Spiral.imperial.ac.uk



Original ArticleIS THERE A ROLE FOR ENHANCED RECOVERY IN LAPAROSCOPIC BARIATRIC SURGERY? - PRELIMINARY RESULTS FROM A SPECIALIST OBESITY TREATMENT CENTREPreliminary data presented at the Association of Laparoscopic Surgeons of Great Britain and Ireland Annual General Meeting, The Royal College of Surgeons of England, London, UK, November 2013, and the 14th World Congress of Endoscopic Surgery, Paris, France, June 2014.ABSTRACTBACKGROUND: There has been a relative lack of research on enhanced recovery in the context of morbid obesity surgery.OBJECTIVE: To determine if the application of enhanced recovery after surgery (ERAS) principles can reduce hospital stay and the factors influencing safe discharge on the first post-operative day.SETTING: University Teaching Hospital, United KingdomMETHODS: Patients undergoing laparoscopic bariatric surgery under the care of a single surgeon between February 2011 and June 2014 were examined. Baseline factors and readmission data were compared for patients discharged on the first post-operative day with those discharged later.RESULTS: 267 consecutive patients underwent bariatric surgery, of which 251 (94%) were enrolled in ERAS. Overall, 83/251 (33.1%) were discharged on day 1 and 168/251 (66.9%) were discharged later. 29/251 (11.6%) were excluded after surgery due to acute/early complications, of which 13/251 (5.2%) underwent re-operation within 48 hours. Of the patients enrolled in ERAS, 29.8% of LRYGB and 62.8% of LSG patients were discharged on day 1. After 23 hour discharge, there were 3/83 (3.6%) readmissions. There was no significant difference in baseline body mass index and gender in the day 1 discharge group; there was a significantly lower mean age (p<0.0001). Higher ASA grades, older patients and patients with diabetes, cardiovascular disease and poor functional status were associated with longer hospital admissions.CONCLUSION: 23 hour admissions for uncomplicated bariatric surgery appears safe in younger (<45 years) and ASA II patients and do not cause higher readmission rates.INTRODUCTIONThere has been a vast increase in bariatric surgery being offered to eligible patients throughout the world. Bariatric surgery has risks, and constitutes a step that many general practitioners are reluctant to recommend to their morbidly obese patients. When compared with non-surgical modalities in the treatment of morbid obesity, bariatric surgery leads to greater weight loss and higher remission rates of type 2 diabetes and other common comorbidities ADDIN REFMGR.CITE <Refman><Cite><Author>Gloy</Author><Year>2013</Year><RecNum>13</RecNum><IDText>Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>13</Ref_ID><Title_Primary>Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials</Title_Primary><Authors_Primary>Gloy,V.L.</Authors_Primary><Authors_Primary>Briel,M.</Authors_Primary><Authors_Primary>Bhatt,D.L.</Authors_Primary><Authors_Primary>Kashyap,S.R.</Authors_Primary><Authors_Primary>Schauer,P.R.</Authors_Primary><Authors_Primary>Mingrone,G.</Authors_Primary><Authors_Primary>Bucher,H.C.</Authors_Primary><Authors_Primary>Nordmann,A.J.</Authors_Primary><Date_Primary>2013</Date_Primary><Keywords>analysis</Keywords><Keywords>Bariatric Surgery</Keywords><Keywords>blood</Keywords><Keywords>Body Mass Index</Keywords><Keywords>Body Weight</Keywords><Keywords>Cholesterol</Keywords><Keywords>complications</Keywords><Keywords>epidemiology</Keywords><Keywords>Humans</Keywords><Keywords>metabolism</Keywords><Keywords>Obesity</Keywords><Keywords>Quality of Life</Keywords><Keywords>Randomized Controlled Trials as Topic</Keywords><Keywords>Recurrence</Keywords><Keywords>Reoperation</Keywords><Keywords>Risk Factors</Keywords><Keywords>surgery</Keywords><Keywords>therapy</Keywords><Keywords>Weight Loss</Keywords><Reprint>Not in File</Reprint><Start_Page>f5934</Start_Page><Periodical>BMJ</Periodical><Volume>347</Volume><User_Def_5>PMC3806364</User_Def_5><Address>Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Hebelstrasse 10, CH-4031 Basel, Switzerland</Address><Web_URL>PM:24149519</Web_URL><ZZ_JournalStdAbbrev><f name="System">BMJ</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>1. The three main surgical techniques used internationally at present are: laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric band (LAGB). Originally popularised by Mason and Ito, Roux-en-Y gastric bypass has become the most common surgical procedure for morbid obesity, with LRYGB currently considered the gold standard operative intervention ADDIN REFMGR.CITE <Refman><Cite><Author>Mason</Author><Year>1969</Year><RecNum>1</RecNum><IDText>Gastric bypass</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>1</Ref_ID><Title_Primary>Gastric bypass</Title_Primary><Authors_Primary>Mason,E.E.