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Background: Enhanced recovery after surgery (ERAS) programmes are evidence-based care improvement processes for surgical patients, which are designed to decrease the impact the anticipated negative physiological cascades following surgery. Aim: To perform a systematic review and meta-analysis of randomised clinical trials (RCTs) to evaluate the impact of ERAS protocols on outcomes following bariatric surgery compared to standard care (SC). Methods: A systematic review was performed in accordance with PRISMA guidelines. Meta-analysis was performed using Review Manager version 5.4 Results: Six RCTs including 740 patients were included. The mean age was 40.2 years, and mean body mass index was 44.1 kg/m2. Overall, 54.1% underwent Roux-en-Y gastric bypass surgery (400/740) and 45.9% sleeve gastrectomy (340/700). Overall, patients randomised to ERAS programmes had a significant reduction in nausea and vomiting (odds ratio (OR): 0.42, 95% confidence interval (CI): 0.19–0.95, P = 0.040), intraoperative time (mean difference (MD): 5.40, 95% CI: 3.05–7.77, P < 0.001), time to mobilisation (MD: − 7.78, 95% CI: − 5.46 to − 2.10, P < 0.001), intensive care unit stay (ICUS) (MD: 0.70, 95% CI: 0.13–1.27, P = 0.020), total hospital stay (THS) (MD: − 0.42, 95% CI: − 0.69 to − 0.16, P = 0.002), and functional hospital stay (FHS) (MD: − 0.60, 95% CI: − 0.98 to − 0.22, P = 0.002) compared to those who received SC. Conclusion: ERAS programmes reduce postoperative nausea and vomiting, intraoperative time, time to mobilisation, ICUS, THS, and FHS compared to those who received SC. Accordingly, ERAS should be implemented, where feasible, for patients indicated to undergo bariatric surgery. Trial registration International Prospective Register of Systematic Reviews (PROSPERO – CRD42023434492. [ABSTRACT FROM AUTHOR]

Background: Evidence shows that 14.2% of opioid-naive patients have long-term opioid dependence after bariatric surgery. Enhanced recovery after surgery (ERAS) protocols are widely used in bariatric surgery, while bariatric surgery targeting opioid prescriptions (BSTOP) protocols were recently introduced. We will investigate the combined impact of ERAS and BSTOP protocols after bariatric surgery. Methods: We conducted a retrospective review for patients who underwent either a sleeve gastrectomy or Roux-en-Y gastric bypass at a tertiary care center. Pre-intervention and post-intervention data were compared. Primary outcomes were length of stay (LOS), 30-day readmission, 30-day complications, and discharge on opioids. Multivariate Poisson regression with robust standard error was used to analyze LOS. Results: There was no significant difference in 30-day emergency room visits (3.3% vs. 4.0%; p value = 0.631), 30-day readmission (4.4% vs. 5.4%; p value = 0.577) or 30-day complication rate (4.2% vs. 6.4%; p value = 0.199). LOS was significantly lower in the post-intervention group; mean (interquartile range) 2 (1–2) days vs. 1 (1–2) day, p value < 0.001. On multivariate analysis, the post-intervention group had 0.74 (95% confidence interval 0.65–0.85; p value < 0.001) times lower LOS as compared to pre-intervention group. Patients with DM had a significantly longer LOS (relative risk: 1.22; p = 0.018). No other covariates were associated with LOS (p value < 0.05 for all). BSTOP analysis found a significant difference between the two groups. Discharge on opioids decreased from 40.6% pre-intervention to 7.1% post-intervention. Conclusion: ERAS and BSTOP protocols reduced length of stay and opioid need at discharge without an increase in complication or readmission rates. [ABSTRACT FROM AUTHOR]

Purpose : Complication rates after fast-track optimization in bariatric surgery are varying. The aim of this study was to identify short-term complications in patients undergoing laparoscopic sleeve gastrectomy (SG) in an ERABS (enhanced recovery after bariatric surgery) optimized setup. Materials and Methods: This study is an observational analysis of a consecutive cohort of 1600 patients undergoing SG at an ERABS-optimized, private hospital during 2020 and 2021. Primary outcomes were length of stay, mortality, readmissions, reoperations, and complications according to the Clavien-Dindo classification (CDC) within postoperative day (POD) 30 and 90. Secondary outcomes were weight loss and quality of life (QoL) according to Moorehead-Ardelt questionnaires during the first postoperative year. Results: Primary outcomes: 99.1% of patients were discharged within POD 1. The 90-day mortality rate was zero. There were 1% readmissions and 1.2% reoperations within POD 30. Total 30-day complication rate was 4.6%, where 3.4% accounted for CDC grades ≤ II, and 1.3% accounted for CDC grade III. There were zero grade IV–V complications. Secondary outcomes: One year after surgery, weight loss was substantial (p < 0.001), with an excess weight loss of 71.9%, and QoL had significantly increased (p < 0.001). Conclusion: This study demonstrates that the use of an ERABS protocol in bariatric surgery does not compromise neither safety nor efficacy. Complication rates were low, and weight loss was significant. This study thus provides strong arguments that ERABS programs are beneficial in bariatric surgery. [ABSTRACT FROM AUTHOR]

