Structured Early Ambulation Protocols and Post-Operative Pain Following Laparoscopic Sleeve Gastrectomy – Is There a Relationship?

Brian Housman, MD, Prasanthi Sunkesula, MD, Krystyna Kabata, PA, Anthony Tortolani, MD, Piotr Gorecki, MD. New York Methodist Hospital

INTRODUCTION: Early ambulation following abdominal operations has been linked to reduced postoperative pulmonary and thromboembolic complications. However little data is available to support this relationship and evaluate patient compliance with structured early ambulation protocols (SEAP). In this study we evaluate this relationship and examine the effect of SEAP after Laparoscopic Sleeve Gastrectomy (LSG) on post-operative pain and thromboembolic complications.

METHODS: All patients undergoing primary LSG between September 2014 and August 2015 at a single institution performed by a single surgeon (PG) were included.  All patients were operated utilizing the same technique and the same perioperative pain management protocols and thromboembolic prophylaxis with subcutaneous Heparin and sequential compression stockings.  Patients, residents and nursing staff were all instructed and educated on potential benefits of early ambulation and formal protocols were in place as part of the quality improvement initiative. Routine postoperative orders were in given to encourage, assist and ambulate patients within 2 hours after returning to the floor and Every 4 hours for 24 h and until discharge. A structured surveys were given to both nurses and patients asking whether or not patients ambulated following surgery at three distinct time points; within 2 hours, within 6 hours, and every 4 hours thereafter.

RESULTS: There were no perioperative mortalities and no reoperations. There were no conversions, no intraoperative complications and no intraoperative blood transfusions. The median postoperative hospital stay was one day.  All 112 (100%) patients ambulated within the first 24 hours; 87 (78%) within 2 hours, 104 (93%) within 6 hours, and 87 (78%) every 4 hours. Of the reasons listed for not ambulating, Pain (17%) was the most common, followed by Fatigue (13%), Dizziness (8.0%) and Breathing Difficulty (7.1%), The Abdomen was the most common site of pain (69%), but incisional pain (8.9%) and chest pain (8.0%) were also reported. 109 patients (97.3%) reported overall satisfaction with their pain control.  Average pain scores (0-10) for Ambulators were significantly lower as compared to Non-Ambulators (within 2 hours 2.32 and 4.24 (p = 0.0056), within 6 hours 2.58 and 5.00 (p = 0.0157), and every 4 hours 2.33 and 4.20, (p = 0.0041) respectively). None of the patients experienced thromboembolic or pulmonary complication.

DISSCUSSION: There is a strong positive correlation between lower post-operative pain scores and compliance with strict and structured early post LSG ambulation protocols. Further studies are needed to determine potential other and longer term clinical significance of SEAP.

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