Italian researchers have highlighted the complex landscape of enhanced recovery after bariatric surgery (ERABS) protocol adherence in Italian bariatric centres. They have found that while certain practices align well with established guidelines, variations persist indicating a need for ongoing education, standardisation efforts and interdisciplinary collaboration.
In 2022, the Italian Society of Obesity Surgery and Metabolic Diseases (SICOb) and the Italian Society of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI) collaboratively formulated the first Italian consensus statement for enhanced recovery after bariatric–metabolic surgery. Within this paper, a compendium of 25 recommendations was proffered, encompassing facets of preoperative evaluation and care, intraoperative management, postoperative directives and discharge protocols.
The SICOb guidelines underwent a comprehensive update in 2023, presenting robust endorsements for a peri- and intra-operative management model that integrates some or all components delineated in ERABS protocols. The adoption of the ERABS approach, as per these guidelines, portends improved recovery outcomes, diminished length of hospital stay and reduced patient stress, all without concomitant increase in complications. The articulation of a national statement assumes paramount significance as it constitutes the key to achieving standardisation across Italian bariatric surgical centres.
The primary aim of this study investigated the actual implementation of ERAS protocols within Italian bariatric centres and provide an objective assessment of the current state of adherence to these principles.
The study consisted of an online survey that consisted of 19 items, which was anonymously administered to 139 centres, with a total of 23,501 surgical and endoscopic procedures performed in 2022.
The questionnaire explored the peri- and intra-operative management of bariatric patients undergoing sleeve gastrectomy (SG), Roux-en-Y Gastric Bypass (RYGB) and one anastomosis gastric bypass (OAGB), which collectively constitute the three most frequently performed procedures in Italy (57%, 12%, and 13%, respectively) according to the National Registry.
Outcomes
In October 2023, 72 out of a total of 139 bariatric centres (51.8%) responded to the online survey proposed, representative of more than 15,000 surgical procedures performed in Italy each year.
Concerning the totality of centres, the majority of the centres’ managing surgeons are well informed about the ERABS protocol, with only 2 (2.8%) having partial knowledge. The majority of centres attempt to apply (64.8%) or evaluate the application of the protocol on a case-by-case basis (29.6%). However, less than half (46.5%) of centres use a specific checklist for ERABS protocol application, contrasting with the previous answers. In excellence centres, this percentage rose to 58.1%, while it remains under 50% in all the other categories.
The use of antibiotics over perioperative prophylaxis has been abandoned by 77.5% of the surgeons, and the TAP block technique is adopted in 69% of centres as a perioperative pain control strategy.
Intraoperative habits of surgeons regarding the positioning of a nasogastric tube (NGT), abdominal drain (DRG) and urinary catheter (UC) during SG and RYGB/OAGB were investigated separately. The use of intraoperative methylene blue test in both procedures was also explored. The application of ERABS protocols concerning the use of the UC and NGT which seem to be widely applied (no routine positioning of NGT in 96% and 86% and no routine positioning of UC in 87.3% and 74.6% in SG and RYGB, respectively). However, there is a poor application of the ERABS protocol in terms of abdominal drain usage. In fact, the routine positioning of abdominal drains is not expected as per protocol; however, abdominal drains were not used in 38% of cases in the SG group and 29.5% in the RYGB group.
The intraoperative employment of a methylene blue test, compared with other intraoperative tests or no intraoperative test, was assessed. The majority of surgeons prefer to perform an intraoperative test in the majority of cases (methylene blue 70.4% or other kinds of tests 1.4%) despite ERABS recommendations.
The early reintroduction of oral feeding with a liquid diet, as recommended by both ERAS and ERABS protocols, identified three time intervals where oral feeding was reintroduced were identified: within 24 h (71.8%), 24–72 h (21.1%), and after 72 h (7.1%).
Postoperative pain is managed in an opioid-free approach in 71.8% of centres, with a higher rate in the North of Italy (93.3%) and a lower rate in the Islands (42.9%). Postoperative mobilisation mainly occurs within 24 h after surgery (98.6%), with 59% within 6 h from surgery.
Despite guidelines recommending no radiologic check before discharge, the employment of pre-discharge radiologic tests report 60.5% of centres perform a pre-discharge radiologic test and 11.3% resort to other tests.
Timing of discharge was analysed separately for SG and OAGB/RYGB and in the majority of centres, patients are discharged on postoperative day (POD) 3 or 4 (53.4% SG and 54.9% RYGB/OAGB), followed by POD 2 (39.6% SG and 35.1% RYGB/OAGB). Only 53.4% of centres offer a phone call monitoring service dedicated to patients, with dedicated bariatric physicians or nurses who can complete the health check.
“The results provide valuable insights for bariatric surgeons, healthcare professionals, and policymakers to address challenges and enhance the implementation of ERABS protocols for improved patient outcomes,” they authors concluded. “Continued research and dialogue within the bariatric community will be crucial for advancing the field and achieving a more standardised and optimized approach to bariatric and metabolic surgery in Italy.”
The findings were reported in the paper, ‘Enhanced recovery after bariatric surgery: a comprehensive survey-based analysis of ERABS actual clinical implementation in Italian bariatric centers’, published in Updates in Surgery. To access this paper, please click here
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