Whereas numerous studies have addressed outcomes after bariatric surgery, only a few have provided a detailed analysis of the immediate postoperative period. The aim of the present study was therefore to meticulously analyze the condition of patients during the first 16 h after single-anastomosis gastric bypass (SAGB).
Methods
A prospective consecutive analysis of pain, nausea, fatigue, dizziness, vomiting, and mobilization during the first 16 h after SAGB was performed in a fast-track optimized high-volume setting. Values were recorded by means of a visual analogue scale (VAS) every 15 min in the postoperative recovery unit (first 2 h) and every 2 h on the ward. Secondary outcomes were length of stay (LOS) and surgical complications.
Results
The mean pain, nausea, fatigue, and dizziness levels never exceeded VAS 4. Two thirds of patients never vomited, whereas one third vomited once or twice. The highest incidence of minor adverse events was, unsurprisingly, seen during the first 2 h after surgery. Although these early minor adverse events after operation were expected and highly acceptable, our data also showed that 10–20% of patients transiently reached VAS values of 7 or more. Two patients experienced minor complications (atelectasis and cellulitis at the trocar site).
Conclusion
Single-anastomosis gastric bypass can be carried out in an enhanced recovery program with a low degree of pain, nausea, fatigue, and dizziness, and with fast mobilization. However, 10–20% of patients reached VAS levels of 7 or more. Therefore, there is still room for improvement of postoperative regimens.
Hinweise
Oleg Dukhno and Ivan Kukeev passed away before publication of this article.
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Main novel aspects
Since a detailed description of the condition of patients the first day after bariatric surgery within an enhanced recovery after surgery (ERAS) setting is lacking, the present study analyzes pain, nausea, vomiting, dizziness, fatigue, and hours of mobilization every second hour on the day of surgery in a consecutive series of patients operated with single-anastomosis gastric bypass (SAGB).
Single-anastomosis gastric bypass can be carried out in an ERAS program with a low degree of pain, nausea, fatigue, and dizziness, and with fast mobilization.
As 10–20% of the patients reached VAS levels of 7 or more, there is still room for improvement of postoperative regimens.
Introduction
Bariatric surgery is an effective treatment for obesity. The most frequent procedures are laparoscopic sleeve gastrectomy and Roux-en‑Y gastric bypass. Single-anastomosis gastric bypass (SAGB; mini-bypass) is currently gaining traction. This procedure is often easier and carries a lower or equal risk of anastomotic leak, as tension in the gastrojejunal anastomosis is rare. Outcomes in terms of complications, weight loss, etc. have been reported in several studies [1]. However, in only a few studies was an enhanced recovery program applied, and important parameters in the immediate postoperative course have been only sparsely reported but summarized in the recent ERAS recommendations [2].
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At Soroka University Medical Center, we have performed more than 1500 SAGB procedures since 2015. We have gradually improved our perioperative organization and now have routinely applied enhanced recovery protocols.
The aim of the present study was to report on immediate postoperative outcomes in a consecutive series of patients undergoing SAGB for obesity.
Methods
Patients
In this consecutive study, 40 patients undergoing SAGB were included. Patients’ demographic data is presented in Table 1. All patients were treated according to the routine protocol for our bariatric patients (Table 2). After a consultation with the bariatric surgeon, patients are referred to the bariatric committee (including bariatric surgeon, therapist, nutritionist, and psychologist) for surgery approval. The typical time from referral to operation is 4–5 weeks. In the preoperative phase, patients were urged to stop smoking and to minimize alcohol consumption. A daily 30-min. walk was advised. Preoperative weight loss was evaluated individually.
Table 1
Demographics
Individual characteristics
n = 40
Gender, n (%)
Female sex
32 (80%)
Male sex
8 (20%)
Age group, n (%)
Median (years)
40.5
18–34 years
14 (35%)
35–44 years
8 (20%)
45–54 years
15 (37.5%)
55–64 years
0 (0%)
65 years and above
3 (7.5%)
Body mass index (BMI; kg/m2), n (%)
Median
43.5
Obese class I (BMI 30.0–34.9)
2 (5%)
Obese class II (BMI 35.0–39.9)
6 (15%)
Obese class III (BMI ≥ 40.0)
32 (80%)
Comorbidities, n (%)
Type 2 diabetes (T2D)
7 (17.5%)
Hypertension (HTN)
4 (10%)
Dyslipidemia (LIP)
7 (17.5%)
Obstructive sleep apnea (OSA)
5 (12.5%)
Table 2
Clinical protocol
Preoperative
Smoking cessation
Alcohol abstinence
Daily 30-min walk
Weight loss evaluated individually
Perioperative
Tramadol 100 mg
Dexamethasone 8 mg
Cefazolin 2 g and metronidazole 0.5 g single doses
Postoperative
Metamizole 0.5 g three times on first postoperative day
Paracetamol 1 g max. four times daily
Anesthesia
Premedication included tramadol once a day 100 mg perorally in the evening before surgery. Dexamethasone 8 mg was given in the operation room to prevent postoperative nausea and vomiting (PONV). Furthermore, patients were given intravenous (iv) antibiotics: cefazolin 2 g and metronidazole 0.5 g. Preoperative carbohydrates were not given.