In 2016, the Enhanced Recovery After Bariatric Surgery guidelines (G16) was published, and in 2022, an update to it was released (G22). Grading of recommendations, assessment, development, and evaluations (GRADE), emphasizing the level of evidence (LoE) of both the guidelines, was performed. An overview of methodology was also performed, considering the following questions: how can research be improved, what can be done in the future using data, and how to collaborate more? Both guidelines did not explain how the LoE conclusions were derived regarding the risk of bias. There is also potential for forming a global consortium that deals with bariatric research, which can serve as a repository for all relevant data. Ensuring that this data is FAIR (findability, accessibility, interoperability, reusability) compliant and using this data to formulate future guidelines will benefit clinicians and patients alike. [ABSTRACT FROM AUTHOR]

Purpose: Evaluate adherence to bariatric surgery enhanced recovery after surgery (ERAS) protocols in pre-operative, operative, and post-operative phases, and to compare opiate use, nausea control, and length of stay (LOS) versus historical controls. Materials and Methods: A retrospective, observational cohort study was conducted to evaluate adherence to ERAS protocols and compare opiate and antiemetic use, pain intensity, and LOS versus those of traditional care (TC) patients preceding protocol implementation at Erie County Medical Center, a community-based hospital in Buffalo, NY, USA. Results: One hundred ERAS and TC patients were compared. Patients were similar in age (42.5 years), gender (female, ~ 80%), race (~ 80 white), and BMI (47 kg/m2). The primary procedure performed was sleeve gastrectomy (89% ERAS, 86% TC). Protocol adherence was high for ERAS phases: prior to admission (85–98%), pre-operative (96–100%), operative (93–99%), post-anesthesia care unit (PACU) (55–61%), and floor (86–98%). Opiate morphine milligram equivalent (MME) was reduced in ERAS vs. TC in hospital by 73% (43.5 ± 42.4 vs. 160 ± 116; p < 0.001), discharge prescribing by 53% (34.8 ± 38.2 vs. 74 ± 125 MME; p = 0.003), and in total by 69% (78.3 ± 67.5 vs. 252 ± 160; p < 0.001). Despite lower opiate use, ERAS had lower pain intensity entering PACU (1.1 ± 1.8 vs. 1.9 ± 2.6; p < 0.011), leaving PACU (1.7 ± 1.5 vs. 2.9 ± 1.5; p < 0.001), and floor day 0 (5.0 ± 2.1 vs. 5.9 ± 1.8; p < 0.001). Fewer ERAS required antiemetic day 0 (63% vs. 94%; p < 0.001). ERAS were discharged in fewer hours than TC (41.1 ± 15.5 vs. 52.1 ± 18.9 h; p < 0.001). Conclusions: Bariatric surgery ERAS protocols were implemented with a high rate of adherence and yielded profound reduction in operative and post-operative opiate use while improving pain control and nausea management in hospital and decreasing LOS. [ABSTRACT FROM AUTHOR]

Purpose: With the rising incidence of failed bariatric procedures, the importance of revisional surgery has been increasing. These revisional procedures come with a higher risk of complications leading to longer hospital stays. We believe though that enhanced recovery after revisional bariatric surgery is possible and needs to be advocated. Materials and Methods: We retrospectively analyzed our laparoscopic conversions of failed gastric banding and failed Mason gastroplasty to Roux-en-Y gastric bypass. A total of 321 patients was included in the study, from February 2010 until December 2019. The primary endpoints were length of stay (LoS), in-hospital complication rate, and early readmission rate (< 30 days). Logistic regression was used to investigate the impact of several independent variables on complication and readmission rates. Results: Fifty-four patients were male and 267 female. The mean age was 44.2 years and mean BMI at the time of conversion was 37.9 kg/m2. We converted 273 failed adjustable gastric bandings (85,0%) and 48 failed Mason gastroplasties (15.0%). The main reason for conversion was the recurrence of obesity. A mean LoS of 2.10 days was calculated. We had an overall in-hospital complication rate of 3.73% and the overall early readmission rate was 3.43%. The odds ratio for LoS on early readmission is 1.52 (p=0.0079; CI 95% [1.12–2.07]). Conclusion: The above data imply that the implementation of advanced ERAS principles for revisional surgery in our center is safe and does not lead to a higher risk of early readmission. [ABSTRACT FROM AUTHOR]

