Best Practices for Fast Track in Bariatric Surgery: Enhanced Recovery After Bariatric Surgery

Best Practices for Fast Track in Bariatric Surgery: Enhanced Recovery After Bariatric Surgery Abdelrahman Nimeri, MBBCh, FACS, FASMBS ACS NSQIP Surgeon Champion Chief of General, Thoracic & Vascular Surgery Director, Bariatric & Metabolic Institute Abu Dhabi Surgery Institute Sheikh Khalifa Medical City

Disclosures Nothing to disclose

Take home Message ERABS starts in the outpatient clinic (proper patient selection, education and realistic expectations). ERABS is a multidisciplinary process. ERABS has a preoperative, intra operative, post operative and post discharge components.

Take home Message ERABS works in bariatric surgery and leads to shorter LOS and lower costs. There is a trend for more complications after discharge & outpatient LRYGB has more morbidity and mortality than 2 day LRYGB. A successful ERABS program requires a structured discharge and re admission process.

ERBS Preoperative Component Patient education. Adequate patient preparation. Proper patient selection.

Patient education and realistic patient expectation is set before the first clinic visit. A questionnaire will help stratify patients who are high risk, intermediate risk from patients who don t qualify for surgery.

ERBS Preoperative Component: patient selection & preparation Outpatient pathway. Systematic screening for OSA. Smoking cessation. MDT case discussion.

Patient referred BMI 40 or 35 with DM, HTN, etc Process at BMI Abu Dhabi Monthly Public Lecture BMI Abu Dhabi Clinic 6 Bariatric Surgeon, Psychologist and Dietician 2-3, Labs 3-6 months Workup on a case by case basis EGD/Colonoscopy/Cardiology/Respirology/Bariatrician Certain cases get presented in our BMI Abu Dhabi monthly meeting Back to BMI Abu Dhabi Clinic 6 Bariatric Surgeon then anesthesiologist Surgery then Follow up

ERBS Preoperative Component: Systematic screening for OSA. STOP BANG questionnaire Snoring, Tiredness during daytime, Observed apnea, high blood Pressure BMI 35, Age 50, Neck Circumference 40 Gender STOP BANG score >3 equals referral for a sleep study

ERBS Preoperative Component: Systematic screening for OSA. close to 30% of males patients had OSA STOP BANG score >3 equals referral for a sleep study

ERBS Preoperative Component: Systematic screening for OSA.

ERBS Preoperative Component: patient selection Which patients are not suitable for Fast Track or ERABS? *Elliott JA et al Updates Surg. 2013 Jun;65(2):85-94

ERBS Preoperative Component: patient selection Of 9,593 LRYGB median length of stay was 2 days (range 0-544) and 26% of patients required 3 days of hospitalization. In multivariate analysis, LOS was predicted by DM, COPD, bleeding diathesis, renal insufficiency, hypoalbuminemia, prolonged OR time, and resident involvement with the procedure, but not by patient age, sex, body mass index, and other co-morbidities. Carter J et al Surg Obes Relat Dis. 2015 Mar-Apr;11(2):288-94.

ERBS Intra & Post operative Components Anesthesia pathway. Inpatient clinical pathway. Proper patient selection.

Dedicated anesthesiologist for all cases.

ERBS Intra & Post operative Components Fast-track surgery for LRYGB with focus on anesthesia and peri-operative care. Experience with 500 cases. The mean total hospital stay was reduced from 3 days at start to 2 days in the end of the series (P<0.05). Bergland A et al Acta Anaesthesiol Scand. 2008 Nov;52(10):1394-9.

ERBS Intra & Post operative Components Sugammadex allows fast-track bariatric surgery Sugammadex allowed a safer and faster recovery from profound rocuronium-induced NMB than neostigmine did in patients with Morbid Obesity. Carron M et al Obes Surg. 2013 Oct;23(10):1558-63.

Inpatient Clinical pathway

ERBS Intra & Post operative Components 65 consecutive patients with CP in 2009 compared to 64 patient without CP 2008. In the CP group, foley catheters were removed earlier (p < 0.0001), patients were mobilized more often (CP group 92.3% vs. pre-cp group 78.1%, p = 0.03), used spirometers more often (56.9% vs. 28.1%, p = 0.002), and received oral supplement nutrition more often (100% vs. 59.4%, p < 0.0001). Ronellenfitsch U et al Obes Surg. 2012 May;22(5):732-9.

ERBS Post discharge Component Emergency room clinical pathway. MBSAQIP or outcome database. Proper patient selection.

What is the evidence that ERABS reduces cost and LOS? ERAS protocols in various abdominal surgeries including colorectal, bariatric, gynecological, gastric, pancreatic, esophageal, and vascular surgery reported cost savings associated with hastening recovery and reducing morbidity and complications. Stowers MD Can J Anaesth. 2015 Feb;62(2):219-30..