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Patients walked to the operating room and placed themselves on the operating room (OR) table for optimal ramping position. In the OR, perioperative noninvasive monitoring was initiated using electrocardiography (ECG), noninvasive blood pressure monitoring, and peripheral oxygen saturation. Preoxygenation was prolonged and given before induction using initial bolus of remifentanil followed by induction with a bolus of propofol. Airway management and oral intubation were achieved using videolaryngoscopy. Suxamethonium was kept at hand, but only as rescue if relaxation was needed for intubation.
Pneumatic pumps (Kendall SCD™ Express Sleeves, CardinalHealth, Leeds, UK) were used to prevent deep venous thrombosis.
Preoperatively, 1000 ml isotonic saline was administered. Anesthesia was maintained with propofol and remifentanil (TIVA). Fentanyl 100 μg was administered 10 min prior to the end of the procedure, with dehydrobenzperidol 0.2 mg iv, ondansetron 4 mg iv, and clemastin 1 mg iv.
Patients were extubated at the end of skin closure and were able to reposition themselves from the OR table to bed within minutes. Urinary catheters were not used.
In the post-anesthesia care unit (PACU), Ringer lactate 1000 ml iv was initiated and, if needed, continued on the ward. Mobilization in the PACU within 30–60 min was stressed.
Surgery
A Veress needle was placed in the supraumbilical region. The abdominal cavity was insufflated with CO2 to a pressure of up to 15 mm Hg. The first trocar (supraumbilical) was placed with an optical trocar, after which the other optical trocars were placed under visual control. The left liver lobe was lifted with the liver retractor (Nathanson retractor) when needed. About 10–15 cm below the angle of His, on the small curvature side below the second branch of the crow’s foot, the omental bursa was opened with an energy device (LigaSure™ retractable L‑hook; Medtronic, Minneapolis, MN, USA). The first stapler 45-mm purple cartridge (Signia™Stapling System; Medtronic, Minneapolis, MN, USA) was placed and fired at a right angle from the small curvature. Next, in the direction of the angle of Hiss a second to fifth stapler 60-mm purple TRS Reinforced Reload cartridge (Medtronic, Minneapolis, MN, USA) placed against a 34 Charrière gastric tube.
The Treitz ligament was then identified, and the small intestine brought up antecolically at approximately 180–200 cm from the ligament of Treitz. The stomach pouch was opened close to the staple row with a LigaSure™ retractable L‑hook, as far as possible towards the greater curvature, after which the dorsal side of the gastroenterostomy was made using a 30-mm vascular cartridge (Medtronic, Minneapolis, MN, USA). The ventral side of the gastroenterostomy was closed using a V-Loc™ (Medtronic, Minneapolis, MN, USA) running suture in two layers.
The integrity of the gastrojejunostomy and gastric pouch staple line was tested intraoperatively for anastomotic leaks using methylene blue. The efferent arm was sutured to the gastric remnant with Vicryl 3‑0 suture. Sites of the trocars were locally anesthetized with 10 cc Bupivacaine + 10 cc lidocaine 1%. All trocars were removed under view. The skin was closed with metal clips.
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Outcomes
The postoperative outcomes registered included postoperative length of stay in the PACU and hospital, pain during rest and mobilization (VAS 0–10), nausea (VAS 0–10), vomiting (± and number), fatigue (VAS 0–10), dizziness (VAS 0–10), and time for mobilization out of bed (±). Registrations were performed every 15 min in the PACU and every 2 h on the ward. Mobilization was defined as out of bed and walking at least 3 m.
Results
Consecutive patients operated between 30/05/2021 and 05/12/2021 participated in the study. The study group thus consisted of 40 patients (32 females) with a median age of 40.5 (range 20–61) years and a mean body mass index (BMI) of 43.5 (range 30–55) kg/m2. Seven patients had type 2 diabetes, 4 had hypertension, 7 dyslipidemia, and 5 patients had obstructive sleep apnea.
The average pain level in the postoperative course is shown in Fig. 1a and the proportion of patients who felt pain at some point during the stay in Fig. 1b. As shown, pain was only moderate and rapidly declined during the operative day.
