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Postoperative Care and Functional Recovery After Laparoscopic Sleeve Gastrectomy Vs OBES SURG (2018) 28:1031–1039 https://doi.org/10.1007/s11695-017-2964-3 ORIGINAL CONTRIBUTIONS Postoperative Care and Functional Recovery After Laparoscopic Sleeve Gastrectomy vs. Laparoscopic Roux-en-Y Gastric Bypass Among Patients Under ERAS Protocol Piotr Major1,2 & Tomasz Stefura 3 & Piotr Małczak1,2 & Michał Wysocki 2,3 & Jan Witowski2,3 & Jan Kulawik1 & Mateusz Wierdak1,2 & Magdalena Pisarska1,2 & Michał Pędziwiatr 1,2 & Andrzej Budzyński1,2 Published online: 23 October 2017 # The Author(s) 2017. This article is an open access publication Abstract Results The rate of postoperative nausea and vomiting and Background The most commonly performed bariatric pro- incidence of intravenous fluid administration during the oper- cedures are laparoscopic sleeve gastrectomy (LSG) and ation was higher in LSG group. LRYGB patients were able to laparoscopic Roux-en-Y gastric bypass (LRYGB). There tolerate higher oral fluid intake volumes during the first and are major differences between LSG and LRYGB during the second postoperative day. Mean diuresis during the second postoperative period. Optimization of the postoperative and the third postoperative day was significantly higher in care may be achieved by using enhanced recovery after LRYGB group. Administration of diuretics and painkillers surgery (ERAS) protocol, which allows earlier functional was comparable between groups, while the risk of fever after recovery. the operation was higher in LRYGB group. Mean length of stay Purpose The aim was to assess differences in the course of was higher in LSG group (LRYGB vs. LSG, 3.46 days ± 1.58 postoperative care conducted in accordance with ERAS pro- vs. 3.64 days ± 4.41, p =0.039). tocol among patients after LSG and LRYGB. Conclusions In our opinion, postoperative treatment after Material and Methods Data concerning patients treated for LSG requires more supervision and longer time until function- morbid obesity were prospectively gathered in one academic al recovery is achieved. center. Patients were divided into two groups: LSG (n =364, 63.41%) and LRYGB (n = 210, 36.59%). Multiple factors were used as endpoints to determine the influence of the type Keywords Bariatric surgery . Sleeve gastrectomy . Gastric of bariatric procedure on postoperative course. bypass . Postoperative care . ERAS * Tomasz Stefura Magdalena Pisarska [email protected]; [email protected] [email protected] Piotr Major Michał Pędziwiatr [email protected] [email protected] Piotr Małczak Andrzej Budzyński [email protected] [email protected] Michał Wysocki [email protected] 1 2nd Department of General Surgery, Jagiellonian University Medical Jan Witowski College, Kopernika 21 St., 31-501 Kraków, Poland [email protected] 2 Jan Kulawik Centre for Research, Training and Innovation in Surgery (CERTAIN [email protected] Surgery), Krakow, Poland Mateusz Wierdak 3 Students’ Scientific Group at 2nd Department of Surgery, JUMC, [email protected] Krakow, Poland 1032 OBES SURG (2018) 28:1031–1039 Introduction We excluded patients with insufficient data (Fig. 1). Study was designed and described according to all STROBE Bariatric surgery seems to be the most effective treatment for checklist points for observational studies [13]. obesity and obesity-related metabolic comorbidities [1]. The Data collection was performed by authors, who were most commonly performed bariatric procedures worldwide also directly involved in treatment process. Database in- are laparoscopic sleeve gastrectomy (LSG) and laparoscopic cluded demographic characteristics and factors related to Roux-en-Y gastric bypass (LRYGB) [2, 3]. Enhanced recov- the surgery. Features describing patient profile included ery after surgery (ERAS) protocol during the course of post- age, sex, maximal preoperative BMI, BMI on a day of operative care includes avoiding use of catheters and intra- operation, American Society of Anesthesiologists (ASA) abdominal drains, prophylactic use of antithrombotic medica- class, and main comorbidities (cardiovascular diseases, ar- tions, early mobilization, early enteral feeding, and multimod- terial hypertension, obstructive sleep apnea syndrome, di- al postoperative analgesia [4, 5]. Perioperative care carried out abetes mellitus type 2). Perioperative variables were type in accordance to ERAS protocol seems to be a safe and feasi- of procedure, operative time, intraoperative adverse events, ble method for both operations, which allows to reduce length postoperative complications, length of hospital stay (LOS), of hospital stay and readmission rates without influencing readmissions, reoperations, fever, postoperative nausea morbidity [6, 7]. Contrary to popular opinion, the main benefit and