Overview: The global prevalence of obesity and increase in bariatric surgeries are burdening the healthcare system. Enhanced recovery postoperative protocols are associated with a reduction in hospitalization costs and length of stay (LOS) and may be an alternative to reduce public health expenses. Objective: To assess the impact of implementing a customized Enhanced Recovery After Bariatric Surgery (ERABS) protocol on hospitalization costs (HC), LOS, and complication rates. Setting: Santa Marcelina Hospital, São Paulo, Brazil. Methods: A retrospective electronic health record analysis of patients who underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy and who were cared for within a clinical pathway (CP) protocol (Jan. 2016–Aug. 2018) or after implementation of an ERABS protocol (Aug. 2018–Jun. 2019). The LOS, HC, and complication, readmission, and reoperation rates were compared between the two groups. Results: Eighty-two patients were included in the study (CP, 56, 87.5% women; ERABS, 26, 92.3% women). Hospital LOS and total HC decreased significantly by 32.5% and 15.2%, respectively (both, p < 0.05), after implementation of ERABS. There were no significant differences in 30-day readmission, complication, or reoperation rates. Conclusion: The implementation of a standardized enhanced recovery program resulted in reduced LOS and HC without an increase in perioperative morbidity. The ERABS protocol is cost-effective and can help ease the healthcare burden. [ABSTRACT FROM AUTHOR]

Objective: Our aim was to conduct an up-to-date systematic review of randomised controlled trials (RCTs) to determine the benefits and harms of enhanced recovery after surgery (ERAS) programme in bariatric surgery. Methods: MEDLINE, Embase, PubMed, CINAHL and the Cochrane Library were searched for RCTs on ERAS versus standard care (SC) until April 2020. The primary endpoint was the length of hospital stay (LOS). Results: Five RCTs included a total of 610 procedures. ERAS adoption is capable of significantly reducing LOS (MD of − 0.51; 95% CI − 0.92 to − 0.10; P = 0.01) and postoperative nausea and vomiting (PONV) (OR 0.42; 95% CI 0.19 to 0.95; P = 0.04). No significant differences in terms of adverse events and readmissions. Conclusions: The implementation of ERAS in bariatric surgery produces a significant reduction in LOS and PONV. [ABSTRACT FROM AUTHOR]

This study aims to understand the prevalent practices on the nutritional aspects of the enhanced recovery after surgery (ERAS) protocol based on the knowledge and practice of surgeons, nutritionists, and anesthesiologists who work in the bariatric and metabolic surgery (BMS) units worldwide. This cross-sectional study enrolled BMS unit professionals from five continents—Africa, America, Asia, Europe, and Oceania. An electronic questionnaire developed by the researchers was provided to evaluate practices about the three nutritional aspects of ERAS protocol in BMS (Thorel et al. 2016): preoperative fasting, carbohydrate loading, and early postoperative nutrition. Only surgeons, nutritionists, and anesthesiologists were invited to participate. One hundred twenty-five professionals answered the questionnaires: 50.4% from America and 39.2% from Europe. The profile of participating professionals was bariatric surgeons 70.2%, nutritionists 26.4%, and anesthesiologists 3.3%. Approximately 47.9% of professionals work in private services, for about 11 to 20 years (48.7%). In all continents, a large majority were aware of the protocol. Professionals from the African continent reported having implemented the ERAS bariatric protocol 4.0 ± 0 years ago. It is worth mentioning that professionals from the five continents implemented the ERAS protocol based on the published literature (p = 0.012). About preoperative fasting abbreviation protocol, a significant difference was found between continents and consequently between services (p = 0.000). There is no uniformity in the conduct of shortening of fasting in the preoperative period and the immediate postoperative period. Early postoperative (PO) period protein supplementation is not performed in a standard fashion in all units globally. ERAS principles and practices are partial and insufficiently implemented on the five continents despite the prevalent knowledge of professionals based on evidence. Moreover, there is no uniformity in fasting, immediate postoperative diet, and early protein supplementation practices globally. [ABSTRACT FROM AUTHOR]

