The Impact of Enhanced Recovery Protocol for Patients Undergoing Bariatric Laparoscopic Roux-en-Y Gastric Bypass

Katie Meister, MD, Katelyn Mellion, MD, Anna Uebele, MD, Lala Hussain, Kevin Tymitz, MD, George Kerlakian, MD. Good Samaritan Hospital

Introduction: Enhanced recovery protocols (ERP) standardize perioperative patient care in an effort to hasten recovery by minimizing the stress response of surgery, improving pain control, accelerating gastrointestinal function, and minimizing hospital length of stay (LOS). This study aims to evaluate the outcome of implementing an ERP for bariatric patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB). 

Methods and Procedures: Our ERP was created to address the specific needs of morbidly obese patients undergoing foregut surgery. Specific modalities include: extensive preoperative patient education, regimented oral hydration until 3 hours preoperatively, multimodal pain management (pregabalin and celecoxib preoperatively, narcotic and non-narcotic analgesia postoperatively), judicious use of perioperative intravenous fluids, and early Foley catheter removal, ambulation, and enteral feeding. This retrospective study examines outcomes of bariatric RYGB specific ERP from January 2013 through June 2015. Exclusion criteria include patients who underwent RYGB for reasons other than weight loss, whose procedure was abandoned, or who concomitantly underwent another procedure. Demographic data include: age, gender, preoperative body mass index (BMI), preoperative comorbidities, American Society of Anesthesiologists (ASA) class. Outcome variables include: LOS, 30-day readmission, 30-day reoperation, 30-day ICU admission. The effect of preoperative comorbidities on patient LOS and 30-day readmission were assessed using Mann Whitney U test and Chi-square or Fisher's Exact tests, respectively. The 30-day readmission rate was compared between patients before and after ERP implementation with Chi-square test. P<0.05 was deemed statistically significant.

Results: A total of 88 patients were analyzed. Average age and preoperative BMI were 46.9 (11.6) years and 47.8 (7.25) kg/m2, respectively. The cohort was 27.3% male. Preoperative comorbidities included: diabetes (48.9%), hypertension (59.1%), history of pulmonary embolism (5.7%), cardiovascular disease (CVD) (6.8%), chronic obstructive pulmonary disease (3.4%), gastroesophageal reflux (33.0%), tobacco use (11.4%), severe limitation to ambulation (3.4%). The ASA classes of patients undergoing RYGB were II (2.3%), III (87.5%), and IV (10.2%). Average LOS, 30-day readmission, 30-day reoperation, and 30-day ICU admission were 2.34 days, 13.6%, 0%, and 0%, respectively. Patients with CVD were more likely to be readmitted within 30 days (p=0.031). Average LOS for patients with preoperative tobacco use was 2.47 days versus 1.30 days for those who did not (p=0.002).

Conclusion: We have reported outcomes of using an ERP specific to bariatric patients undergoing RYGB. Patients with preoperative tobacco use had a longer LOS, while those with CVD were more likely to be readmitted. Future studies are needed to compare outcomes between non-ERP and ERP populations.

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