The Impact of Enhanced Recovery Protocol for Patients Undergoing Bariatric Laparoscopic Sleeve Gastrectomy

Katelyn Mellion, MD, Katie Meister, 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, and accelerating gastrointestinal function. The purpose of this study is to evaluate the outcome of implementing an ERP for bariatric patients undergoing laparoscopic sleeve gastrectomy (LSG). 

Methods and Procedures: The bariatric 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 LSG specific ERP from January 2013 to June 2015. Exclusion criteria include patients who underwent LSG 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: length of stay (LOS), 30-day readmission, 30-day reoperation, 30-day ICU admission. Mann Whitney U and Fisher's Exact tests were used to determine the effect of preoperative comorbidities on patient LOS and 30-day readmission, respectively. 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 45.7 (10.9) years and 44.6 (9.8) kg/m2, respectively. The cohort was 15.9% male. Preoperative comorbidities included: diabetes (15.9%), hypertension (33.0%), history of pulmonary embolism (1.1%), cardiovascular disease (0%), chronic obstructive pulmonary disease (2.3%), gastroesophageal reflux (22.7%), tobacco use (9.1%), severe limitation to ambulation (3.4%). The ASA classes of patients undergoing LSG were II (21.6%), III (77.3%), and IV (1.1%). Average LOS, 30-day readmission, 30-day reoperation, and 30-day ICU admission were 2.09 days, 8.0%, 0%, and 0%, respectively. Patients with hypertension were more likely to be readmitted within 30 days (p=0.037). 30-day readmission rate prior to ERP implementation was 16.2% vs 8% after (p=0.111).

Conclusion: We have reported outcomes of using an ERP specific to bariatric patients undergoing LSG. There is a trend toward fewer readmissions in ERP patients compared to patients undergoing LSG without an ERP. Patients with hypertension are more likely to be readmitted. Future studies are needed to further compare outcomes between non-ERP and ERP populations.

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