</Authors_Primary><Authors_Primary>Ito,C.</Authors_Primary><Date_Primary>1969/9</Date_Primary><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Body Weight</Keywords><Keywords>Duodenal Ulcer</Keywords><Keywords>Gastroenterostomy</Keywords><Keywords>Gastrointestinal Diseases</Keywords><Keywords>Humans</Keywords><Keywords>Intestines</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>Obesity</Keywords><Keywords>Postoperative Complications</Keywords><Keywords>radiography</Keywords><Keywords>Stomach</Keywords><Keywords>surgery</Keywords><Reprint>Not in File</Reprint><Start_Page>329</Start_Page><End_Page>339</End_Page><Periodical>Ann.Surg.</Periodical><Volume>170</Volume><Issue>3</Issue><User_Def_5>PMC1387676</User_Def_5><Web_URL>PM:5804373</Web_URL><ZZ_JournalStdAbbrev><f name="System">Ann.Surg.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>2. LRYGB combines a restrictive and a metabolic surgical procedure, leading to sustained excess body weight loss. LSG is a technically simpler procedure in comparison to LRYGB, where the size of the stomach is reduced, restricting food intake, but preserving the function of the stomach. LAGB involves placing an inflatable silicone ring around the cardia of the stomach. This is attached to a port placed subcutaneously, allowing the band to be inflated and deflated according to the wishes and weight loss needs of the patient.There have been numerous reports on enhanced recovery after surgery (ERAS) in various surgical specialities, particularly in the context of lower gastrointestinal surgery PFJlZm1hbj48Q2l0ZT48QXV0aG9yPlZhcmFkaGFuPC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48

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ADDIN EN.CITE.DATA 3. There has been a relative dearth of research on the use of ERAS protocols in bariatric surgery. A recent randomized clinical trial of ERAS versus standard care after LSG has demonstrated a shortened in-hospital length of stay (LOS) and was found to be cost effective with no increase in perioperative morbidity ADDIN REFMGR.CITE <Refman><Cite><Author>Lemanu</Author><Year>2013</Year><RecNum>2</RecNum><IDText>Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>2</Ref_ID><Title_Primary>Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy</Title_Primary><Authors_Primary>Lemanu,D.P.</Authors_Primary><Authors_Primary>Singh,P.P.</Authors_Primary><Authors_Primary>Berridge,K.</Authors_Primary><Authors_Primary>Burr,M.</Authors_Primary><Authors_Primary>Birch,C.</Authors_Primary><Authors_Primary>Babor,R.</Authors_Primary><Authors_Primary>MacCormick,A.D.</Authors_Primary><Authors_Primary>Arroll,B.</Authors_Primary><Authors_Primary>Hill,A.G.</Authors_Primary><Date_Primary>2013/3</Date_Primary><Keywords>Adult</Keywords><Keywords>Analysis of Variance</Keywords><Keywords>Clinical Protocols</Keywords><Keywords>Cost-Benefit Analysis</Keywords><Keywords>economics</Keywords><Keywords>etiology</Keywords><Keywords>Female</Keywords><Keywords>Gastrectomy</Keywords><Keywords>Humans</Keywords><Keywords>Laparoscopy</Keywords><Keywords>Length of Stay</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Obesity</Keywords><Keywords>Obesity,Morbid</Keywords><Keywords>Perioperative Care</Keywords><Keywords>Postoperative Complications</Keywords><Keywords>Recovery of Function</Keywords><Keywords>surgery</Keywords><Keywords>Surgical Procedures,Elective</Keywords><Keywords>Treatment Outcome</Keywords><Reprint>Not in File</Reprint><Start_Page>482</Start_Page><End_Page>489</End_Page><Periodical>Br.J.Surg.</Periodical><Volume>100</Volume><Issue>4</Issue><Misc_3>10.1002/bjs.9026 [doi]</Misc_3><Address>Department of Surgery, South Auckland Clinical School, Auckland, New Zealand. daniel_lemanu@</Address><Web_URL>PM:23339040</Web_URL><ZZ_JournalStdAbbrev><f name="System">Br.J.Surg.