. 21.
    Henzi I, Walder B, Tramer MR (2000) Dexamethasone for the prevention of postoperative nausea and vomiting: a quantitative systematic review. Anesth Analg 90:186–194CrossRefGoogle Scholar
  22. 22.
    Brandstrup B, Tonnesen H, Beier-Holgersen R, Hjortso E, Ording H, Lindorff-Larsen K et al (2003) Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg 238:641–648CrossRefGoogle Scholar
  23. 23.
    Watts R, Thiruvenkatarajan V, Calvert M, Newcombe G, van Wijk R (2017) The effect of perioperative esmolol on early postoperative pain: a systematic review and meta-analysis. J Anaesthesiol Clin Pharmacol 33(1):28–39CrossRefGoogle Scholar
  24. 24.
    Weinbroum A (2012) Non-opioid IV adjuvants in the perioperative period: pharmacological and clinical aspects of ketamine and gabapentinoids. Pharmacol Res 65(4):411–429CrossRefGoogle Scholar
  25. 25.
    Arumugam S, Lau CS, Chamberlain RS (2016) Use of preoperative gabapentin significantly reduces postoperative opioid consumption: a meta-analysis. J Pain Res 9:631–640CrossRefGoogle Scholar
  26. 26.
    Wick EC, Grant MC, Wu CL (2017) Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques: a review. JAMA Surg 152(7):691–697CrossRefGoogle Scholar
  27. 27.
    Amr YM, Amin SM (2011) Comparative study between effect of pre- versus post-incisional transversus abdominis plane block on acute and chronic post-abdominal hysterectomy pain. Anesth Essays Res 5(1):77–82CrossRefGoogle Scholar
  28. 28.
    Mittal T, Dey A, Siddhartha R, Nali A, Sharma B, Malik V (2018) Efficacy of ultrasound-guided transversus abdominis plane (TAP) block for postoperative analgesia in laparoscopic gastric sleeve resection: a randomized single blinded case control study. Surg Endosc 32(12):4985–4989CrossRefGoogle Scholar
  29. 29.
    Pappas-Gogos G, Tsimogiannis KE, Zikos N, Nikas K, Manataki A, Tsimoyiannis EC (2008) Preincisional and intraperitoneal ropivacaine plus normal saline infusion for postoperative pain relief after laparoscopic cholecystectomy: a randomized double-blind controlled trial. Surg Endosc 22(9):2036–2045CrossRefGoogle Scholar
  30. 30.
    Mehta V, Vasu TS, Phillips B, Chung F (2013) Obstructive sleep apnea and oxygen therapy: a systematic review of the literature and meta-analysis. J Clin Sleep Med. CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Geubbels N, Bruin SC, Acherman YI, van de Laar AW, Hoen MB, de Brauw LM (2014) Fast track care for gastric bypass patients decreases length of stay without increasing complications in an unselected patient cohort. Obes Surg 24(3):390–396CrossRefGoogle Scholar
  32. 32.
    Pryor HI, Singleton A, Lin E, Lin P, Vaziri K (2013) Practice patterns in high-risk bariatric venous thromboembolism prophylaxis. Surg Endosc 27(3):843–848CrossRefGoogle Scholar
  33. 33.
    Osland E, Yunus RM, Khan S, Memon MA (2011) Early versus traditional postoperative feeding in patients undergoing resectional gastrointestinal surgery: a meta-analysis. J Parenter Enter Nutr 35:473–487CrossRefGoogle Scholar
  34. 34.
    Weibel S, Jelting Y, Pace NL, et al. (2018) Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults. Cochrane Database Syst Rev. 6(6):CD009642.PubMedGoogle Scholar
  35. 35.
    McCarthy GC, Megalla SA, Habib AS (2010) Impact of intravenous lidocaine infusion on postoperative analgesia and recovery from surgery: a systematic review of randomized controlled trials. Drugs 70(9):1149–1163CrossRefGoogle Scholar
  36. 36.
    Hoehn RS, Seitz AP, Singer KE et al (2019) Enhanced recovery protocol for laparoscopic sleeve gastrectomy: are narcotics necessary? J Gastrointest Surg 23:1541CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Authors and Affiliations

  1. 1.Division of Minimally Invasive & Bariatric Surgery, Department of SurgeryBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonUSA
  2. 2.Department of Anesthesia, Critical Care and Pain MedicineBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonUSA

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