Meta-Analysis of Enhanced Recovery Protocols in Bariatric Surgery

Ahmed, Ola; Rogers, Ailín C.; Bolger, Jarlath; Mastrosimone, Achille; Robb, William B.

doi:10.1007/s11605-018-3709-x

Cited by 67 publications

(45 citation statements)

References 42 publications

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“…ERABS may also decrease costs of care in the early postoperative period . A meta‐analysis of ERABS barriers by Ahmed et al , prospective cohort studies by Mannaerts et al and Blanchet et al , and a retrospective study of consecutive patients by Matlok et al affirm these correlations and find ERABS generally safe and effective. Factors that delayed discharge after SG reported by Jonsson et al include preoperative opioid use, history of psychiatric illnesses, chronic kidney disease, and revisional procedures, but not ASA class, diabetes, congestive heart failure, HTN, distance to home, and insurance status.…”

Section: Executive Summarymentioning

confidence: 93%

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures – 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

Mechanick

Apovian

Brethauer

et al. 2020

Obesity

340

464

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Objective The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists. Methods Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. Results New or updated topics in this CPG include: contextualization in an adiposity‐based chronic disease complications‐centric model, nuance‐based and algorithm/checklist‐assisted clinical decision‐making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). Conclusions Bariatric procedures remain a safe and effective intervention for higher‐risk patients with obesity. Clinical decision‐making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

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Section: Executive Summarymentioning

confidence: 93%

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures – 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

Mechanick

Apovian

Brethauer

et al. 2020

Obesity

340

464

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“…According to Ahmed et al [32], bariatric surgery involves a complex cohort of patients, who need care based on highquality evidence. Thus, consensus guidelines on the viability of ERAS and real clinical applicability are necessary in order to improve peri-and postoperative results.…”

Section: Discussionmentioning

confidence: 99%

Enhanced Recovery After Surgery (ERAS) protocol in bariatric and metabolic surgery (BMS)—analysis of practices in nutritional aspects from five continents

et al. 2020

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This study aims to understand the prevalent practices on the nutritional aspects of the enhanced recovery after surgery (ERAS) protocol based on the knowledge and practice of surgeons, nutritionists, and anesthesiologists who work in the bariatric and metabolic surgery (BMS) units worldwide. This cross-sectional study enrolled BMS unit professionals from five continents-Africa, America, Asia, Europe, and Oceania. An electronic questionnaire developed by the researchers was provided to evaluate practices about the three nutritional aspects of ERAS protocol in BMS (Thorel et al. 2016): preoperative fasting, carbohydrate loading, and early postoperative nutrition. Only surgeons, nutritionists, and anesthesiologists were invited to participate. One hundred twenty-five professionals answered the questionnaires: 50.4% from America and 39.2% from Europe. The profile of participating professionals was bariatric surgeons 70.2%, nutritionists 26.4%, and anesthesiologists 3.3%. Approximately 47.9% of professionals work in private services, for about 11 to 20 years (48.7%). In all continents, a large majority were aware of the protocol. Professionals from the African continent reported having implemented the ERAS bariatric protocol 4.0 ± 0 years ago. It is worth mentioning that professionals from the five continents implemented the ERAS protocol based on the published literature (p = 0.012). About preoperative fasting abbreviation protocol, a significant difference was found between continents and consequently between services (p = 0.000). There is no uniformity in the conduct of shortening of fasting in the preoperative period and the immediate postoperative period. Early postoperative (PO) period protein supplementation is not performed in a standard fashion in all units globally. ERAS principles and practices are partial and insufficiently implemented on the five continents despite the prevalent knowledge of professionals based on evidence. Moreover, there is no uniformity in fasting, immediate postoperative diet, and early protein supplementation practices globally.

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“…From then onwards, guidelines have been established regarding recommendations for integral ERAS components in bariatric eld [14]. Recently, several systemic reviews and meta-analyses have demonstrated the superiority of enhanced recovery protocols in terms of carrying out more e cient surgical procedures, lessening the length of hospitalization and effectively reducing overall morbidities compared with standard care [8,17,18]. That being said, to generally implement the ERAS regimen remains questionable since this approach is not without risks [9,19].…”

Section: Discussionmentioning

confidence: 99%

Initial result of unselective implementation of enhanced recovery after surgery in a low-volume bariatric unit: a feasibility and safety study

Chiu

et al. 2020

Preprint

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Background The feasibility and safety of unselectively applying an enhanced recovery after surgery (ERAS) protocol in a low-volume bariatric unit were determined.Material and methods We retrospectively reviewed all patients undergoing bariatric surgeries under a single surgeon between January 2015 and December 2018. Our ERAS protocol initiated in January 2017 with all patients enrolled unselectively. For those receiving non-primary procedures or with BMI < 32.5 kg/m2 were excluded from this analysis. Demographic features and all 30-day outcome measures, including operation time, length of stay (LOS), ER visits, readmissions, reoperations were collected and compared between the ERAS (2017–2018) and control (2015–2016) groups.Results One hundred eighty-four consecutive patients underwent bariatric surgeries during the study period. Of those fulfilling the inclusion criteria, 62 (40.8%) were treated before and 90 (59.2%) were treated after ERAS implementation. No differences in baseline demographics were found between the groups except ERAS group had more Roux-en-Y gastric bypass procedures (58.9% vs. 12.9%). A markedly reduced operation time (101 min vs. 147 min; p < 0.001) and shortened LOS (2.6 days vs. 3.3 days; p < 0.001) were observed, with significantly more ERAS patients achieving POD1 discharge (45.6% vs. 1.6%; p < 0.001). There were no significant differences in terms of ER visits (2.2% vs. 8%), readmissions (1.1% vs. 4.8%) or total complication rates between the groups (5.5% vs. 9.7%).Conclusion Unselective ERAS implementation in low-volume units is feasible and safe, with significantly reduced operation times and a shortened LOS without increased complications.

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Meta-Analysis of Enhanced Recovery Protocols in Bariatric Surgery

Abstract: Bariatric surgery involves a complex cohort of patients who require high-quality evidence-based care to improve outcomes. Consensus guidelines on the feasibility of ERAS and alternative clinical pathways are required in the setting of bariatric surgery.

Cited by 67 publications

References 42 publications

Enhanced Recovery After Surgery (ERAS) protocol in bariatric and metabolic surgery (BMS)—analysis of practices in nutritional aspects from five continents

Initial result of unselective implementation of enhanced recovery after surgery in a low-volume bariatric unit: a feasibility and safety study

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