vomiting, stool passage after surgery during the hos- from implementing the protocol is not the ability to discharge pitalization, diuretics management, painkillers manage- the patient as early as it is possible, but as soon as they reach ment, and data concerning postoperative fluid management full functional recovery. High demand for bariatric operations (intravenous fluid administration, oral fluid intake, and di- creates tendency to perform them as outpatient procedures. uresis) during the operation day and first three consecutive Optimization of the postoperative period according to ERAS postoperative days. Patients were divided into two groups: protocol is a key factor for this approach [8, 9]. Major differ- LSG and LRYGB. An intraoperative adverse event was ences between patients after LSG and LRYGB during postop- defined as any iatrogenic harmful event occurring during erative course are not well known. Achieving early recovery operation, which had not derived from standard LSG or of gastrointestinal function seems to be significant factor con- LRYGB technique. We defined postoperative complica- tributing to decreasing discomfort or risk of prolonged hospi- tions as adverse events occurring within 1 year of the pro- tal stay after abdominal surgery [10]. Although there are plen- cedure. Rhabdomyolysis was defined as elevated levels of ty of studies comparing early and late postoperative outcomes creatinine phosphokinase (CPK > 1000 IU/l) with of those two procedures, none so far focused on postoperative coexisting increase of myoglobin level. Gastrointestinal care, especially with ERAS approach. leakage was defined as leakage from the GI tract clinically diagnosed and confirmed with radiological examination. Postoperative hemorrhage was defined as a significant Purpose drop in hemoglobin count with either clinically demon- strated hemorrhage requiring reoperation or need of eryth- The aim was to assess the differences in postoperative course rocyte transfusion. LOS was defined as period from admis- among patients treated according to ERAS protocol submitted sion to discharge, based on number of nights spent in hos- to LSG and LRYGB. pital. All patients were admitted to hospital 1 day prior to surgery, so if the patient would be discharged on the day of surgery, his LOS would be 1 day. Material and Methods Treatment Protocol Study Design In order to minimize bias, patients were treated in accordance Data concerning bariatric patients treated for morbid obe- with enhanced recovery after surgery (ERAS) pathway, in- sity in one academic center were prospectively gathered. cluding preoperative, intraoperative, and postoperative inter- Recommendations of the Metabolic and Bariatric Surgery ventions [6, 14, 15]. During the preoperative period, patients Section of the Polish Surgical Society were used as indi- were appropriately counseled. The health status of all patients cation for surgery, that is body mass index (BMI) ≥ 35 kg/ was assessed with particular emphasis on incidence of type 2 m2 with obesity-related comorbidities or BMI ≥ 40 kg/m2 diabetes mellitus, hypertension, obstructive sleep apnea, and [11, 12]. Inclusion criteria for this study were informed gastroesophageal reflux disease (GERD). Incidence of GERD consent to participate in the study, meeting the eligibility was assessed during history taking by a direct question and criteria for bariatric treatment, either for LSG or LRYGB. questions concerning taking proton-pump inhibitors. OBES SURG (2018) 28:1031–1039 1033 Fig. 1 Study flowchart Enrollment Assessed for eligibility (n=580) Excluded (n=6) Lack of necessary data (n=6) Included (n=574) Allocation Allocated to LSG group (n=364) Allocated to LRYGB group (n=210) Analysis Analysed (n=364) Analysed (n=210) Preoperative consultations included also routine endoscopy (glomerular filtration rate). Every bariatric patient in our cen- of the upper gastrointestinal tract with assessment of hiatal ter is scheduled to have three follow-up appointments: hernia and esophageal, gastric, or duodenal mucosa patholo- 2 weeks after discharge, 1 month after discharge, and gy.Incaseofalargehiatalherniawithinflammatorylesions 3 months after discharge. in esophageal mucosa, patients were treated with pantoprazole and qualified for LRYGB. If hiatal hernia did Surgical Technique not coexist with inflammatory lesions in esophageal mucosa or clinical symptoms of GERD requiring pharmacotherapy, Surgical techniques for LSG and LRYGB were standardized we suggested LSG with possible simultaneous cruroplasty in [17]. Veress needle was used to achieve pneumoperitoneum case of large gap in the diaphragm. Final decision was made (15 mmHg). Routine procedure required insertion of four tro- by patients. During endoscopy, gastric
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