Top

Published in:

01-02-2016 | Original Contributions

Results of Implementing an Enhanced Recovery After Bariatric Surgery (ERABS) Protocol

Authors: Guido H. H. Mannaerts, Stefanie R. van Mil, Pieter S. Stepaniak, Martin Dunkelgrün, Marcel de Quelerij, Serge J. Verbrugge, Hans F. Zengerink, L. Ulas Biter

Published in: Obesity Surgery | Issue 2/2016

Abstract

Background

With the increasing prevalence of morbid obesity and healthcare costs in general, interest is shown in safe, efficient, and cost-effective bariatric care. This study describes an Enhanced Recovery After Bariatric Surgery (ERABS) protocol and the results of implementing such protocol on procedural times, length of stay in hospital (LOS), and the number of complications, such as readmissions and reoperations.

Methods

Results of implementing an ERABS protocol were analyzed by comparing a cohort treated according to the ERABS protocol (2012–2014) with a cohort treated before implementing ERABS (2010–2012). Differences between both cohorts were analyzed using independent t tests and chi-squared tests.

Results

A total of 1.967 patients (mean age 43.3 years, 80 % female) underwent a primary bariatric procedure between 2010 and 2014, of which 1.313 procedures were performed after implementation of ERABS. A significant decrease of procedural times and a significantly decreased LOS, from 3.2 to 2.0 nights (p < 0.001), were seen after implementation of ERABS. Significantly more complications were seen post-ERABS (16.1 vs. 20.7 %, p = 0.013), although no significant differences were seen in the number of major complications.

Conclusion

Implementation of ERABS can result in shorter procedural times and a decreased LOS, which may lead to more efficient and cost-effective bariatric care. The increase in complications was possibly due to better registration of complications.

The main goal of an ERABS protocol is efficient, safe, and evidence-based bariatric care, which can be achieved by standardization of the total process.

Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014; Available from: http://www.ncbi.nlm.nih.gov/pubmed/24880830.

Eckel RH, Alberti KGMM, Grundy SM, et al. The metabolic syndrome. Lancet [Internet] 2010 [cited 2014 Jul 26];375(9710):181–3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20109902.

Nguyen DM, El-Serag HB. The epidemiology of obesity. Gastroenterol Clin North Am [Internet] 2010 [cited 2014 Jul 27];39(1):1–7. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2833287&tool=pmcentrez&rendertype=abstract.

Ferguson C, Langwith C, Tan E, Sc M. A Heavy burden: the individual costs of being overweight and obese in the United States. 2010.

Picot J, Jones J, Colquitt JL, et al. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess [Internet] 2009 [cited 2014 Jul 10];13(41):1–190, 215–357, iii–iv. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19726018.

Colquitt JL, Picot J, Loveman E, et al. Surgery for obesity. Cochrane Database Syst Rev [Internet] 2009 [cited 2014 Sep 17];(2):CD003641. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19370590.

Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med [Internet] 2009 [cited 2014 Jul 10];122(3):248–56.e5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19272486.

Sjöström L, Narbro K, Sjöström CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med [Internet] 2007 [cited 2014 Sep 10];357(8):741–52. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17715408.

Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr [Internet] 2012 [cited 2014 Jul 24];31(6):783–800. Available from: http://www.sciencedirect.com/science/article/pii/S026156141200180X.

10.

Nygren J, Thacker J, Carli F, et al. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr [Internet] 2012 [cited 2014 Jul 23];31(6):801–16. Available from: http://www.sciencedirect.com/science/article/pii/S0261561412001793.

11.

Cerantola Y, Valerio M, Persson B, et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS(®)) society recommendations. Clin Nutr [Internet] 2013 [cited 2014 Aug 5];32(6):879–87. Available from: http://www.sciencedirect.com/science/article/pii/S0261561413002549.

12.

Lemanu DP, Srinivasa S, Singh PP, et al. Optimizing perioperative care in bariatric surgery patients. Obes Surg [Internet] 2012 [cited 2014 Sep 17];22(6):979–90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22488683.

13.

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 [Internet] 2012 [cited 2014 Sep 17];22(3):398–402. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21735322.

14.

Lemanu DP, Singh PP, Berridge K, et al. Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy. Br J Surg [Internet] 2013 [cited 2014 Sep 15];100(4):482–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23339040.

15.

Elliott JA, Patel VM, Kirresh A, et al. Fast-track laparoscopic bariatric surgery: a systematic review. Updates Surg [Internet] 2013 [cited 2014 Oct 21];65(2):85–94. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23371325.

16.

Geubbels N, Bruin SC, Acherman YIZ, et al. Fast track care for gastric bypass patients decreases length of stay without increasing complications in an unselected patient cohort. Obes Surg [Internet] 2014 [cited 2014 Sep 17];24(3):390–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24254930.