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>4. There have been no similar clinical trials of ERAS in LRYGB. The UK National Health Service is under considerable bed and resource pressures and, as such, there is a drive to discharge patients as early as it is safe to do so. It is therefore important to establish whether ERAS principles can be applied to morbid obesity surgery.The aim of this study was to determine if the application of ERAS principles promotes early post-operative patient discharge after LRYGB and LSG, and to establish the factors influencing safe discharge on the first post-operative day.METHODSBetween February 2011 and June 2014, data was collected prospectively on consecutive bariatric patients undergoing LRYGB and LSG by a single consultant bariatric surgeon. LAGB is no longer routinely performed at our institution. Patients experiencing early post-operative complications which delayed discharge were excluded. Baseline factors and readmission data were compared for patients discharged on the first post-operative day with those discharged after post-operative day one. All patients had undergone tier 2-3 weight loss programmes with comprehensive input and support from dieticians, psychologists, bariatric specialist nurses, a dedicated physician and a bariatric surgeon prior to being counselled and consented for obesity surgery. The pre-operative workup included routine blood tests, chest radiograph and an electrocardiograph, with the patient prescribed a low carbohydrate liver-shrinking diet for 2 weeks prior to their operation. Gastric antisecretory therapy and thromboprophylaxis were started the night before the operation and continued for 2 weeks thereafter. Patients underwent intensive pre-operative education in managing their expectations within this multidisciplinary setting and were counselled with regards to discharge on the first post-operative day.For LRYGB, the basic operative technique included the creation of a 30 mL vertical gastric pouch guided by a calibrating bougie. The operation proceeded with an ante-colic ante-gastric Roux limb with division of the omentum, a linear stapled gastro-jejunostomy with sutured closure of the defect, a linear stapled jejuno-jejunostomy with sutured closure of the defect. All anastomoses were tested with blue dye under pressure with distal bowel occlusion and any leaks identified were immediately repaired. Both Petersen’s and inter-mesenteric defects were closed with a non-absorbable suture. No nasogastric or abdominal drains were left in situ after the operation. LSG involves multiple firings of a 60 mm stapler with buttressing bovine material along the greater curvature of the stomach along a 38 French calibrating tube to reduce the size of the stomach. The post-operative care was standardized in accordance with ERAS, with a morphine sulphate patient-controlled analgesic (PCA) pump and the introduction of free fluids immediately after recovery from anaesthesia. Early mobilisation was encouraged and close attention was paid to the haemodynamic parameters in the post-operative period. The PCA was stopped the morning after the operation with conversion to oral analgesia and the patient was discharged in the afternoon after further review of pain control and haemodynamic parameters.The endpoints assessed in our study included in-hospital LOS, 30-day hospital readmission, early (<30-day) and late complications, and 30-day mortality. The variables assessed included patient demographic, comorbidities and ASA grade. As our main outcome variable (LOS) was not normally distributed and had a high kurtosis, non-parametric analysis was performed with significance set at 95% using SPSS? version 13 (IBM, New York, USA).RESULTSTwo hundred and sixty seven consecutive patients undergoing weight loss surgery under the care of a single consultant surgeon (MB) were included in this analysis over a 40-month period. The patient characteristics are summarised in Table 1.Additional procedures performed at the time of bariatric surgery are summarized in Table 2.Of the 212 consecutive LRYGB patients, 196/212 (92.5%) were enrolled in ERAS. 25/196 (12.8%) were excluded as they developed a complication immediately after the operation. This delayed their discharge and therefore these patients were not suitable for ERAS. Of these, 11/196 (5.6%) developed medical complications (Clavien-Dindo Classification Grade II), and 12/196 (6.1%) underwent re-operation within 48 hours (Clavien-Dindo Classification Grade IIIb). 2/196 (1%) patients with bleeding were treated with transfusion alone (Clavien-Dindo Classification Grade II), and did not require re-operation (Table 3). 51/171 (29.8%) were discharged on day 1 and 120/171 (70.2%) were discharged later. There were 9/171 (5.3%) readmissions within 30 days after discharge (Table 4).Of the 55 consecutive LSG patients, all were enrolled in ERAS. 4/55 (7.3%) developed early complications and were excluded, of which 1/55 (1.8%) underwent re-operation within 48 hours (Clavien-Dindo Classification Grade IIIb) (Table 3). 