© Springer Nature Singapore Pte Ltd. 2017
Saravana Kumar and Rachel Maria Gomes (eds.)Bariatric Surgical Practice Guide10.1007/978-981-10-2705-5_2222. Enhanced Recovery After Bariatric Surgery
(1)
Department of General, Bariatric and Upper GI Surgery, Mediclinic Dubai Mall, Dubai, UAE
22.1 Introduction
Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of ERAS protocols include preoperative counseling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, they challenge traditional surgical doctrine, and as a result their implementation has been slow [1]. Also referred to as Fast Track Surgery (FTS) these protocols have been successfully practiced in colorectal surgery over many years [2]. The body of evidence is quite compelling, but so far their adoption in bariatric surgery has been rather sporadic and patchy.
Traditionally bariatric surgery has been perceived as being a ‘high risk’ surgery partly due to the difficulties with anesthesia of the obese patient and the existence of multiple co-morbidities in these patients. In part, the perceptions which were derived from the days of open bariatric surgery, where post-operative complications used to be high, are still active with the practitioners of bariatric surgery. With the widespread adoption of the laparoscopic approach in bariatric surgery, peri-operative morbidity has fallen dramatically. Recent evidence fromthe Longitudinal Assessment of Bariatric Surgery (LABS) group has shown us that the peri-operative mortality and morbidity of bariatric surgery is as low as that of laparoscopic cholecystectomy [3]. There are sporadic reports of some centers successfully adopting ERAS programs [4–8]. A wider adoption of such protocols has the potential to alter the perceptions that Bariatric Surgery is not so dangerous or complicated, leading to greater acceptance of bariatric surgery by patients and referring physicians.
22.2 Principles of ERAS
ERAS Programs require the adoption of the philosophy of early recovery by all members of the team involved in the care of the obese patient, similar to the processes and protocols laid out in a Day Surgery Unit.
The key elements of an ERAS Program incorporate the following
- 1.
Pre-operative information to the patient
- 2.
Pre-operative optimization of organ function
- 3.
Stress reduction in the operating room
- 4.
Effective pain relief and prophylaxis for nausea and vomiting
- 5.
Modification of the post-operative care with the aim of early mobilization and early enteral feeding
The expected outcomes of an ERAS program are
- 1.
Reduction in morbidity
- 2.
Enhanced recovery
- 3.
Early discharge
- 4.
Patient satisfaction
- 5.
Cost savings
22.3 Designing an ERAS Program
The design and implementation of an ERAS Program involves the creation of procedure specific care plans, staff training on the principles of ERAS, and multi-disciplinary collaboration between the pre-operative team, the surgeon, the endocrinologist/physician, the anesthetic team and the post-operative nursing professionals, and most importantly the involvement of the patient who is fully informed of the post-operative journey. In a larger organization it may be desirable to appoint designated personnel who should be part of the “ERAS Bariatric Team” and who receive appropriate training into the ERAS protocols.
Clear guidelines for the pre-operative care pathways, intraoperative protocols and post- operative care plans should be developed and all personnel receive rigorous training in the implementation of these pathways.
22.3.1 Pre-operative Pathways
22.3.1.1 Pre-operative Investigations and Treatments
Investigation for H. Pylori infection and eradication therapy
Investigation of vitamin deficiencies and correction
Investigation for anemia and appropriate treatment
Investigation of metabolic disease and optimization of metabolic status including the recommendations on post-operative management of diabetes in the immediate post-operative period
Investigation for cardio-respiratory function and appropriate treatment including the recommendations on post-operative management of hypertension and heart disease.
Upper GI endoscopy is increasingly being adopted as an essential pre –op evaluation modality routinely. However, in a patient who gives a history of GERD or other suspicious upper GI symptoms, this should be a mandatory step.
22.3.1.2 Pre-operative Optimization Diet
Fat Free Diet
Vitamin Supplements
Protein Supplements
The purpose of this diet is to build a reserve of essential nutrients in anticipation of a low nutrition catabolic post-operative state, when the patient receives only a liquid diet until 2 weeks. The second objective is to reduce the hepatic steatosis to make the surgery safer by slimming down the liver so it can be easily lifted off the stomach and does not get traumatized and bleed during surgery.
22.3.1.3 Patient Counseling on the Recovery Process
Early Enteral Nutrition
Early Mobilization
Incentive Spirometry
These measures should be clearly discussed and demonstrated to the patient during the pre-operative visit. This is a critical requirement as patient’s active participation in the implementation of the postoperative care pathways is essential to ensure predictable outcomes.
22.3.2 Intra Operative Protocols
Several intra-operative measures have an impact on the post-operative recovery process. The objective is to reduce the inflammatory response to surgical trauma, to prevent post-operative nausea and vomiting, reduce pain enabling early mobilization and commencing early enteral nutrition. Several of the measures described below are designed to get the patient upright immediately after surgery and spend as little time as possible in bed.
22.3.2.1 Minimally Invasive Techniques
The migration from open to laparoscopic surgery was a game changer in the widespread adoption of bariatric surgery and the reduction in the morbidities and the mortality associated with bariatric surgery. The most common complications related to bariatric surgery prior to the introduction of laparoscopic surgery were related to the state of recumbency i.e. DVT and PE as well as basal pneumonias. The advantages of laparoscopic surgery are well known, but become especially important in the context of bariatric surgery where a shorter operating time and reduction in the surgical trauma making this otherwise major surgery as safe as a laparoscopic cholecystectomy. An efficient and co-ordinated operating team familiar with the procedure and surgeon to reduce the total operating time to less than 120 min further reduces the incidence of complications including DVT [9].
22.3.2.2 Ultra Short Acting Volatile Anesthetic Agents and Muscle Relaxants
It is important to have the patient breathe spontaneously as soon as possible immediately after surgery, so that assisted ventilation and oxygenation can be discontinued. The longer the patient remains under the influence of muscle relaxants the longer it takes to have the patient mobilizing.
Related posts:
Selection of Bariatric Surgery Procedures in Special Circumstances
Standardization of Technique in Roux-en-Y Gastric Bypass
Outcomes of Diabetic Microvascular Complications After Bariatric Surgery
Management of Leaks After Sleeve Gastrectomy
Management of Leaks After Gastric Bypass
Importance of Protein After Bariatric Surgery
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