What is the evidence that ERABS reduces cost and LOS? RCT of 116 LSG (78 ERABS & 40 to control LSG compared to 38 historical LSG. Groups were similar in demographics complications. The mean cost per patient was significantly higher in the historical group than in the ERABS (P = 0 010) and control (P = 0 018) groups. Lemanu DP et al Br J Surg. 2013 Mar;100(4):482-9.

What is the evidence that ERABS reduces cost and LOS? Median hospital stay was significantly shorter in the ERABS group (1 day) than in the control (2 days; P < 0 001) and historical (3 days; P < 0 001) groups. It was also shorter in the control group than in the historical group (P = 0 010). Lemanu DP et al Br J Surg. 2013 Mar;100(4):482-9.

What is the evidence that ERABS reduces cost and LOS? Matched for age & sex primary LRYGB in 2011 (CPC group) & 2012 (FTS group) (BMI and waist circumference were significantly lower (p < 0.05) in the FTS compared to CPC). OR time was reduced from 80 to 56 min (p < 0.001), time from arrival at the OR to PACU was reduced from 119 to 82 min (p < 0.001); mean LOS was reduced from 65 to 43 h (p < 0.001). Major complications occurred in 3 versus 4 % in the FTS and CPC, respectively. Dogan K et al Obes Surg. 2015 Jan;25(1):28-35.

ERBS Post discharge Component Data were obtained from the BOLD for 51,788 LRYGB from 2007 & 2010. Logistic regression models were used to evaluate age, sex, race, BMI, insurance status, co morbidities, and LOS as predictors for 30-day mortality, serious complications, and readmissions. Morton JM et al Ann Surg. 2014 Feb;259(2):286-92.

Cohort studies Study Procedures Discharge PO intake Re admission LOS Complications Barreca et al SOARD 2015 288 patients LRYG & LSG 36% discharged POD#1 (28.5% LRYGB 60.9% after LSG) (4%) patients POD#1 compared to (5.3%) patients discharged 2 POD(P =.620). Matlok et al Med Sci Monit 2015 170 patients BMI 46.7 Kg/M2 66% LRYGB 21% LSG 13% LAGB PO intake by 162 (95.3%) patients and 163 (95.8%) were fully mobile. LOS 2.9 days Re admission 1.7%

ERBS Post discharge Component Data were obtained from the BOLD for 51,788 LRYGB from 2007 & 2010. The distribution of LOS in days was 0 (1.0%), 1 (18.4%), 2 (59%), 3 (17.5%), and 4 (4.1%). There was no significant trend between LOS status and 30-day readmission rates. Morton JM et al Ann Surg. 2014 Feb;259(2):286-92.

ERBS Post discharge Component For LOS of 0 day, there was a trend toward an increase 30-day serious complications (OR 1.9; P < 0.16). Using the median LOS 2 days as reference, the logistic regression analysis ambulatory LOS of was significantly associated with increased risk of 30- day mortality (odds ratio: 13.02; P < 0.0001) as was LOS 1 day (odds ratio: 2.02; P < 0.0552). Morton JM et al Ann Surg. 2014 Feb;259(2):286-92.

ERBS Post discharge Component Overall, 30-day mortality, 0.1%; serious complications, 0.5%; and readmissions, 3.8%. median LOS was 2 days. The distribution of LOS in days was 0 (1.0%), 1 (18.4%), 2 (59%), 3 (17.5%), and 4 (4.1%). Morton JM et al Ann Surg. 2014 Feb;259(2):286-92.

ERBS Post discharge Component Consecutive unselected patients who underwent a primary LRYGB in the years before (n = 104) and after implementation of fast track care (n = 360). The median length decreased after implementation of fast track (3 days versus 1 day, p < 0.001). Geubbels N et al Obes Surg. 2014 Mar;24(3):390

ERBS Post discharge Component More grades I-IVa complications occurred outside the hospital after the implementation of fast track care (24.8 % versus 51.5 %). Lower age (b = 0.118, 95 % CI: 0.002-0.049, p < 0.05) and the implementation of fast track (b = - 0.270, 95 % CI: -1.969 to -0.832, p < 0.001) were the only factors that significantly shortened LOS. Geubbels N et al Obes Surg. 2014 Mar;24(3):390

ERBS Post discharge Component A total of 1967 (mean age 43.3 years, 80% females) had primary bariatric surgery, 654 before & 1313 after implementation of ERABS from 2010-2014. OR time and LOS (3.2 to 2 nights) decreased significantly (P<0.001). Complications increased from 16.1% to 20.7% P=0.013). Mannaerts GH et al Obes Surg. 2015 May 24. [Epub ahead of print]

Take home Message ERABS starts in the outpatient clinic (proper patient selection, education and realistic expectations). ERABS is a multidisciplinary process. ERABS has a preoperative, intra operative, post operative and post discharge components.

Take home Message ERABS works in bariatric surgery and leads to shorter LOS and lower costs. There is a trend for more complications after discharge & outpatient LRYGB has more morbidity and mortality than 2 day LRYGB. A successful ERABS program requires a structured discharge and re admission process.