Applying Enhanced Recovery After Bariatric Surgery (ERABS) Protocol for Morbidly Obese Patients With End-Stage Renal Failure

Proczko M et al. Applying Enhanced Recovery After Bariatric Surgery (ERABS) Protocol for Morbidly Obese Patients With End-Stage Renal Failure. Obes Surg. 2019 Apr;29(4):1142-1147

What is already known:

Those patients with end-stage renal failure will ultimately require a kidney transplant. Many centres will only consider patients who have a BMI of less than 35, as obesity is a major risk factor for post-operative complications.

What this paper adds:

If bariatric treatment was to be considered a bridge therapy for kidney transplantation, then it must be safe for the patient. In this retrospective review, 21 patients with end-stage renal failure were matched with a propensity matched cohort all undergoing bariatric surgery. The overall rate of complications were similar in both groups showing that ERAS for bariatric surgery is safe for those with end-stage renal failure.

Chris Jones, Guildford.


Influence of Preoperative Weight Loss on Outcomes of Bariatric Surgery for Patients Under the Enhanced Recovery After Surgery Protocol

Stefura T et al. Influence of Preoperative Weight Loss on Outcomes of Bariatric Surgery for Patients Under the Enhanced Recovery After Surgery Protocol. Obesity Surgery. PMID: 30632072. DOI: 10.1007/s11695-018-03660-z

What is already known:

ERAS protocols have been safely implemented in bariatric patients to improve patient outcomes, reduce length of stay and lead to fewer postoperative complications. Bariatric Surgery is becoming increasingly prevalent and patients are usually advised to lose weight pre-operatively but the effects of this on perioperative complications when evaluated within an ERAS protocol have not yet been studied. Current ERAS Society guidelines for use in Bariatric Surgery state that preoperative weight loss as “strong” recommendation grade; but this is often overlooked due to barriers to its implementation.

What this paper adds:

This was a multicentre study looking at prospectively collected data on 909 bariatric patients undergoing laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB), using ERAS protocols, in two hospitals in Poland. They aimed to look at factors affecting preoperative weight loss and the effects weight loss had on short term outcomes. They separated patients into those who lost <5% of body weight and those >5% body weight pre-operatively. They found that factors associated with increased weight loss were presence of diabetes mellitus (p=0.027) and obstructive sleep apnoea (p=0.007). Steatohepatitis was more common (p <0.001) in those who lost < 5% and in male patients (p=0.02). The median operative times were significantly lower in patients who lost > 5% body weight (LSG p<0.001, LRYGB p=0.010). Patients who lost > 5% body weight went on to have higher median total weight loss on follow up (p=0.009). There was no difference in post-operative complication rates between to the two groups. Randomised studies looking into the effects of pre-operative weight loss are needed but this small study shows that preoperative weight loss can lead to reduced surgical times and greater overall weight loss after bariatric surgery. However not losing weight preoperatively did not increase complications postoperatively, showing the importance of a good ERAS programme.

Katie Wimble, Guildford


Applying Enhanced Recovery After Bariatric Surgery (ERABS) Protocol for Morbidly Obese Patients With End-Stage Renal Failure

Proczko M et al. Applying Enhanced Recovery After Bariatric Surgery (ERABS) Protocol for Morbidly Obese Patients With End-Stage Renal Failure. Obes Surg. 2019 Apr;29(4):1142-1147

What is already known:

ERAS protocols have been safely implemented in bariatric patients. Obesity is a known risk factor for the development of end stage renal disease (ESRD). No current studies have looked at the safety of ERAS protocols in patients requiring bariatric surgery as a bridge to organ transplantation in patients with ESRD.

What this paper adds:

This single centre retrospective study looked at propensity matched patients with ESRD undergoing bariatric surgery as a bridge to renal transplantation. This resulted in two groups of 19 patients. There were no significant differences in minor or major complications up to 30 days postoperatively. Only one patient in the ESRD group needed a re-operation due to an anastomotic leak. Length of stay was on average 1.8 days longer in the ESRD group due to the need for dialysis postoperatively. This small study confirms that Bariatric ERAS protocols are safe in patients with ESRD with no changes needed to the ERAS protocols.

Katie Wimble, Guildford


An ERAS protocol for bariatric surgery: is it safe to discharge on post-operative day 1?

Lam J et al. An ERAS protocol for bariatric surgery: is it safe to discharge on post-operative
day 1? Surg Endosc. 2019 Feb;33(2):580-586.

What is already known:

The ERAS society published guidelines for Bariatric surgery in 2016 [they can be found here]. Bariatric surgery has been shown to help improve or resolve many obesity-related conditions, such as type 2 diabetes, high blood pressure, heart disease, and more. Laparoscopic Sleeve Gastrectomy is one of the most commonly performed bariatric operations in the USA.

What this paper adds:

This was a single centre retrospective review of their programme after it had been introduced. They included over 200 patients and with a comprehensive ERAS pathway they showed that after laparoscopic surgery patients could be safely discharged on postoperative day 1. With no difference in readmission rates, post-operative complications or mortality. They also found with a good multimodal analgesic programme they could reduce intraoperative opioid use and still reduced pain scores on postoperative day 1.

Chris Jones, Guildford.


Implementing enhanced recovery after bariatric surgery protocol: a retrospective study

Proczko M, Kaska L, Twardowski P, Stepaniak P. Implementing enhanced recovery after bariatric surgery protocol: a retrospective study. J Anesth. 2016 Feb;30(1):170-3.

What is already known:

ERAS programmes have been widely shown to reduce hospital length of stay for a number of surgical specialities, particularly through early post-operative mobilisation and multi-modal analgesia. Outside of ERAS much research has looked into the benefits of non-clinical interventions – human factors – on clinician’s performance and subsequent patient outcomes across the medical field.

What this paper adds:

This brief paper demonstrates the successful implementation of an ERAS programme for bariatric surgery with reduced hospital length of stay alongside some other interesting benefits. Both operating and anaesthetic times were reduced as was the turnover time between cases. The paper does not detail the individual ERAS elements adhered to, but the programme includes a number of interventions aimed at improving the human factors of a bariatric list including a “working with a fixed team” concept whereby the surgeons, anaesthetists and circulating nurses work together on a regular basis improving the overall team’s efficiency. Cases were concentrated on specific lists during the week rather than being spread out across several lists with different teams. Although logistically challenging such interventions can improve theatre efficiency significantly alongside patient-specific outcomes.

Ben Morrison, Guildford.


Is there a role for enhanced recovery after laparoscopic bariatric surgery?

Barreca M, Renzi C, Tankel J, Shalhoub J, Sengupta N. Is there a role for enhanced recovery after laparoscopic bariatric surgery? Preliminary results from a specialist obesity treatment center. Surg Obes Relat Dis. 2016 Jan;12(1):119-26.

What is already known:

The ERAS society has recently published guidelines for bariatric surgery (link) however there is limited research in this field.

What this paper adds:

This is a UK review of prospectively collected data from a single specialist centre (288 patients). They showed that an ERAS program was feasible and safe for this group of patients. They demonstrated a significant increase in patients being discharged on postoperative day one after undergoing laparoscopic roux-en-Y bypass (from 1.6% to almost 40%), with no increase in readmission rates. Interestingly neither ASA score or comorbidity had an influence on whether a patient would be discharged on the first post-operative day, (OR:50.95;95%CI:6.55–396.12; P 0.001).

 Chris Jones, Guildford.