Less pain and earlier discharge after implementation of a multidisciplinary enhanced recovery after surgery (ERAS) proto
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and Other Interventional Techniques
Less pain and earlier discharge after implementation of a multidisciplinary enhanced recovery after surgery (ERAS) protocol for laparoscopic sleeve gastrectomy Daniel B. Jones1 · Mohamad Rassoul A. Abu‑Nuwar1 · Cindy M. Ku2 · Leigh‑Ann S. Berk1 · Linda S. Trainor1 · Stephanie B. Jones2 Received: 5 August 2019 / Accepted: 24 December 2019 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Background Laparoscopic sleeve gastrectomy (LSG) may be complicated by postoperative pain, nausea, and vomiting, with consequent increases in length of stay (LOS), decreased patient satisfaction, and higher costs. While enhanced recovery after surgery (ERAS) protocols have been in circulation for many years, there is no standard ERAS protocol for bariatric surgery. Methods Data were collected prospectively and compared to a historical control. All patients undergoing LSG, ages 18 to 75, were included in the pathway; those with preoperative chronic opioid use were excluded from our results. Statistical analysis was performed using t-statistics and chi-squared test. Ninety patients undergoing LSG, performed by a single surgeon, were included in our ERAS group from November 26, 2018, to April 30, 2019, and were compared to a historical control of 570 patients who underwent LSG over the previous 5 years (pre-ERAS). Measured outcomes included discharge opioid prescriptions issued, hospital length of stay, 30-day readmissions, reoperations, morbidity, and mortality. Results Ten (11%) ERAS patients vs 100% of pre-ERAS patients received opioid prescriptions upon, or after, discharge (p 70, hx urinary retention) Regional anesthesia Bilateral TAP Block (20 ml of 0.25% bupivacaine, or 0.5% ropivacaine) Intra-Op Induction 2 mg midazolam after transfer to OR table, if not given during pre-op block Consider using low-dose ketamine, lidocaine, or esmolol instead of fentanyl Propofol induction dose to adjusted body weight Non-depolarizing neuromuscular blockade to IBW or succinylcholine 1 mg/kg Actual body weight Postinduction Dexamethasone 8 mg IV if not diabetic Antibiotics
Maintenance & analgesia Your choice of sevoflurane or desflurane Hydromorphone 35 degrees Celsius) For diabetics: blood glucose / = 30 degrees Anti-emetics Please order Ondansetron 4 mg (1st line), Prochlorperazine (2nd line), Haloperidol 0.5 mg IV (3rd line) Please order hydromorphone bolus per PACU Analgesic Minimize benzodiazepine use
Cefazolin
2 gm IV, 3 gm for > 120 kg Levofloxacin 500 mg IV if cefazolin allergy
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Smoking cessation impairs physiology and functional reserve and has a direct effect on wound healing, morbidity, and mortality. It has been shown in multiple studies including meta-analysis that stopping smoking at least 4 weeks prior to surgery reduces postoperative complications [14]. Smoking cessation is a requirement of most bariatric programs, and at many times for a period far longer than 4 weeks. It is an important intervention with proven results. The recommendation
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