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ERAS - LRYGB and LSG

Differences in ERAS protocols among LRYGB and LSG patients

The risk of postoperative fever was higher in LRYGB group but the administration of diuretics and painkillers was comparable in both groups

There are significant differences in the course of postoperative care conducted accordingly with enhanced recovery after surgery (ERAS) protocol among patients treated with laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB), according to a study by researchers from Centre for Research Training and Innovation in Surgery (CERTAIN Surgery) and Jagiellonian University Medical College, Kraków, Poland. The paper, ‘Postoperative Care and Functional Recovery After Laparoscopic Sleeve Gastrectomy vs. Laparoscopic Roux-en-Y Gastric Bypass Among Patients Under ERAS Protocol’, published in Obesity Surgery, states that postoperative treatment after LSG requires “significantly more supervision and longer time until functional recovery is achieved.”

Although LSG and LRYGB are the most commonly performed bariatric procedures, there are major differences between the procedures during the post-operative period. In addition, enhanced recovery after surgery (ERAS) protocol, can facilitate earlier functional recovery. Therefore, the authors sought to assess differences in the course of postoperative care conducted in accordance with ERAS protocol among patients after LSG and LRYGB. To the authors knowledge, this was the first study that focused on postoperative care, especially with ERAS approach.

The primary endpoints were factors determining the influence of the type of bariatric procedure on postoperative functional recovery and the secondary endpoint included an analysis of operative outcomes influenced by the type of bariatric procedure.

In total, 574 patients met inclusion criteria and underwent LSG or LRYGB (362 females, 212 males, mean age 42.77±11 years). Three hundred sixty-four (63.41%) patients underwent LSG (245 females, 119 males, mean age 40.88±11.1 years) and 210 (36.59%) patients underwent LRYGB (117 females, 93 males, mean age 46.06±10.08 years). Median maximal preoperative BMI and BMI on a day of operation were significantly higher in LRYGB group, as was higher ASA classes. Patients in LRYGB group also presented with significantly greater rates of comorbidities, including cardiovascular diseases (CVD), arterial hypertension (HTN), and diabetes mellitus (DM). Rates of obstructive sleep apnoea (RD) were similar in both groups.

Outcomes

The outcomes revealed a higher risk of postoperative nausea and vomiting (PONV) in LSG group (LRYGB vs. LSG, OR 0.16, CI 0.05–0.54, p=0.003), compared to the LRYGB group, and the amount of intravenous fluid administration during the operation day was significantly higher in LSG group (LRYGB vs. LSG, OR 0.60, CI 0.41–0.89, p=0.01).

Oral fluid intake during the first (LRYGB vs. LSG, 1532.94 ml ±575.4 vs. 1213.62 ml ±689.46, p<0.001) and the second (LRYGB vs. LSG, 1978.23 ml ± 776.86 vs. 1456.77 ml ± 743.38, p<0.001) postoperative day was significantly higher among patients who underwent LRYGB. However, they reported that there was no difference in oral fluid intake during the third postoperative day.

The risk of postoperative fever was higher in LRYGB group (LRYGB vs. LSG, OR 1.93, CI 1.22–3.05, p=0.005), but the administration of diuretics (LRYGB vs. LSG, OR 1.25, CI 0.89–1.77, p=0.198) and painkillers (LRYGB vs. LSG, OR 1.03, CI 0.72–1.47, p=0.880) was comparable in both groups. Rates of stool passage during hospitalisation were similar in both groups (LRYGB vs. LSG, OR 1.34, CI 0.95–1.88, p=0,094).

Mean length of hospital stay was significantly higher in LSG group (LRYGB vs. LSG, 3.46 days ± 1.58 vs. 3.64 days ± 4.41, p=0.039), although readmission rates were not influenced by the operation (LRYGB vs. LSG, OR 1.70, CI 0.87–3.32, p=0.119).

As expected, operative time was significantly longer in LRYGB group [LSG vs. LRYGB, 100 (80–120) vs. 140 (110–180), p<0.001) and the mean volume of intraoperative fluids administration was also significantly higher in LRYGB group (LRYGB vs. LSG, 1552.47 ml ± 537.24 vs. 1336.05 ml ± 501.87, p<0.001). The incidence of intraoperative adverse events was comparable in both groups and the rates of general postoperative complications and specific complications, including gastrointestinal leakage, gastrointestinal stricture, postoperative, wound infection, and pneumonia, were not linked the type of bariatric procedure performed.

There were no significant differences in severity of postoperative complications, assessed in accordance with Clavien-Dindo classification, between LSG and LRYGB groups and the authors did not observe any significant relation between the type of procedure and increased risk of reoperation.

“We believe that prolonged LOS among patients undergoing ERAS protocol after LSG is a result of higher incidence of PONV and lower oral fluid intake, which are both associated with worse functional recovery,” the authors concluded. “In our opinion, postoperative treatment after LSG requires more supervision and longer time until functional recovery is achieved…Readmission may be more likely to occur within the first few weeks after surgery for LSG patients compared to LRYGB patients; nevertheless, LRYGB should be followed closely within the first three months to manage potential complications that would require readmission. There was no statistically significant difference in incidence of readmissions among our patients.”

To access this paper, please click here

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