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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]

Background: Present guidelines recommend bariatric surgery at BMI ≥40 kg/m or BMI ≥35 kg/m with obesity-related morbidity. Methods: Evidence for cost and mortality/morbidity risk of bariatric surgery and obesity-related diseases was evaluated determining equivalency point of absolute incremental mortality risk by BMI and risks associated with bariatric surgery. A stochastic model was developed evaluating costs related to surgical procedure at a given BMI. Results: Bariatric surgery produces significant lifetime cost savings associated with diabetes, gallstones, hypertension, high cholesterol, colon cancer, heart disease, and stroke in men at BMI 30 kg/m for laparoscopic gastric bypass. For women, laparoscopic gastric bypass saves cost at BMI 32 kg/m and laparoscopic gastric banding at BMI 37 kg/m. In white men, relative to single-year mortality risks by BMI, surgical intervention becomes risk-beneficial at BMI 25 kg/m for laparoscopic gastric banding, BMI 27 kg/m for laparoscopic gastric bypass procedure and open gastric banding, and BMI 37 kg/m for open gastric bypass. Risk benefit for African-American men by procedure occurs at BMI <25 kg/m, BMI 27 kg/m, and BMI 42 kg/m, respectively. In white women, surgical intervention is beneficial at BMI 25.5 kg/m (laparoscopic gastric banding), BMI 28.5 kg/m (laparoscopic gastric bypass procedure), and BMI 45 kg/m (open gastric banding). Risk benefit for black women by procedure occurs at BMI 27.5 kg/m, BMI 33.5 kg/m, and BMI 50+ kg/m, respectively. Conclusion: Risk and cost benefit suggest surgical guidelines should be reconsidered. Threshold for bariatric surgery should be redefined to BMI 35 kg/m or BMI 30 kg/m with comorbidities. [ABSTRACT FROM AUTHOR]

Background: Postoperative nausea and vomiting is a major cause of patient dissatisfaction towards surgery. For bariatric surgery, increased vomiting/retching is detrimental to surgical anastomosis. The present study evaluated the efficacy of aprepitant (neurokinin-1 inhibitor) as a prophylactic antiemetic in morbidly obese patients for laparoscopic bariatric surgery. Methods: After institutional review board approval, 125 morbidly obese patients were recruited into this double-blind placebo-controlled trial. On random division, the patients received a tablet of aprepitant (80 mg) in group A, or a similar-appearing placebo in group P, an hour prior to surgery. All patients received intravenous ondansetron (4 mg) intraoperatively. Postoperatively, the patients were evaluated for nausea and vomiting by a blinded evaluator at 30 min, 1, 2, 6, 24, 48, and 72 h. Results: Both groups were evenly distributed for age, body mass index, type, and length of surgery. Cumulative incidence of vomiting at 72 h was significantly lower in group A (3 %) compared to group P (15 %; p = 0.021). Odds ratio for vomiting in group P compared to group A was 5.47 times. On Kaplan-Meier plot, time to first vomiting was also significantly delayed in group A ( p = 0.019). A higher number of patients showed complete absence of nausea or vomiting in group A compared to group P (42.18 vs. 36.67 %). On the other hand, nausea scores were unaffected by aprepitant, and no significant difference between groups was found at any of the measured time points. Conclusions: In morbidly obese patients undergoing laparoscopic bariatric surgery, addition of aprepitant to ondansetron can significantly delay vomiting episodes simultaneously lowering the incidence of postoperative vomiting. [ABSTRACT FROM AUTHOR]