32/51 (62.8%) were discharged on day 1 and 19/51 (37.2%) discharged later. In the LSG group, there was 1/51 (2%) readmission within 30 days after discharge for control of pain which did not require an operation (Clavien-Dindo Classification Grade II) (Table 4). There was no mortality in both study groups.In the first year of this study, only 1 (2%) of the LRYGB patients went home on the first post-operative day. Subsequently, the rate of discharge on the first post-operative day has been between 25% and 41%. In contrast, the rate of discharge in the LSG group in the first year was 50%, and has remained between 50% and 67% in subsequent years (Figure 1).There was no significant difference in baseline body mass index and gender in the day 1 discharge group; there was a significantly lower mean age (p<0.0001). Examining whether ASA grade was associated with a longer post-operative stay, we found that a higher ASA grade was associated with longer hospital admissions (mean LOS for ASA II being 1.8 days vs ASA III being 2.3 days, p = 0.028, Mann-Whitney test). Using Mann-Whitney test, LOS was longer with patients who had diabetes, with a difference between LOS in diabetics vs non-diabetics (p = 0.002, Mann-Whitney test). Furthermore, patients with cardiovascular disease had a longer LOS (p = 0.036, Mann-Whitney test) as did patients with poorer functional status.DISCUSSIONIn our experience, bariatric surgery can be safely performed in the context of an ERAS programme with nearly half of patients being discharged within 23 hours from the operation. The aims of ERAS include reduction of physiological stress, early return of bodily function and safe reduction of hospital LOS ADDIN REFMGR.CITE <Refman><Cite><Author>Lassen</Author><Year>2009</Year><RecNum>4</RecNum><IDText>Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>4</Ref_ID><Title_Primary>Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations</Title_Primary><Authors_Primary>Lassen,K.</Authors_Primary><Authors_Primary>Soop,M.</Authors_Primary><Authors_Primary>Nygren,J.</Authors_Primary><Authors_Primary>Cox,P.B.</Authors_Primary><Authors_Primary>Hendry,P.O.</Authors_Primary><Authors_Primary>Spies,C.</Authors_Primary><Authors_Primary>von Meyenfeldt,M.F.</Authors_Primary><Authors_Primary>Fearon,K.C.</Authors_Primary><Authors_Primary>Revhaug,A.</Authors_Primary><Authors_Primary>Norderval,S.</Authors_Primary><Authors_Primary>Ljungqvist,O.</Authors_Primary><Authors_Primary>Lobo,D.N.</Authors_Primary><Authors_Primary>Dejong,C.H.</Authors_Primary><Date_Primary>2009/10</Date_Primary><Keywords>Clinical Protocols</Keywords><Keywords>Colon</Keywords><Keywords>Humans</Keywords><Keywords>Laparoscopy</Keywords><Keywords>Perioperative Care</Keywords><Keywords>Practice Guidelines as Topic</Keywords><Keywords>Rectum</Keywords><Keywords>surgery</Keywords><Reprint>Not in File</Reprint><Start_Page>961</Start_Page><End_Page>969</End_Page><Periodical>Arch.Surg.</Periodical><Volume>144</Volume><Issue>10</Issue><Misc_3>144/10/961 [pii];10.1001/archsurg.2009.170 [doi]</Misc_3><Address>Department of Gastrointestinal Surgery, University Hospital Northern Norway, 9038 Tromso, Norway. lassen@unn.no</Address><Web_URL>PM:19841366</Web_URL><ZZ_JournalStdAbbrev><f name="System">Arch.Surg.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>5. 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ADDIN EN.CITE.DATA 3, with essentially a lack of data on the application of ERAS in bariatric surgery. An observational case series including over 400 patients undergoing LRYGB over a 4 year period showed a decrease in the mean hospital LOS from 2 days to 1 day, with a 3.4% post-operative complication rate, of which 60% were within the first 24 hours ADDIN REFMGR.CITE <Refman><Cite><Author>Bamgbade</Author><Year>2012</Year><RecNum>5</RecNum><IDText>Fast-track laparoscopic gastric bypass surgery: outcomes and lessons from a bariatric surgery service in the United Kingdom</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>5</Ref_ID><Title_Primary>Fast-track laparoscopic gastric bypass surgery: outcomes and lessons from a bariatric surgery service in the United Kingdom</Title_Primary><Authors_Primary>Bamgbade,O.A.</Authors_Primary><Authors_Primary>Adeogun,B.O.</Authors_Primary><Authors_Primary>Abbas,K.</Authors_Primary><Date_Primary>2012/3</Date_Primary><Keywords>Adolescent</Keywords><Keywords>Adult</Keywords><Keywords>adverse effects</Keywords><Keywords>Aged</Keywords><Keywords>epidemiology</Keywords><Keywords>Female</Keywords><Keywords>Gastric Bypass</Keywords><Keywords>Great Britain</Keywords><Keywords>Humans</Keywords><Keywords>Laparoscopy</Keywords><Keywords>Learning Curve</Keywords><Keywords>Length of Stay</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>mortality</Keywords><Keywords>Obesity</Keywords><Keywords>Obesity,Morbid</Keywords><Keywords>Patient Selection</Keywords><Keywords>Postoperative Complications</Keywords><Keywords>Reoperation</Keywords><Keywords>Risk Factors</Keywords><Keywords>statistics &amp; numerical data</Keywords><Keywords>surgery</Keywords><Keywords>Treatment Outcome</Keywords><Keywords>Young Adult</Keywords><Reprint>Not in File</Reprint><Start_Page>398</Start_Page><End_Page>402</End_Page><Periodical>Obes.Surg.