Enhanced Recovery Protocol for Laparoscopic Sleeve Gastrectomy: Are Narcotics Necessary?
Enhanced recovery after surgery (ERAS) protocols have improved patient experience and outcomes in a variety of fields, including bariatric surgery. Given the increasing opioid epidemic in the USA, we sought to determine the impact of our own ERAS protocol on narcotic usage following laparoscopic sleeve gastrectomy.
Retrospective chart review was performed on patients undergoing primary laparoscopic sleeve gastrectomy for 6 months before and after implementation of an ERAS protocol. Our protocol strongly discouraged the use of narcotics in the postoperative period. Specific outcomes of interest were postoperative narcotic usage, length of stay, complications, and readmissions.
Patient characteristics were similar in the two groups. ERAS implementation did not correlate with changes in length of stay, complications, or readmissions. However, ERAS implementation was associated with dramatic reductions in the use of intravenous narcotics (100% vs 47%, p < 0.01) and oral schedule 2 narcotics (56% vs 6%, p < 0.01), with an increase in the usage of tramadol (0% vs 36%, p < 0.01). After ERAS implementation, 52% of patients were managed without the use of schedule 2 narcotics (0% pre-ERAS, p < 0.01) and 33% received no narcotics of any kind (0% pre-ERAS, p < 0.01).
Implementation of an ERAS protocol for laparoscopic sleeve gastrectomy is associated with a dramatic reduction in the use of narcotics in the postoperative period. This has implementation for the usage of narcotics for laparoscopic surgery and potential elimination of narcotics for certain patients and procedures.
KeywordsNarcotic Opioid Enhanced recovery after surgery ERAS Sleeve gastrectomy Bariatric surgery Minimally invasive surgery
The authors would like to acknowledge Kristina Arnold for her assistance with data acquisition and Koffi Wima for his assistance with data analysis.
RH designed the study and drafted the manuscript; RH, AS, and KS acquired the data; all authors interpreted the data, revised the manuscript, gave final approval of the manuscript, and are accountable for the work and its integrity.
Compliance with Ethical Standards
Conflicts of Interest
The authors declare that they have no conflict of interest.
- 2.Egli F, Hofer S, Greminger P, Rhyner K. [Combined GM-CSF and erythropoietin therapy in myelodysplastic syndrome]. Schweiz Med Wochenschr. 1989;119(49):1777–80.Google Scholar
- 4.King AB, Spann MD, Jablonski P, Wanderer JP, Sandberg WS, McEvoy MD. An enhanced recovery program for bariatric surgical patients significantly reduces perioperative opioid consumption and postoperative nausea. Surg Obes Relat Dis. 2018;14(6):849–56. doi: https://doi.org/10.1016/j.soard.2018.02.010.CrossRefGoogle Scholar
- 5.Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N et al. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS(®)) Society recommendations. World J Surg. 2013;37(2):259–84. doi: https://doi.org/10.1007/s00268-012-1772-0.CrossRefGoogle Scholar
- 10.Singh PM, Panwar R, Borle A, Goudra B, Trikha A, van Wagensveld BA 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;27(2):489–501. doi: https://doi.org/10.1007/s11695-016-2442-3.CrossRefGoogle Scholar
- 12.Kelly MA. Current Postoperative Pain Management Protocols Contribute to the Opioid Epidemic in the United States. Am J Orthop (Belle Mead NJ). 2015;44(10 Suppl):S5–8.Google Scholar
- 15.Mohanty S, Lee JS, Ross RA, Stricklen A, Carlin AM, Ghaferi AA. New Persistent Opioid Use after Bariatric Surgery. American College of Surgeons Clinical Congress. 2017. https://www.facs.org/media/press-releases/2017/ghaferi. Accessed August 15 2018.
- 18.Barreca M, Renzi C, Tankel J, Shalhoub J, Sengupta N. Is there a role for enhanced recovery after laparoscopic bariatric surgery? Preliminary results from a specialist obesity treatment center. Surg Obes Relat Dis. 2016;12(1):119–26. doi: https://doi.org/10.1016/j.soard.2015.03.008.CrossRefGoogle Scholar
- 20.Matłok M, Pędziwiatr M, Major P, Kłęk S, Budzyński P, Małczak P. One hundred seventy-nine consecutive bariatric operations after introduction of protocol inspired by the principles of enhanced recovery after surgery (ERAS®) in bariatric surgery. Med Sci Monit. 2015;21:791–7. doi: https://doi.org/10.12659/MSM.893297. CrossRefGoogle Scholar
- 23.DEA. Drug Scheduling. https://www.dea.gov/druginfo/ds.shtml. Accessed July 25 2018.
- 25.Shafi S, Collinsworth AW, Copeland LA, Ogola GO, Qiu T, Kouznetsova M et al. Association of Opioid-Related Adverse Drug Events With Clinical and Cost Outcomes Among Surgical Patients in a Large Integrated Health Care Delivery System. JAMA Surg. 2018;153(8):757–63. doi: https://doi.org/10.1001/jamasurg.2018.1039.CrossRefGoogle Scholar