17.

Dogan K, Kraaij L, Aarts EO, et al. Fast-track bariatric surgery improves perioperative care and logistics compared to conventional care. Obes Surg [Internet] 2014 [cited 2014 Oct 21];Available from: http://www.ncbi.nlm.nih.gov/pubmed/24993524.

18.

Elte JWF, Castro Cabezas M, Vrijland WW, et al. Proposal for a multidisciplinary approach to the patient with morbid obesity: the St. Franciscus Hospital morbid obesity program. Eur J Intern Med [Internet] 2008 [cited 2014 Sep 17];19(2):92–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18249303.

19.

Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg [Internet] 2009 [cited 2014 Sep 14];250(2):187–96. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19638912.

20.

Dindo D, Demartines N, Clavien P-A. Classification of surgical complications. Ann Surg [Internet] 2004 [cited 2014 Jul 9];240(2):205–13. Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00000658-200408000-00003.

21.

Fried M, Yumuk V, Oppert J-M, et al. Interdisciplinary European Guidelines on metabolic and bariatric surgery. Obes Facts [Internet] 2013 [cited 2014 Dec 23];6(5):449–68. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24135948.

22.

Fried M, Hainer V, Basdevant A, et al. Inter-disciplinary European guidelines on surgery of severe obesity. Int J Obes (Lond) [Internet] 2007 [cited 2014 Sep 17];31(4):569–77. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17325689.

23.

Benevides ML, Oliveira SDS, Aguilar-Nascimento JE. Combination of haloperidol, dexamethasone, and ondansetron reduces nausea and pain intensity and morphine consumption after laparoscopic sleeve gastrectomy. Brazilian J Anesthesiol [Internet] 2013 [cited 2014 Sep 17];63(5):404–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24565295.

24.

Ogunnaike BO, Jones SB, Jones DB, et al. Anesthetic considerations for bariatric surgery. Anesth Analg [Internet] 2002;95(6):1793–805. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12456461.

25.

Brodsky JB, Lemmens HJM, Brock-Utne JG, et al. Morbid obesity and tracheal intubation. Anesth Analg [Internet] 2002;94(3):732–6; table of contents. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23814988.

26.

Lemmens HJM, Brodsky JB. General anesthesia, bariatric surgery, and the BIS monitor. Obes Surg [Internet] 2005 [cited 2014 Sep 17];15(1):63. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15760499.

27.

Navarro Martínez MJ, Pindado Martínez ML, Paz Martín D, et al. Perioperative anesthetic management of 300 morbidly obese patients undergoing laparoscopic bariatric surgery and a brief review of relevant pathophysiology. Rev Esp Anestesiol Reanim [Internet] 2011 [cited 2014 Sep 17];58(4):211–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21608276.

28.

Lemmens HJM, Brodsky JB. Anesthetic drugs and bariatric surgery. Expert Rev Neurother [Internet] 2006;6(7):1107–13. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16831123.

29.

Leifsson BG, Gislason HG. Laparoscopic Roux-en-Y gastric bypass with 2-metre long biliopancreatic limb for morbid obesity: technique and experience with the first 150 patients. Obes Surg [Internet] 2005;15(1):35–42. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15760497.

30.

Gadiot RPM, Biter LU, Zengerink HJF, et al. Laparoscopic sleeve gastrectomy with an extensive posterior mobilization: technique and preliminary results. Obes Surg [Internet] 2012 [cited 2014 Sep 17];22(2):320–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21826582.

31.

Carron M, Veronese S, Foletto M, et al. Sugammadex allows fast-track bariatric surgery. Obes Surg [Internet] 2013 [cited 2014 Sep 17];23(10):1558–63. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23519634.

32.

Bergland a, Gislason H, Raeder J. Fast-track surgery for bariatric laparoscopic gastric bypass with focus on anaesthesia and peri-operative care. Experience with 500 cases. Acta Anaesthesiol Scand [Internet] 2008 [cited 2014 Sep 17];52(10):1394–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19025533.

33.

Quelerij de M, Velzen van C, Meijer N, et al. Prevalence and determinants of complications in a bariatric ICU population. Neth J Anesth. 2012;12–7.

34.

Dobesh PP, Wittkowsky AK, Stacy Z, et al. Key articles and guidelines in the treatment of venous thromboembolism. Pharmacotherapy [Internet] 2009 [cited 2014 Sep 17];29(11):1385. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19857153.

35.

Clements RH, Yellumahanthi K, Ballem N, et al. Pharmacologic prophylaxis against venous thromboembolic complications is not mandatory for all laparoscopic Roux-en-Y gastric bypass procedures. J Am Coll Surg [Internet] 2009 [cited 2014 Sep 17];208(5):917–21; discussion 921–3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19476861.

