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ERAS protocol

ERAS protocol reduces hospital stay for LSG patients

ERAS programme was cost‐effective was not associated with an increase in perioperative morbidity

The results from a randomised clinical trial have shown that perioperative care with enhanced recovery following laparoscopic sleeve gastrectomy, led to reduced hospital stay. The outcomes also revealed that the ERAS programme was cost‐effective was not associated with an increase in perioperative morbidity.

The outcomes from the “Enhanced Recovery After Laparoscopic Sleeve Gastrectomy - a Randomised Controlled Trial”, which were reported in the British Journal of Surgery, could have significant clinical implications on the importance of establishing enhanced recovery after surgery (ERAS) perioperative care pathways for patients undergoing a sleeve gastrectomy.

ERAS

ERAS is a multimodal perioperative care pathway designed to achieve early recovery for patients undergoing major surgery. The pathway aims to implement evidence-based best practices, covers all areas of the patient's journey (before, during and after surgery), and provides guidance to the multi-disciplinary team involved in perioperative care helping them to work as a well-coordinated team to provide the best care.

The investigators from the University of Auckland, New Zealand, compared patients under an ERAS perioperative care programme, to patients who underwent the standard perioperative care. The primary outcome was median length of hospital stay. Secondary outcomes included readmission rates, postoperative morbidity, postoperative fatigue and mean cost per patient.

One hundred and sixteen patients were included in the analysis: 40 were allocated to the bariatric ERAS perioperative care protocol group, 38 to the control group that received standard care and 38 to a historical group of patients (n=38) who underwent laparoscopic sleeve gastrectomy at the same institution between 2006 and 2010, selected using matched propensity scores.

ERAS patients were subject to several preoperative components including preoperative education, goal setting etc. Patients in the ERAS group underwent the following treatment protocol:

Preop

  • Preop education
  • Formal goal setting session
  • Tour of the ward
  • Morning of surgery
  • Clear fluids up to two hours prior to surgery
  • Two carbohydrate drinks two hours prior to surgery

Intraop

  • 8mg IV dexamethasone at the time of anaesthetic induction
  • Standardized anaesthesia
  • Intraperitoneal local anaesthetic
  • Avoidance of prophylactic nasogastric tubes and abdominal drains

Postop

  • Early instigation of oral intake
  • Early mobilisation
  • Standardised multimodal analgesia, antiemesis and thromboprophylaxis
  • Telephone call day one and day seven post op
  • two week follow up in clinic

The perioperative care in the control group was largely dependent upon the instructions given by the responsible surgeon and anaesthetist.

Results

The outcomes showed that there were no differences in baseline characteristics between groups with patients in the ERAS group staying one day on average. This was one day less than in the control (p<0·001) and historical (three days; p<0·001) groups. Hospital stay was also shorter in the control group than in the historical group (p= 0·010).

There were no differences in readmission rate split evenly with 16 readmissions in the ERAS group and control group. There were also eight in the historical group. There 18 complications total occurring during the running of the study, ten in the ERAS group and eight in the control group. There were also 15 in the historical group.

The mean cost per patient was significantly higher in the historical group (NZD$27,700) than in the ERAS (NZ$14,836; p=0·010) and control (NZ$15,566; p=0·018) groups.

The authors concluded that the ERAS programme resulted in significantly reduced hospital stay as well as additional benefits, and that there is the potential to implement such programmes across bariatric surgery.

 “The benefit of ERAS is that standardises care which serves to address problems relating to heterogeneity of care,” said Dr Daniel Lemanu, Research Fellow, University of Auckland, New Zeland, and co-author of the study. “Though some components of the ERAS programme were novel, most were already in use in standard perioperative care, but not all together as they were in the ERAS programme.”

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