Purpose: The enhanced recovery after surgery (ERAS) pathway is an evidence-based perioperative pathway that results in less pain, earlier recovery, and lower complication rates. Studies to prove their efficacy over standard recovery pathways in the Indian population are scarce. Our study intends to compare the outcomes of these pathways in the Indian community focusing on hospital stay, postoperative pain, and time for rescue analgesia. Materials and Methods: This is a single-blinded RCT involving 112 patients who underwent laparoscopic sleeve gastrectomy (LSG). The groups were divided into ERAS and standard pathway arms by closed envelope technique. The primary outcome was the length of hospital stay, while the secondary outcomes included pain score; postoperative nausea, and vomiting (PONV); time for rescue analgesia; and ambulation. Results: Of 112 patients included, 56 were allocated in the ERAS group, and the remaining 56 were included in the standard pathway group. We found no significant differences in the baseline characteristics between the two groups. Mean hospital stay was significantly lower in the ERAS group compared to the standard group (p = 0.003). In comparison to the standard group, ERAS patients were ambulated early, and the difference was highly significant (p < 0.001). Pain scores between the two groups showed a significant difference during the 4th hour and 8th hour. We also found a significant variation between the time for first rescue analgesia and the two groups (p < 0.001). Conclusion: Patients who followed ERAS protocol were found to have shortened hospital stay, decreased pain, early ambulation, and reduced need for rescue analgesia. Trial Registration: ClinicalTrials.gov Identifier: NCT03191318 [ABSTRACT FROM AUTHOR]

Background: Enhanced Recovery After Surgery (ERAS) pathways have been shown to improve postoperative outcomes. However, its application in bariatric surgery is still limited. The aim of the study was to define the safety of ERAS in bariatric patients with regard to postoperative complications, length of hospital stay (LOS), and readmission rates within 30 days from surgery. Methods: The effectiveness and safety of an ERAS protocol was prospectively investigated in morbidly obese patients who underwent bariatric surgery in a single-institute experience over a 2-year period. Results: Between June 2016 and September 2018, a total of 89 laparoscopic sleeve gastrectomy (SG), 105 Roux-en-Y gastric bypass (RYGB), and 8 one-anastomosis gastric bypass (OAGB) were performed. Twenty patients (9.9%) were revisional cases. Mean (standard deviation, SD) BMI and age at time of surgery were 43.2 (± 6.2) kg/m2 and 46 (± 11.3) years, respectively. Median (range) surgical time was 118 (45–255) minutes. Overall postoperative complication rate was 7.4%, with 6 (3.0%) patients developing grade III–IV complications according to the Clavien-Dindo classification. Median (range) LOS was 2 (1–50) days, with mean (SD) LOS of 2.3 (± 3.6) days. Overall, 36.6% of patients were discharged by first postoperative day and 77.7% by second postoperative day. Readmission rate was 4.5%. No mortality was observed during the study period. Conclusions: According to the results of the present study, ERAS in primary and revisional bariatric surgery is safe and feasible, with short LOS, low morbidity and readmission rates, and no mortality. A significant reduction of mean LOS was progressively noted over the study period. [ABSTRACT FROM AUTHOR]

Background: Although enhanced recovery after bariatric surgery (ERABS) has proven to be safe and cost-effective, this concept is relatively new in the Middle East. Methods: A retrospective analysis of consecutive registered cohorts of patients who underwent primary and purely laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) were compared before introduction of ERABS (2010–2014) and after ERABS (2015–2017) at Tawam Hospital/Johns Hopkins, the UAE. Results: A total of 462 eligible bariatric patients (LSG 414 and LRYGB 48) were operated on before and 1602 (LSG 1436 and LRYGB 166) after introduction of the ERABS. Significant improvements of mean patient time of the patient being within the OR for LSG (from 2:27 to 1:23 min, p = 0.000) and LRYGB (from 3:17 to 1:59 min, p = 0.000) were achieved when comparing pre-ERABS with after introduction of ERABS. Furthermore, there was a significant decrease in LOS in both LSG (from 3.2 to 1.5 days, p = 0.000) and in LRYGB (from 3.5 to 1.7 days, p = 0.000). Major (CD classification III–IV) complications decreased significantly in LSG (from 13.8 to 0.8%, p = 0.000) and were similar in LRYGB (from 4.2% to 3.0%, p = NS). The readmission rate for LSG (from 2.9 to 2.6%, p = NS) or LRYGB (from 0 to 4.8%, p = NS) and the reoperation rates after LSG (from 0.7 to 0.5%, p = NS) and LRYGB (from 0 to 2.4%, p = NS) did not differ between both groups following introduction of ERABS. Conclusions: Implementation of a standardized ERABS program in the Middle East is feasible and safe and leads to reduced LOS and OR times. [ABSTRACT FROM AUTHOR]

