Less pain and earlier discharge after implementation of a multidisciplinary enhanced recovery after surgery (ERAS) protocol for laparoscopic sleeve gastrectomy
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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.
KeywordsERAS 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.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.Estimate of Bariatric Surgery Numbers, 2011–2017 | American Society for Metabolic and Bariatric Surgery, 2019. https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers; [Accessed 3 May 2019].
- 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
- 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
- 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.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