</Periodical><Volume>22</Volume><Issue>3</Issue><Misc_3>10.1007/s11695-011-0473-3 [doi]</Misc_3><Address>Department of Anaesthesia, Central Manchester University Hospital, Oxford Road, Manchester, M13 9WL, UK. mubitim@yahoo.co.uk</Address><Web_URL>PM:21735322</Web_URL><ZZ_JournalStdAbbrev><f name="System">Obes.Surg.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>6. A further case series of over 200 patients undergoing LRYGB, LSG and LAGB utilised standardised ERAS principles and showed successful discharge on the first post-operative day in 37% of LRYGB and 28% of LSG patients ADDIN REFMGR.CITE <Refman><Cite><Author>Awad</Author><Year>2014</Year><RecNum>6</RecNum><IDText>Enhanced recovery after bariatric surgery (ERABS): clinical outcomes from a tertiary referral bariatric centre</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>6</Ref_ID><Title_Primary>Enhanced recovery after bariatric surgery (ERABS): clinical outcomes from a tertiary referral bariatric centre</Title_Primary><Authors_Primary>Awad,S.</Authors_Primary><Authors_Primary>Carter,S.</Authors_Primary><Authors_Primary>Purkayastha,S.</Authors_Primary><Authors_Primary>Hakky,S.</Authors_Primary><Authors_Primary>Moorthy,K.</Authors_Primary><Authors_Primary>Cousins,J.</Authors_Primary><Authors_Primary>Ahmed,A.R.</Authors_Primary><Date_Primary>2014/5</Date_Primary><Keywords>Gastrectomy</Keywords><Keywords>Gastric Bypass</Keywords><Keywords>Length of Stay</Keywords><Keywords>mortality</Keywords><Keywords>surgery</Keywords><Reprint>Not in File</Reprint><Start_Page>753</Start_Page><End_Page>758</End_Page><Periodical>Obes.Surg.</Periodical><Volume>24</Volume><Issue>5</Issue><User_Def_5>PMC3972428</User_Def_5><Misc_3>10.1007/s11695-013-1151-4 [doi]</Misc_3><Address>Imperial Weight Centre, St. Mary&apos;s Hospital, Imperial College Healthcare NHS Trust, London, UK, drsherifawad@yahoo.co.uk</Address><Web_URL>PM:24357126</Web_URL><ZZ_JournalStdAbbrev><f name="System">Obes.Surg.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>7. The largest case series on ERAS in bariatric surgery included 2000 patients undergoing LRYGB; over 84% were discharged within 23 hours, with a 30-day readmission rate of 1.7% ADDIN REFMGR.CITE <Refman><Cite><Author>McCarty</Author><Year>2005</Year><RecNum>7</RecNum><IDText>Optimizing outcomes in bariatric surgery: outpatient laparoscopic gastric bypass</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>7</Ref_ID><Title_Primary>Optimizing outcomes in bariatric surgery: outpatient laparoscopic gastric bypass</Title_Primary><Authors_Primary>McCarty,T.M.</Authors_Primary><Authors_Primary>Arnold,D.T.</Authors_Primary><Authors_Primary>Lamont,J.P.</Authors_Primary><Authors_Primary>Fisher,T.L.</Authors_Primary><Authors_Primary>Kuhn,J.A.</Authors_Primary><Date_Primary>2005/10</Date_Primary><Keywords>Adolescent</Keywords><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Ambulatory Surgical Procedures</Keywords><Keywords>Body Mass Index</Keywords><Keywords>Clinical Competence</Keywords><Keywords>Female</Keywords><Keywords>Follow-Up Studies</Keywords><Keywords>Gastric Bypass</Keywords><Keywords>Humans</Keywords><Keywords>Laparoscopy</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>mortality</Keywords><Keywords>Obesity</Keywords><Keywords>Obesity,Morbid</Keywords><Keywords>Outpatients</Keywords><Keywords>Patient Readmission</Keywords><Keywords>Patient Selection</Keywords><Keywords>Prospective Studies</Keywords><Keywords>Reproducibility of Results</Keywords><Keywords>standards</Keywords><Keywords>statistics &amp; numerical data</Keywords><Keywords>surgery</Keywords><Keywords>Treatment Outcome</Keywords><Reprint>Not in File</Reprint><Start_Page>494</Start_Page><End_Page>498</End_Page><Periodical>Ann.Surg.</Periodical><Volume>242</Volume><Issue>4</Issue><User_Def_5>PMC1402348</User_Def_5><Misc_3>00000658-200510000-00004 [pii]</Misc_3><Address>Department of Surgery, Baylor University Medical Center, Dallas, Texas 75246, USA. ToddMc@BaylorHealth.edu</Address><Web_URL>PM:16192809</Web_URL><ZZ_JournalStdAbbrev><f name="System">Ann.Surg.