Background: Due to the slow development of bariatric surgery in mainland China, we aimed to provide fact-based status reports and recommendations for the development of bariatric surgery in mainland China by investigating the basic context, social environment, and perioperative treatment options of surgeons who perform bariatric surgery. Study Design: A questionnaire was prepared based on a literature review, consultations with experts and current issues. The three-part questionnaire was sent to medical professionals in the field of bariatric surgery. The results were gathered, and analysis was performed after collecting the data. Results: In total, 98.5% of respondents were employed at public grade 3 class A hospitals, 70.8% were chief physicians and professors, 53.2% were trained at other institutions before their first bariatric surgery, 65.0% were previously engaged in gastrointestinal surgery, 76.9% were currently engaged in multiple fields of general surgery, 39.5% believed that low self-acceptance was the primary obstacle, 39.0% regarded news media networks as the most valued publicity platform, 48.0% accepted patients less than 16 years old, and 46.0% accepted patients greater than 65 years old. Additionally, 84.6% of respondents addressed comorbidities, 73.4% developed exercise guidance for patients, 81.6% believed that the total hospitalization cost was greater than 50,000 (CNY), 41.5% chose oral purgative for bowel preparation, 40.0% allowed patients to resume oral intake of liquids on the first day after surgery, and 70.7% routinely placed an abdominal drainage tube. Conclusion: Bariatric surgery has great potential in mainland China, but many inconsistencies exist. This field is still in its infancy, and much work is needed. [ABSTRACT FROM AUTHOR]

Introduction: The enhanced recovery after surgery (ERAS) protocol, which emphasizes preoperative interventions, is safely implemented in patients undergoing bariatric surgery. Patients are additionally encouraged to achieve weight loss preoperatively. We aimed to identify factors contributing to preoperative weight loss and assess their influence on outcomes of bariatric surgery among patients under the ERAS protocol. Materials and Methods: We reviewed a prospectively created database in two bariatric centers with 909 bariatric patients treated in accordance with ERAS principles. The database included demographic characteristics, factors related to the surgery or perioperative period, and short-term outcomes. Our endpoints included analyses of (1) factors potentially contributing to preoperative weight loss and (2) the influence of preoperative weight loss on short-term outcomes of bariatric treatment. Results: Diabetes mellitus (p = 0.007), obstructive sleep apnea (p < 0.001), and previous surgery (p = 0.012) were identified as predictors of preoperative weight loss. Steatohepatitis (p < 0.001) and respiratory disorder (p = 0.004) decreased the chance of achieving satisfactory preoperative body mass reduction. Except for operative time, early outcomes of bariatric surgery were not influenced by preoperative weight loss. Patients who achieved preoperative weight loss were less likely to be lost to follow-up (p = 0.023). Postoperative weight loss was better in patients who could lose ≥ 5% total weight preoperatively (p = 0.009). Conclusion: Unsatisfactory preoperative weight loss among patients treated under ERAS principles is not associated with increased risk of complications. Satisfactory preoperative weight loss predicts superior postoperative weight loss and follow-up participation. [ABSTRACT FROM AUTHOR]

“Enhanced recovery after surgery” (ERAS) protocols may reduce morbidity, length of hospital stay (LOS), and costs. During the 4-year evolution of a bariatric ERAS protocol, we found that administration of thrombophylaxis selectively to high-risk morbidly obese patients (assessed postoperatively by Caprini score ≥ 3) undergoing omega loop gastric bypass (“mini” gastric bypass) or sleeve gastrectomy resulted in safe outcomes. Both procedures proved equally effective with this protocol. The vast majority of rapidly mobilized, low-risk patients did not appear to require antithrombotic heparin. Similar to other reported ERAS outcomes, our recent year’s results in 485 patients included a mean LOS of 1.08 ± 0.64 days (range 1-14), with 460 (95.0%) discharged on day 1 and 99.6% by day 2. There were 13 30-day complications (2.7%), two reinterventions (0.4%), and no hemorrhages. [ABSTRACT FROM AUTHOR]

Background: The most commonly performed bariatric procedures are laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). There are major differences between LSG and LRYGB during postoperative period. Optimization of the postoperative care may be achieved by using enhanced recovery after surgery (ERAS) protocol, which allows earlier functional recovery.Purpose: The aim was to assess differences in the course of postoperative care conducted in accordance with ERAS protocol among patients after LSG and LRYGB.Material and Methods: Data concerning patients treated for morbid obesity were prospectively gathered in one academic center. Patients were divided into two groups: LSG (n = 364, 63.41%) and LRYGB (n = 210, 36.59%). Multiple factors were used as endpoints to determine the influence of the type of bariatric procedure on postoperative course.Results: The rate of postoperative nausea and vomiting and incidence of intravenous fluid administration during the operation was higher in LSG group. LRYGB patients were able to tolerate higher oral fluid intake volumes during the first and the second postoperative day. Mean diuresis during the second and the third postoperative day was significantly higher in LRYGB group. Administration of diuretics and painkillers was comparable between groups, while the risk of fever after the operation was higher in LRYGB group. Mean length of stay was higher in LSG group (LRYGB vs. LSG, 3.46 days ± 1.58 vs. 3.64 days ± 4.41, p = 0.039).Conclusions: In our opinion, postoperative treatment after LSG requires more supervision and longer time until functional recovery is achieved. [ABSTRACT FROM AUTHOR]