36.

Sasse KC, Ganser J, Kozar M, et al. Seven cases of gastric perforation in Roux-en-Y gastric bypass patients: what lessons can we learn? Obes Surg [Internet] 2008 [cited 2014 Sep 17];18(5):530–4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18324450.

37.

Schug SA, Raymann A. Postoperative pain management of the obese patient. Best Pract Res Clin Anaesthesiol [Internet] 2011 [cited 2014 Sep 17];25(1):73–81. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21516915.

38.

Lobo DN, Bostock KA, Neal KR, et al. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet [Internet] 2002;359(9320):1812–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12044376.

39.

Jacobsen HJ, Bergland A, Raeder J, et al. High-volume bariatric surgery in a single center: safety, quality, cost-efficacy and teaching aspects in 2,000 consecutive cases. Obes Surg [Internet] 2012 [cited 2014 Sep 17];22(1):158–66. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22116595.

40.

McCarty TM, Arnold DT, Lamont JP, et al. Optimizing outcomes in bariatric surgery. Trans . Meet Am Surg Assoc [Internet] 2005 [cited 2014 Sep 17];123(&NA;):188–95. Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00153307-200501230-00020.

41.

Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg [Internet] 2008 [cited 2014 Sep 17];248(2):189–98. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18650627.

42.

Birkmeyer JD, Dimick JB, Staiger DO. Operative mortality and procedure volume as predictors of subsequent hospital performance. Ann Surg [Internet] 2006 [cited 2014 Sep 17];243(3):411–7. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1448928&tool=pmcentrez&rendertype=abstract.

43.

Main DS, Henderson WG, Pratte K, et al. Relationship of processes and structures of care in general surgery to postoperative outcomes: a descriptive analysis. J Am Coll Surg [Internet] 2007 [cited 2014 Sep 17];204(6):1157–65. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17544074.

44.

Lublin M, Lyass S, Lahmann B, et al. Leveling the learning curve for laparoscopic bariatric surgery. Surg Endosc [Internet] 2005 [cited 2014 Sep 17];19(6):845–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15868262.

45.

Chowdhury MM, Dagash H, Pierro A. A systematic review of the impact of volume of surgery and specialization on patient outcome. Br J Surg [Internet] 2007 [cited 2014 Aug 6];94(2):145–61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17256810.

46.

Lemmens L, van Zelm R, Borel Rinkes I, et al. Clinical and organizational content of clinical pathways for digestive surgery: a systematic review. Dig Surg [Internet] 2009 [cited 2014 Sep 17];26(2):91–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19252405.

47.

Grantcharov TP, Kehlet H. Laparoscopic gastric surgery in an enhanced recovery programme. Br J Surg [Internet] 2010 [cited 2014 Sep 17];97(10):1547–51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20665480.

48.

Stepaniak PS, Heij C, Buise MP, et al. Bariatric surgery with operating room teams that stayed fixed during the day: a multicenter study analyzing the effects on patient outcomes, teamwork and safety climate, and procedure duration. Anesth Analg [Internet] 2012 [cited 2014 Sep 17];115(6):1384–92. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23144431.

Title: Results of Implementing an Enhanced Recovery After Bariatric Surgery (ERABS) Protocol
Authors: Guido H. H. Mannaerts
Stefanie R. van Mil
Pieter S. Stepaniak
Martin Dunkelgrün
Marcel de Quelerij
Serge J. Verbrugge
Hans F. Zengerink
L. Ulas Biter
Publication date: 01-02-2016
Publisher: Springer US
Published in: Obesity Surgery / Issue 2/2016
Print ISSN: 0960-8923
Electronic ISSN: 1708-0428
DOI: https://doi.org/10.1007/s11695-015-1742-3

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Results of Implementing an Enhanced Recovery After Bariatric Surgery (ERABS) Protocol

Abstract

Background

Methods

Results

Conclusion

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 2/2016

Preoperative Methods to Reduce Liver Volume in Bariatric Surgery: a Systematic Review

Incidence of Successful Pregnancy After Weight Loss Interventions in Infertile Women: a Systematic Review and Meta-Analysis of the Literature

Laparoscopic Roux-en-Y Gastric Bypass Versus Laparoscopic Sleeve Gastrectomy to Treat Morbid Obesity-Related Comorbidities: a Systematic Review and Meta-analysis

Micronutrient Deficiencies in Morbidly Obese Women Prior to Bariatric Surgery

Does Preincisional Infiltration with Bupivacaine Reduce Postoperative Pain in Laparoscopic Bariatric Surgery?

Gastric Bypass Surgery but not Caloric Restriction Improves Reproductive Function in Obese Mice