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>8. In our series, a low complication rate was observed amongst all patients undergoing bariatric surgery (10.9%, 29/267), a similar readmission rate (3.8%, 10/267) when compared to other published case series, and 4.9% (13/267) of all patients in our series returning to theatre for bleeding, obstruction or anastomotic leak.Over a third of all patients undergoing LRYGB had more than one significant co-morbidity, including obstructive sleep apnoea, diabetes mellitus or severe osteoarthritis. Obstructive sleep apnoea has a prevalence of 34% amongst the bariatric population, with obesity surgery curing 35.2% of these individuals of their obstructive sleep apnoea ADDIN REFMGR.CITE <Refman><Cite><Author>Morong</Author><Year>2014</Year><RecNum>8</RecNum><IDText>The effect of weight loss on OSA severity and position dependence in the bariatric population</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>8</Ref_ID><Title_Primary>The effect of weight loss on OSA severity and position dependence in the bariatric population</Title_Primary><Authors_Primary>Morong,S.</Authors_Primary><Authors_Primary>Benoist,L.B.</Authors_Primary><Authors_Primary>Ravesloot,M.J.</Authors_Primary><Authors_Primary>Laman,D.M.</Authors_Primary><Authors_Primary>de,Vries N.</Authors_Primary><Date_Primary>2014/3/1</Date_Primary><Keywords>Body Mass Index</Keywords><Keywords>surgery</Keywords><Reprint>Not in File</Reprint><Periodical>Sleep Breath.</Periodical><Misc_3>10.1007/s11325-014-0955-3 [doi]</Misc_3><Address>Department of Otolaryngology, Sint Lucas Andreas Hospital, Jan Tooropstraat 164, 1006 AE, Amsterdam, The Netherlands, sharon.morong@</Address><Web_URL>PM:24584563</Web_URL><ZZ_JournalStdAbbrev><f name="System">Sleep Breath.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>9. 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ADDIN EN.CITE.DATA 11. Furthermore, bariatric surgery may benefit obese patients with hip or knee osteoarthritis ADDIN REFMGR.CITE <Refman><Cite><Author>Gill</Author><Year>2011</Year><RecNum>11</RecNum><IDText>The benefits of bariatric surgery in obese patients with hip and knee osteoarthritis: a systematic review</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>11</Ref_ID><Title_Primary>The benefits of bariatric surgery in obese patients with hip and knee osteoarthritis: a systematic review</Title_Primary><Authors_Primary>Gill,R.S.</Authors_Primary><Authors_Primary>Al-Adra,D.P.</Authors_Primary><Authors_Primary>Shi,X.</Authors_Primary><Authors_Primary>Sharma,A.M.</Authors_Primary><Authors_Primary>Birch,D.W.</Authors_Primary><Authors_Primary>Karmali,S.</Authors_Primary><Date_Primary>2011/12</Date_Primary><Keywords>Adult</Keywords><Keywords>analysis</Keywords><Keywords>Bariatric Surgery</Keywords><Keywords>complications</Keywords><Keywords>epidemiology</Keywords><Keywords>etiology</Keywords><Keywords>Humans</Keywords><Keywords>Obesity</Keywords><Keywords>Osteoarthritis,Hip</Keywords><Keywords>Osteoarthritis,Knee</Keywords><Keywords>physiology</Keywords><Keywords>prevention &amp; control</Keywords><Keywords>surgery</Keywords><Keywords>Treatment Outcome</Keywords><Keywords>Weight Loss</Keywords><Reprint>Not in File</Reprint><Start_Page>1083</Start_Page><End_Page>1089</End_Page><Periodical>Obes.Rev.</Periodical><Volume>12</Volume><Issue>12</Issue><Misc_3>10.1111/j.1467-789X.2011.00926.x [doi]</Misc_3><Address>Department of Surgery, University of Alberta, Edmonton, Alberta, Canada</Address><Web_URL>PM:21883871</Web_URL><ZZ_JournalStdAbbrev><f name="System">Obes.Rev.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>12.Factors delaying patient discharge on the first post-operative day include poor pain control, postoperative nausea and vomiting, the presence of drains, difficulty during the procedure, and the need for high dependency care. In order to facilitate the early discharge of patients following surgery, patient expectations need to be managed pre-operatively with patient education using ERAS principles in a multidisciplinary setting. Fluid intake is started in the immediate post-operative period and patient mobilization commenced on the day of surgery ADDIN REFMGR.CITE <Refman><Cite><Author>Gatt</Author><Year>2005</Year><RecNum>12</RecNum><IDText>Fast-track surgery (Br J Surg 2005; 92: 3-4)</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>12</Ref_ID><Title_Primary>Fast-track surgery (Br J Surg 2005; 92: 3-4)</Title_Primary><Authors_Primary>Gatt,M.</Authors_Primary><Authors_Primary>MacFie,J.