Background: Bariatric surgery has become an increasingly popular method for weight loss and mitigation of co-morbidities in the obese population. Like any field, there is a desire to standardize and accelerate the postoperative period while maintaining safe outcomes. Methods: All laparoscopic sleeve gastrectomies (LSG) and gastric bypasses (LGB) were performed over a 5-year period were logged along with several aspects of postoperative care. Trends were followed in aspects of postoperative care over years as well as any documentation of complications or re-admissions. Results: A total of 545 LSGs and LBPs were performed between 2012 and 2016. Improvements were noted in nearly every field over time, including faster Foley removal, decreased length of hospital stay, decreased use of patient controlled analgesics (PCAs), and faster advancement of diet. There was also an abandonment of utilization of the ICU and step down setting for these patients, leading to significant decreases in hospital cost. There was no change in complications, re-operations, or re-admission in this time period. Conclusions: The surgeons involved in this project have built a busy bariatric surgery practice, while continually evolving the postoperative algorithm. Nearly every aspect of postoperative care has been deescalated while decreasing length of stay and cost to the hospital. All of this has been obtained without incurring any increase in complications, re-operations, or re-admissions. The authors of this paper hope to use this article as a launching point for a formal advanced recovery pathway for bariatric surgery at their institution and others. [ABSTRACT FROM AUTHOR]

Background: Strategic multidisciplinary protocols for 'enhanced recovery after surgery' (ERAS) have demonstrated reductions in length of hospital stay (LOS), morbidity, and costs in conjunction with bariatric procedures. Methods: We prospectively investigated the effectiveness and safety of an ERAS protocol with laparoscopic omega loop gastric bypass ('mini' gastric bypass, MGB) and LSG in morbidly obese patients. Results: Average LOS was 1.24 days (range 1-14); 86.1% discharged on day 1; 96.9% by day 2, a value comparable or better than that of other ERAS studies vs standard care according to meta-analysis. Complications 2.9%; readmission 2.1%; reintervention 1.3%. Conclusion: The program was equally safe with both procedures. Postoperative antithrombotic heparin does not appear necessary in low-risk patients. Bariatric surgical ERAS programs are evolving and not yet standardized. [ABSTRACT FROM AUTHOR]

Background: We discuss the anesthetic outcome in morbidly obese patients under the enhanced recovery after surgery (ERAS) protocol. Our evidence-based clinical pathways focused on prehabilitation and included interventions like aggressive preoperative optimization of medical comorbidities, familiarizing with perioperative protocols, thromboprophylaxis, opioid free multimodal analgesia, and early ambulation. Methods: We did a retrospective analysis of prospectively collected data of 823 patients who underwent laparoscopic bariatric surgery. Our goal was to assess the effects of BMI on the recovery and anesthetic outcome parameters, under the categories of severely obese (SeO: BMI <39.9 kg/m), morbidly obese (MO: BMI 40-49.9 kg/m), super-morbidly obese (SMO: BMI 50-59.9 kg/m), and super-super morbidly obese (SSMO: BMI >60 kg/m). Time to ambulate (TA) was the primary variable. Results: Requirement for non-invasive ventilation (NIV) was the only significant predictor of TA and discharge readiness (DR); the DR was further affected by functional capacity and presence of chest pain. Our analysis indicated that each unit increase in BMI (kg/m) contributes to increase in ambulation time by 1.24 min (95 % CI: 0.648 to 1.832 min; P < 0.001) and DR by 0.52 h (95 % CI: 0.435 to 0.606 h; P < 0.001). The odds ratio for requirement for NIV (per unit change in BMI) was 1.163 (CI: 1.127/1.197; P < 0.001). Conclusions: Aggressive preoperative optimization can avert effects of BMI on anesthetic outcome. Practice of prehabilitation and preoperative optimization of comorbidities using evidence-based clinical pathways can complement the principles of ERAS in patients undergoing bariatric surgery to facilitate their discharge readiness. [ABSTRACT FROM AUTHOR]

Application of the enhanced recovery after surgery (ERAS) to the bariatric surgical procedures is at its early stages with little consolidated evidence. This meta-analysis evaluates present literature and indicates pathways for development of evidence-based standardized ERAS protocols for bariatric surgery. Comparative trials between ERAS and conventional bariatric surgery published till June 2016 were searched in the medical database. Comparisons were made for length of stay (LOS), readmission, complications (major/minor), and reoperation rates. Trial sequential analysis (TSA) for the strength of meta-analysis was performed for the primary outcome LOS. Five subgroups with a total of 394 and 471 patients in ERAS and conventional group respectively were included. LOS was shorter in ERAS group by 1.56 ± 0.18 days (random-effects, p < 0.001, I = 93.07 %). The sample size in ERAS was well past the 'information size' variable which was calculated to be 189 as per the TSA for power 85%. MH odds ratio [1.41 (95% CI 1.13 to1.76)] was higher for minor complications in the ERAS group (fixed effects, I = 0, p < 0.001). Superiority/inferiority of ERAS could not be established for major or overall complications, readmission, and anastomotic leak rates. No publication bias was found in the included trials (Egger's test, X-intercept = 6.14, p = 0.66). Evaluation based on Cochrane collaboration recommendations suggested that all the five included trials had a high risk of methodological bias. ERAS protocols for bariatric procedures allow faster return to home for patients. The present bariatric ERAS protocols have high heterogeneity and would benefit from standardization. Minor complication rates increase with implementation of ERAS, however without any significant effect on overall patient morbidity. Further randomized trials comparing ERAS with conventional care are required to consolidate these findings. [ABSTRACT FROM AUTHOR]

