Enhanced recovery after surgery (ERAS) protocol is well established in many surgical disciplines and leads to a decrease in the length of hospital stay and morbidity. Multimodal protocols have also been introduced to bariatric surgery.

1. Enhanced Recovery After
Bariatric Surgery
Dr. H.V.Shivaram
MS;FAIS;FACS(USA):FRCS (Glasgow);FMBS

2. Disclosures
Head of the Department of Surgery & Allied Specialties & Program
Director, Bariatric & Metabolic Surgery at Aster CMI Hospital, Bangalore
National Executive Committee Member of Association of Surgeons of India
Executive Board Member of Obesity & Metabolic Surgery Society of India

3. Introduction
 Bariatric Surgery - the most effective method of treating morbid obesity
 Exponential increase in number of bariatric surgeries in India
 ERAS guidelines for Bariatric surgery : published in 2016 in WJS by ERAS
Society
 Pathways developed initially for elective colorectal surgery and later for
other surgical specialties
 ERAS protocols have not been widely practiced by Bariatric Surgeons

4. What is ERAS ?
d
Pathways and facility culture
for a surgical specialty
 Patient centered
 Evidence based
 Multidisciplinary
team developed
1.Reduce surgical stress
response
2.Optimize physiologic
function
3.Facilitate recovery
Enhanced recovery after surgery (ERAS) is a multi-professional
and multidisciplinary approach to the care of the surgical patient

5. History of ERAS
1990 s -- Fast track Surgery concept for cardiac surgery
Later to colorectal surgery
Care bundles to speed up recovery & discharge
1995-- ERAS - first outlined by a Danish surgeon, Henrik Kehlet
for colonic resections
2001 -- ERAS® Society (www.erassociety.org) - evidence based
pathways & extended to all surgical specialties
ERAS®Society implementation program - training module

7. www.erassociety.org

8.  Limited hospital beds; patient load increasing
 Pressure for faster recovery & early discharge
 Health care model is changing:
“Fee-for-service” “Pay for performance”
 Enormous cost saving for insurers & managers
Why ERAS ?

9.  Faster recovery
 Fewer severe complications
 Shorter Length of stay
 Fewer readmissions
 Full control of complex care
 Increased staff satisfaction
 Less workload for nurses
 Large savings potential
Protocol and Care pathway compliance results in:

11. Nerve Block

12. Key components of any ERAS

14. Misconception
ERAS = Early Discharge
Day Care Surgery
Short Stay Surgery

15. Enhanced Recovery in Bariatric Surgery
Why ??
 Pre- admission work up and optimization done
 Most of our patients go home on next day
 Hard to improve LOS
 Post op ileus is not an issue
 Wound infection rates are quite low …

16. Pre Admission – Bariatric
 Patient & family Education
 Nutritional assessment & correction
 Comorbidities optimization
 Smoker: STOP 4 weeks before surgery
 Alcohol: STOP
 Multidisciplinary team consultation
Why ??

19. Recommendations of ERAS Society
Based on quality of evidence
High
Moderate
Low
Very low
Recommendations
Strong recommendation- Means panel is confident that
desirable effects outweigh the undesirable effects
Weak recommendation -Panel is less confident that
desirable effects outweigh undesirable effects

20. Elements Recommendations Level of Evidence Grade of Recomn.
Pre-op.information,
education and
counselling
Patients should receive
preoperative
counselling
Moderate Strong
Prehabilitation and
exercise
Improves functional
recovery
Low Weak
Pre – Op weight loss 1.Reduces post op
complications
2.Post op weight loss
High
Low quality
Strong
Glucocorticoids 8mg Dexa IV 90min
prior to GA- reduces
PONV
Low Strong
Pre Op Fasting Clear fluids upto 2hrs &
solids upto 6hrs prior to
induction
Nondiabetics – High
Diabetics
Strong
weak
Carbohydrate
Loading
Has metabolic & clinical
benefits in major
surgeries
Low for obese patients Strong
DVT Prophylaxis LMWH Strong Strong
P
R
E
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P
E
R
A
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21. Elements Recommendations Level of Evidence Grade of Recomn.
Peri-op. Fluid
management
Goal directed fluid
therapy.
Post op start enteral
feeds
Moderate Strong
PONV Multimodal approach Low Strong
Standardised
Anesthetic protocol
No specific agent or
technique
Low Weak
Airway Management 1.Awarenesss of
difficulties
2.Tracheal intubation
Moderate Strong
Ventilation strategy Lung protective
ventilation
Moderate Strong
Neuromuscular Block Qualitative monitoring
improves recovery
Moderate Strong
Monitoring An.deapth BIS monitoring High Strong
Nasogastric Tube Post op. no need Low Strong
Abdominal drain Routine use – no need Low Weak
I
N
T
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V
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22. Elements Recommendations Level of Evidence Grade of Recomn.
Post Op Analgesia Multimodal High Strong
Thromboprophylaxis Mechanical+ LMWH
Dosage & Duration to be
individualized
High
Low
Strong
Weak
Early post op
nutrition
Monitor protein intake;
Iron,calcium,B12-
supplement
Glycemic control in DM
Moderate
High
Strong
Strong
Post Op Oxygenation Without OSA
With OSA
Low
High ( 14 RCTs)
Strong
Strong
Non Invasive Positive
pressure Ventilation
Without OSA – CPAP no need
Severe OSA - recommended
OSA on home CPAP
Obese Hypoventilation
Syndrome - also need ICU
monitoring
Moderate
Low
Moderate
Low
Weak
Strong
Strong
Strong
P
O
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T
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P
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R
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I
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World J Surg (2016) 40:2065–

23. Discharge & Follow Up

30. Results: Reduction of hospital stay (from 4.7 to 2.1 d) and a low morbidity rate.
From July 2015 to July 2018, a total of 2400 consecutive patients underwent
primary or revisional bariatric surgery (2122 SG and 278 RYGB). Rate of readmission
was 0.9%.
Conclusions: This study demonstrates that our ERAS protocol is safe, feasible, and
efficient. Patient preparation and multidisciplinary/parallel team work are crucial
points

31. It is time that Bariatric surgeons
embrace ERAS and reap the benefits