</Authors_Primary><Date_Primary>2005/4</Date_Primary><Keywords>Humans</Keywords><Keywords>Intraoperative Care</Keywords><Keywords>methods</Keywords><Keywords>Postoperative Complications</Keywords><Keywords>prevention &amp; control</Keywords><Keywords>surgery</Keywords><Keywords>Surgical Procedures,Operative</Keywords><Reprint>Not in File</Reprint><Start_Page>494</Start_Page><Periodical>Br.J.Surg.</Periodical><Volume>92</Volume><Issue>4</Issue><Misc_3>10.1002/bjs.5043 [doi]</Misc_3><Web_URL>PM:15782392</Web_URL><ZZ_JournalStdAbbrev><f name="System">Br.J.Surg.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>13. In our experience, the early post-operative recovery phase is key in the discharge of patients within 23 hours, with recurrent visits to the patient’s bedside and assessment of the observational parameters. Obvious difficulties in the assessment of the abdomen of the obese patient meant that a higher level of suspicion was necessary in the identification of patients who were not following the usual pathway of recovery, and any deviation from the norm meant that the patient was kept in hospital for further assessment and/or imaging, with a low threshold for emergency re-laparoscopy. This relies on the experience of both the surgeon and the centre. This cautious approach has led to a low rate of readmissions and no deaths in this series. On discharge, specific instructions were given to the patient to contact and return to our hospital, if any problems were encountered at home. In 2012 and 2013 of our study, taking into account the learning curve, over 40% of LRYGB patients were discharged on the first postoperative day, with an overall 4.3% (9/212) 30-day hospital readmission rate. Between 50-67% of LSG patients were discharged on the first post operative day, with an overall 1.8% (1/55) 30-day hospital readmission rate. This compares very favourably with the 20% readmission rate in the recent randomized study of sleeve gastrectomy patients within an ERAS protocol ADDIN REFMGR.CITE <Refman><Cite><Author>Lemanu</Author><Year>2013</Year><RecNum>2</RecNum><IDText>Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>2</Ref_ID><Title_Primary>Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy</Title_Primary><Authors_Primary>Lemanu,D.P.</Authors_Primary><Authors_Primary>Singh,P.P.</Authors_Primary><Authors_Primary>Berridge,K.</Authors_Primary><Authors_Primary>Burr,M.</Authors_Primary><Authors_Primary>Birch,C.</Authors_Primary><Authors_Primary>Babor,R.</Authors_Primary><Authors_Primary>MacCormick,A.D.</Authors_Primary><Authors_Primary>Arroll,B.</Authors_Primary><Authors_Primary>Hill,A.G.</Authors_Primary><Date_Primary>2013/3</Date_Primary><Keywords>Adult</Keywords><Keywords>Analysis of Variance</Keywords><Keywords>Clinical Protocols</Keywords><Keywords>Cost-Benefit Analysis</Keywords><Keywords>economics</Keywords><Keywords>etiology</Keywords><Keywords>Female</Keywords><Keywords>Gastrectomy</Keywords><Keywords>Humans</Keywords><Keywords>Laparoscopy</Keywords><Keywords>Length of Stay</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Obesity</Keywords><Keywords>Obesity,Morbid</Keywords><Keywords>Perioperative Care</Keywords><Keywords>Postoperative Complications</Keywords><Keywords>Recovery of Function</Keywords><Keywords>surgery</Keywords><Keywords>Surgical Procedures,Elective</Keywords><Keywords>Treatment Outcome</Keywords><Reprint>Not in File</Reprint><Start_Page>482</Start_Page><End_Page>489</End_Page><Periodical>Br.J.Surg.</Periodical><Volume>100</Volume><Issue>4</Issue><Misc_3>10.1002/bjs.9026 [doi]</Misc_3><Address>Department of Surgery, South Auckland Clinical School, Auckland, New Zealand. daniel_lemanu@</Address><Web_URL>PM:23339040</Web_URL><ZZ_JournalStdAbbrev><f name="System">Br.J.Surg.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>4. Similar rates of readmission were achieved in the case series published by the Imperial Weight Centre (2.7%) ADDIN REFMGR.CITE <Refman><Cite><Author>Awad</Author><Year>2014</Year><RecNum>6</RecNum><IDText>Enhanced recovery after bariatric surgery (ERABS): clinical outcomes from a tertiary referral bariatric centre</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>6</Ref_ID><Title_Primary>Enhanced recovery after bariatric surgery (ERABS): clinical outcomes from a tertiary referral bariatric centre</Title_Primary><Authors_Primary>Awad,S.</Authors_Primary><Authors_Primary>Carter,S.</Authors_Primary><Authors_Primary>Purkayastha,S.</Authors_Primary><Authors_Primary>Hakky,S.</Authors_Primary><Authors_Primary>Moorthy,K.</Authors_Primary><Authors_Primary>Cousins,J.</Authors_Primary><Authors_Primary>Ahmed,A.R.