The current understanding of prophylaxis of pulmonary complications in bariatric surgery is weak. Purpose: The aim of this study was to observe how changes in perioperative and postoperative treatments affect the incidence of pulmonary complications in bariatric patients. Materials: This is a retrospective clinical study of 400 consecutive bariatric patients. The patients, who either underwent a sleeve gastrectomy or a Roux-en-Y gastric bypass, were divided consecutively into four subgroups with different approaches to perioperative treatment. Methods: The first group (patients 0-100) was recovered in the intensive care unit with minimal mobilization (ICU). They had a urinary catheter and a drain. The second group (patients 101-200) was similar to the first group, but the patients used a continuous positive airway pressure (CPAP) device intermittently (ICU-CPAP). The third group (patients 201-300) was recovered on a normal ward without a urinary catheter or a drain and used a CPAP device (ward-slow). The fourth group (patients 301-400) walked to the operating theater and was mobilized in the recovery room during the first 2 h after the operation (ward-fast). CPAP was also used. Primary endpoints were pulmonary complications, pneumonia, and infection, non-ultra descriptus (NUD). Results: The number of pulmonary complications among the groups was significantly different. A long operation time increased the risk for infection ( p < 0.001 95 % CI from 2.02 to 6.59 %). Conclusions: Operation time increases the risk for pulmonary complications. Changes in perioperative care toward the ERAS protocol may have a positive effect on the number of pulmonary complications. [ABSTRACT FROM AUTHOR]

Enhanced recovery after surgery (ERAS) protocol is well established in many surgical disciplines and leads to a decrease in the length of hospital stay and morbidity. Multimodal protocols have also been introduced to bariatric surgery. This review aims to evaluate the current literature on ERAS in obesity surgery and to conduct a meta-analysis of primary and secondary outcomes. MEDLINE, Embase, Scopus and Cochrane Library were searched for eligible studies. Key journals were hand-searched. We analysed data up to May 2016. Eligible studies had to contain four described ERAS protocol elements. The primary outcome was the length of hospital stay; the secondary outcomes included overall morbidity, specific complications, mortality, readmissions and costs. Random effect meta-analyses were undertaken. The initial search yielded 1151 articles. Thorough evaluation resulted in 11 papers, which were analysed. The meta-analysis of the length of stay presented a significant reduction standard mean difference (Std. MD) = −2.39 (−3.89, −0.89), p = 0.002. The analysis of overall morbidity, specific complications and Clavien-Dindo classification showed no significant variations among the study groups. ERAS protocol in bariatric surgery leads to the reduction of the length of hospital stay while maintaining no or low influence on morbidity. [ABSTRACT FROM AUTHOR]

Background: High intraabdominal pressure (IAP) during laparoscopic surgery has been associated with postoperative discomfort. Effects on nausea and access have not been subjected to randomized studies. In cholecystectomy, lower IAP may cause less pain, but nausea and surgical access in RYGB surgery have not been investigated. We studied the influence of two IAP levels on surgical access, operation time, postoperative pain, and nausea. Methods: Fifty consecutive female gastric bypass patients were randomized to intraabdominal pressure of 12 (IAP) or 18 (IAP) mm Hg. Surgeons and personnel were blinded to randomization; study groups were well matched for age and BMI. Operative time was noted in minutes. Visual analogue scales were used for assessing access and for patients assessing pain (abdomen-shoulder) and nausea (supine-standing) at six time points during the first 16 postoperative hours. Rescue medication was recorded. Results: In 3/25 patients in the IAP group, the code was broken due to access problems vs. 0/25 in the IAP group ( p = 0.1398). Operative time did not differ. Access was significantly better for IAP (92.2 ± 2.3 vs. 69.3 ± 4.2; p = 0.0001). Postoperative shoulder pain was maximal after 6 h but throughout less than in the abdomen ( p < 0.0001); there were no differences in pain between IAP and IAP ( p = 0.7408). Postoperative nausea was significantly greater standing than supine but without differences between groups. Conclusion: Higher IAP gives better surgical access in laparoscopic Roux-en-Y gastric bypass with no negative effect on pain or nausea. [ABSTRACT FROM AUTHOR]

