title: Is there a role for enhanced recovery after laparoscopic bariatric surgery? Preliminary results from a specialist obesity treatment center.
abstract: BACKGROUND
  There has been a relative lack of research on the effect of enhanced recovery in the context of morbid obesity surgery.
  
  
  OBJECTIVE
  To determine if the application of enhanced recovery after surgery (ERAS) principles can contribute to reduce postoperative hospital length of stay after bariatric surgery, controlling for other factors that may influence safe discharge on the first postoperative day.
  
  
  METHODS
  University teaching hospital, United Kingdom.
  
  
  METHODS
  Between February 2011 and December 2014, prospectively collected data on all patients undergoing laparoscopic bariatric surgery under the care of a single surgeon were reviewed. From January 2012, all patients were enrolled in an ERAS protocol and were assessed for fitness for early discharge (within 24 hr from the operation). Baseline patient characteristics and additional concomitant procedures data were compared for patients treated before and after implementation of the ERAS protocol; 30-day readmission data were analyzed for patients discharged on the first postoperative day and those discharged later. The effect of the implementation of the ERAS protocol on discharge on the first postoperative day was analyzed using multivariate analysis, while taking into account the effects of potential confounders (e.g., age, gender, American Society of Anesthesiologists [ASA] grade, concomitant surgical procedures, etc.).
  
  
  RESULTS
  Two-hundred and eighty-eight consecutive patients underwent bariatric surgery. Of these, 278 (96.5%) were potentially suitable for early discharge, while 10 (3.5%) patients developed an acute postoperative complication that delayed discharge irrespective of the effect of ERAS. All these patients required a reoperation within 48 hours and therefore were not considered suitable for early discharge and were not included in the statistical analysis. During the entire study period, 100 of 278 (36%) patients were discharged on the first postoperative day, 28.5% after laparoscopic Roux-en-Y gastric bypass (LRYGB) and 60.9% after laparoscopic sleeve gastrectomy (LSG); 178 of 278 (64%) patients were discharged after ≥ 2 days (mean: 2.58, range: 2-5). After implementation of the ERAS protocol in January 2012, the rate of patients discharged on the first postoperative day increased significantly from 1.6% to 39.7% after LRYGB (P<.01). Early discharge increased from 50% to 67.5% after LSG; although this change did not reach statistical significance (P = .294), it nevertheless represents a clinically relevant result. Four (4%) patients were readmitted after having been discharged on the first postoperative day, 10 (5.3%) patients after having been discharged ≥ 2 postoperative days. This difference was not statistically significant (P = .620).
  
  
  CONCLUSIONS
  The implementation of an enhanced recovery program after bariatric surgery is feasible, well tolerated, and can significantly reduce the length of hospital stay without increasing readmission rates. Controlling for several possible confounders, implementation of the ERAS protocol remained the strongest predictor of discharge on the first postoperative day after laparoscopic bariatric surgery.
authors.affiliation: Centre for Obesity Research, Luton and Dunstable University Hospital, Luton, United Kingdom. Electronic address: marco.barreca@ldh.nhs.uk.
authors.forename: Marco
authors.initials: M
authors.lastname: Barreca
authors.affiliation: Department of Epidemiology and Public Health, University College London, United Kingdom.
authors.forename: Cristina
authors.initials: C
authors.lastname: Renzi
authors.affiliation: Centre for Obesity Research, Luton and Dunstable University Hospital, Luton, United Kingdom.
authors.forename: James
authors.initials: J
authors.lastname: Tankel
authors.affiliation: Centre for Obesity Research, Luton and Dunstable University Hospital, Luton, United Kingdom.
authors.forename: Joseph
authors.initials: J
authors.lastname: Shalhoub
authors.affiliation: Centre for Obesity Research, Luton and Dunstable University Hospital, Luton, United Kingdom.
authors.forename: Neel
authors.initials: N
authors.lastname: Sengupta
mesh_terms: D000328:Adult; D000368:Aged; D050110:Bariatric Surgery / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006784:Hospitals, Teaching; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay / Q000639:trends; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000503:physiopathology / Q000601:surgery*; D011184:Postoperative Period; D020127:Recovery of Function; D012189:Retrospective Studies; D013997:Time Factors; D055815:Young Adult
keywords: Enhanced recovery after surgery (ERAS); Laparoscopic Roux-en-Y gastric bypass (LRYGB); Laparoscopic sleeve gastrectomy (LSG); Length of stay (LOS)