</Authors_Primary><Date_Primary>2014/5</Date_Primary><Keywords>Gastrectomy</Keywords><Keywords>Gastric Bypass</Keywords><Keywords>Length of Stay</Keywords><Keywords>mortality</Keywords><Keywords>surgery</Keywords><Reprint>Not in File</Reprint><Start_Page>753</Start_Page><End_Page>758</End_Page><Periodical>Obes.Surg.</Periodical><Volume>24</Volume><Issue>5</Issue><User_Def_5>PMC3972428</User_Def_5><Misc_3>10.1007/s11695-013-1151-4 [doi]</Misc_3><Address>Imperial Weight Centre, St. Mary&apos;s Hospital, Imperial College Healthcare NHS Trust, London, UK, drsherifawad@yahoo.co.uk</Address><Web_URL>PM:24357126</Web_URL><ZZ_JournalStdAbbrev><f name="System">Obes.Surg.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>7. In our final year, we extended our catchment area and the number of patients who came from further afield increased substantially. We also noted an increase in patients who lacked appropriate family support (data not shown). Even though these patients were fit for discharge on day 1, they stayed in hospital longer as they did not want to go home. This explains the drop in post operative day 1 discharge in both the LRYGB group to 25% and the LSG group to 50% in 2014.Limitations of this study include the lack of a control group to compare outcomes, and the lack of previous LOS data prior to the introduction of the ERAS pathway for recovery of patients undergoing LRYGB. Post-operative LOS is a surrogate marker of recovery, and does not reflect the true recovery of the patient, who has to convalesce at home. Patients are instructed clearly on discharge both verbally and in written documentation of the danger signs which should prompt a return to the base hospital, which is a tertiary referral centre for bariatric surgery and is best placed to deal with potential complications with require surgical reintervention.Thus, in summary, we have demonstrated that enhanced recovery can be applied to Bariatric surgery, leading to more than 40% of patients being discharged within 23 hours. It is a safe and feasible option in younger patients (<45) and patients with an ASA grade of 2. There was an acceptable rate of readmissions and surgical complications necessitating reintervention.CONCLUSIONBariatric surgery has risks, and constitutes a step that many general practitioners are reluctant to recommend to their morbidly obese patients to lose weight and treat obesity related diseases. However, this study has demonstrated that applying ERAS principles to bariatric surgery is feasible, safe and associated with low levels of morbidity and no mortality. Future randomised studies are warranted to characterize the impact of ERAS on outcomes in bariatric surgery.Acknowledgements: We would like to thank the nurses and other doctors involved in this study; but most of all, the patients. Conflicts of interest: We confirm that none of the authors have a conflict of interest. ADDIN REFMGR.REFLIST Reference List(1) Gloy VL, Briel M, Bhatt DL, et al. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. BMJ 2013; 347:f5934.(2) Mason EE, Ito C. Gastric bypass. Ann Surg 1969; 170(3):329-339.(3) Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 2010; 29(4):434-440.(4) Lemanu DP, Singh PP, Berridge K, et al. Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy. Br J Surg 2013; 100(4):482-489.(5) Lassen K, Soop M, Nygren J, et al. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 2009; 144(10):961-969.(6) Bamgbade OA, Adeogun BO, Abbas K. Fast-track laparoscopic gastric bypass surgery: outcomes and lessons from a bariatric surgery service in the United Kingdom. Obes Surg 2012; 22(3):398-402.(7) Awad S, Carter S, Purkayastha S, et al. Enhanced recovery after bariatric surgery (ERABS): clinical outcomes from a tertiary referral bariatric centre. Obes Surg 2014; 24(5):753-758.(8) McCarty TM, Arnold DT, Lamont JP, Fisher TL, Kuhn JA. Optimizing outcomes in bariatric surgery: outpatient laparoscopic gastric bypass. Ann Surg 2005; 242(4):494-498.(9) Morong S, Benoist LB, Ravesloot MJ, Laman DM, de VN. The effect of weight loss on OSA severity and position dependence in the bariatric population. Sleep Breath 2014.(10) Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 2012; 366(17):1567-1576.(11) Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical therapy for diabetes--3-year outcomes. N Engl J Med 2014; 370(21):2002-2013.(12) Gill RS, Al-Adra DP, Shi X, Sharma AM, Birch DW, Karmali S. The benefits of bariatric surgery in obese patients with hip and knee osteoarthritis: a systematic review. Obes Rev 2011; 12(12):1083-1089.(13) Gatt M, MacFie J. Fast-track surgery (Br J Surg 2005; 92: 3-4). Br J Surg 2005; 92(4):494. ................
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