Background: Due to the rise in severe obesity in Western countries and the increase in bariatric surgery, enhanced recovery (ER) pathways should be developed and promoted. Methods: A monocentric prospective series of 103 bariatric surgery patients managed with the ER pathway (group ER) was compared with a retrospective and immediately previous series of 103 patients managed with standard care (group CS). The aim of the present study was to assess and compare the differences in terms of mean postoperative length of stay (LOS), costs for surgery and recovery, and the differences in terms of complications, readmission, and reoperation rate in the short term between the ER and CS groups. Results: The mean LOS was 4.18 days in group CS and 1.79 days in group ER ( p < 0.0001). The mean operative time (OT) per patient was 190.20 min in the group CS and 133.54 min in the group ER, resulting in an average cost of 7272.57€ per patient in group CS and 5424.09€ per patient in group ER. The average recovery cost was 1809.94€ for the group CS series and 775.07 for the group ER one. Overall complications (Clavien-Dindo up to II) occurred in 6 patients (5.8 %) in group CS and in 2 patients (1.9 %) in group ER ( p = 0.149) and specific complications (Clavien-Dindo IIIb) occurred for 9 patients (8.7 %) in Group CS and for 14 patients (13.5 %) in group ER ( p = 0.268) after hospital discharge within 1-month of follow-up. Twelve patients (11.5 %) in group CS and 13 (12.5 %) in group ER were readmitted after discharge ( p = 0.831) within 1-month of follow-up; 8 patients (7.7 %) in group CS versus 9 patients (8.8 %) in group ER needed to be reoperated ( p = 0.800) within 1-month follow-up. Conclusions: Enhanced recovery pathway reduces significantly LOS in bariatric surgical patients and shortens the mean OT of the procedure, with no significant differences in terms of surgical outcomes. Furthermore, recovery charges were lower and operative time was shorter allowing for procedural cost reduction. [ABSTRACT FROM AUTHOR]

Background: Enhanced recovery after surgery (ERAS) programs are well established for patients undergoing colorectal surgery. Relatively little is known about ERAS following bariatric surgery in general or following laparoscopic Roux-en-Y gastric bypass (LRYGB) in particular. Patients and Methods: This is a prospective, observational study of 388 consecutive patients that underwent LRYGB with ERAS in a general hospital. The ERAS protocol included standardizations of pre-, intra-, and postoperative modalities in order to reduce the stress response of the patients. Primary outcome measures were length of stay (LOS), postoperative morbidity, readmissions, and reoperations. Results: Mean (SD) baseline body mass index (BMI) and age was 46.4 (6.7) kg/m and 45.1 (11.2) years, respectively. Fifty-four percent of the patients were on medication for hypertension (HT) and 38 % for type 2 diabetes mellitus (DM2). Mean (SD) and median (range) surgical time was 73.8 (16.9) and 65 (40-143) min, respectively. Mean LOS was 1.3 days (1.1), median 1 day (1-14). Of all patients, 322 (83 %) were discharged on the first postoperative day (POD). Overall morbidity was 9.8 %. Three patients (0.8 %) had life-threatening complications. The readmission rate was 4.9 %, and 3.4 % of the patients had to be reoperated. With a follow-up rate of 83 % at 1 year, total weight loss (TWL) was 31 % and excess BMI loss (EBMIL) 70 %. Total remission of DM2 and HT was achieved in 70 and 42 % of the patients, respectively. Conclusion: Enhanced recovery following LRYGB with ERAS programs is possible and safe even in a low volume, general hospital. Early discharge does not increase postoperative morbidity or readmissions. [ABSTRACT FROM AUTHOR]

Enhanced recovery after surgery (ERAS) programs have been shown to minimise morbidity in other types of surgery, but comparatively less data exist investigating ERAS in bariatric surgery. This article reviews the existing literature to identify interventions which may be included in an ERAS program for bariatric surgery. A narrative literature review was conducted. Search terms included 'bariatric surgery', 'weight loss surgery', 'gastric bypass', 'ERAS', 'enhanced recovery', 'enhanced recovery after surgery', 'fast-track surgery', 'perioperative care', 'postoperative care', 'intraoperative care' and 'preoperative care'. Interventions recovered by the database search, as well as interventions garnered from clinical experience in ERAS, were used as individual search terms. A large volume of evidence exists detailing the role of multiple interventions in perioperative care. However, efficacy and safety for a proportion of these interventions for ERAS in bariatric surgery remain unclear. This review concludes that there is potential to implement ERAS programs in bariatric surgery. [ABSTRACT FROM AUTHOR]