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How can lean thinking improve ERAS program in bariatric surgery?

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Abstract

Introduction

Enhanced recovery after bariatric surgery protocol (ERABS) decreased length of hospital stay (LOS) without influencing clinical outcomes. ERABS improved logistics aspects in operating room (OR) with OR time savings. Lean management was used to reorganize OR logistics and to improve its efficiency. This study analyzed clinical and OR logistic aspects in ERABS protocols.

Methods

Retrospective analysis of prospectively maintained database of obese patients undergoing bariatric surgery from 2017 to 2019 was performed. Since September 2018, patients were treated with ERABS protocol (ERABS group). All patients treated with a standard protocol between January 2017 and September 2018 (control group) were compared to ERABS group. Preoperative (anthropometric data, surgical and medical history) and intraoperative (type of procedure) were analyzed in two groups. LOS was the primary outcomes parameter analyzed; complications, readmissions and reoperations within 30 days were the secondary outcomes. Logistic endpoints were evaluated in time saving and efficiency: surgical time, team work time and total anesthesia time.

Results

471 patients underwent bariatric surgery: 239 patients (control group) compared to 232 patients (ERABS group). ERABS presented more previous surgical history rate (p = 0.04) compared to control group with difference of type of procedure performed (p < 0.001). Roux-en-Y gastric bypass was mainly procedure in both groups (61.1% in control group compared to 52.6% in ERABS groups). Mean LOS was shorter in ERABS (3.16 days) compared to control group (4.81 days) with no difference in clinical outcomes rate. All logistics endpoints showed a time savings in ERABS group compared to control group (surgical procedure, total anesthesia and team work time, p < 0.001). In multivariate analysis, LOS was associated to ERAS status (IRR 0.722; p < 0.0001), team work time (IRR 1.002; p = 0.002), surgical procedure time (IRR 1.002; p < 0.0001). ERAS status was not associated with complication neither readmission, but surgical procedure time was a factor associated with complication (IRR 1.011; p = 0.0008).

Conclusion

This study confirmed that ERABS protocol is safe and a feasible alternative with improved LOS. OR reorganization and logistic efficiency achieved using lean management helped reduce all OR times and these are likely related to the improvement in LOS and complication.

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Authors and Affiliations

  1. Obesity Surgery Unit, Surgical Department, “AO Brotzu” Hospital, Cagliari, Italy

    Giovanni Fantola, Marina Agus, Matteo Runfola, Daniela Sanna, Federica Fortunato, Stefano Pintus & Roberto Moroni

  2. Department of Life and Environmental Sciences, University of Cagliari, Cagliari, Italy

    Cinzia Podda

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  1. Giovanni Fantola
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  2. Marina Agus
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Contributions

GF: conception and design, acquisition of data, analysis and interpretation of data, rafting the article, final approval of the version to be published. MA: acquisition of data, revising article. MR: rafting the article, final approval of the version to be published. CP: analysis and interpretation of data. FF: acquisition of data, revising article. DS: rafting the article, final approval of the version to be published. SP: acquisition of data, revising article. RM: conception and design, rafting the article, final approval of the version to be published.

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Correspondence to Giovanni Fantola.

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Disclosures

Giovanni Fantola, Marina Agus, Matteo Runfola, Cinzia Podda, Federica Fortunato, Daniela Sanna, Stefano Pintus and Roberto Moroni have no conflicts of interest or financial ties to disclose.

Ethical statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the Helsinky declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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Fantola, G., Agus, M., Runfola, M. et al. How can lean thinking improve ERAS program in bariatric surgery?. Surg Endosc 35, 4345–4355 (2021). https://doi.org/10.1007/s00464-020-07926-5

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  • DOI: https://doi.org/10.1007/s00464-020-07926-5

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