Fig. 1
a Mean pain level in the postoperative course. Postoperative visual analog scale (VAS) pain scores (0–10, where 0 is no pain and 10 is maximal pain) in 15-min intervals for the first 2 h after surgery (post-anesthesia care unit, PACU) followed by 2‑h intervals. b Proportion of patients experiencing different pain levels in the PACU and ward. Highest VAS pain score levels at any time during the study period (0–10, where 0 is no pain and 10 is maximal pain)
×
In the PACU, all 40 patients received morphine 10 mg iv, ketorolac 30 mg iv, and tramadol 50 mg per OS. On the ward, only 5/40 patients received additional analgesics, mostly morphine 5 mg iv.
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The average nausea level (Fig. 2a) and distribution of nausea felt at some point during the stay (Fig. 2b) are shown and demonstrate nausea to be a minor, transient problem. Two thirds of patients never vomited, whereas one third vomited once or twice.
Fig. 2
a Mean nausea level in the postoperative course. Postoperative visual analog scale (VAS) nausea scores (0–10, where 0 is no nausea and 10 is maximal nausea) in 15-min intervals for the first 2 h after surgery (post-anesthesia care unit, PACU) followed by 2‑h intervals. b Proportion of patients experiencing different nausea levels in the PACU and ward. Highest VAS nausea score levels at any time during the study period (0–10, where 0 is no nausea and 10 is maximal nausea)
×
All patients received PONV treatment postoperatively with ondansetron 4 mg × 3 iv only for the first day of surgery.
The postoperative fatigue level increased to around 6 but rapidly declined during the first 20 h, as shown in Fig. 3a. The distribution of patients who felt fatigue at some point postoperatively is shown in Fig. 3b.
Fig. 3
a Mean fatigue level in the postoperative course. Postoperative visual analog scale (VAS) fatigue scores (0–10, where 0 is no fatigue and 10 is maximal fatigue) in 15-min intervals for the first 2 h after surgery (post-anesthesia care unit, PACU) followed by 2‑h intervals. b Proportion of patients experiencing different fatigue levels in the PACU and ward. Highest VAS fatigue score levels at any time during the study period (0–10, where 0 is no fatigue and 10 is maximal fatigue)
×
The frequency of postoperative dizziness was low during the postoperative course, as shown in Fig. 4a. The level of dizziness distribution is shown in Fig. 4b. The low levels of dizziness did not limit early mobilization, which happened in more than 75% of patients at 6 h postoperatively (Fig. 5).
Fig. 4
a Mean dizziness level in the postoperative course. Postoperative visual analog scale (VAS) dizziness scores (0–10, where 0 is no dizziness and 10 is maximal dizziness) in 15-min intervals for the first 2 h after surgery (post-anesthesia care unit, PACU) followed by 2‑h intervals. b Proportion of patients experiencing different dizziness levels in the PACU and ward. Highest VAS dizziness score levels at any time during the study period (0–10, where 0 is no dizziness and 10 is maximal dizziness)
Fig. 5
Proportion of patients mobilized in the post-anesthesia care unit and on the ward
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The duration of PACU stay ranged from 40 to 70 min and depended on hemodynamic stability and pain level. The median duration of the hospital stay was 25 h (range 24–96 h quartiles), and only 5/40 patients stayed longer than 1 day. All patients were discharged home, and 1 patient was readmitted within 30 days due to cellulitis at the trocar site. No other complications were registered within 30 days postoperatively, except for 1 patient who stayed in hospital for 4 days due to atelectasis.
Discussion
Implementation of enhanced recovery programs is important to minimize surgical stress and complications. Previous studies were mainly retrospective and compared outcomes according to the degree of adherence to structured guidelines from the ERAS Society [3‐7].
Such studies are difficult to interpret as they do not consider the relative importance of each guideline component—a problem also seen in other types of surgery [8, 9].
As described in the guideline publication from 2016 [10] and revised in 2022 [2], some recommendations had a high level of evidence, whereas others did not.
The present study demonstrated that a simple enhanced recovery program, for a consecutive series of patients operated on with SAGB, could be undertaken with a short (1–2 days) hospital stay, low pain score, minimal opioid medication, short-lasting fatigue, and acceptable level of nausea for a short period of time. The main difference between our study and other studies is that patients were very closely monitored for many recovery variables in the immediate postoperative phase. Furthermore, all patients followed a simple protocol which had been implemented for routine use.
The main components of our protocol were preoperative information, anesthesia with short-acting agents and without relaxation, limited opioid consumption, early mobilization, and peroral intake immediately after waking up. These measures could easily be adapted to any center.
The strengths of our study lie in the simple approach, conduction in a single-center setting on a consecutive basis, and multiple registrations during the postoperative phase. The fact that the study was carried out in a single high-volume center may also be a limitation, as adhesion to protocols might be more difficult in low-volume settings.
A limitation of our study is that evaluation scores were registered under influence of treatment with pain killing drugs. This affects the evaluation scores. However, this is unavoidable in a clinical setting but does render it more difficult to transfer our data to centers with different treatment regimens.
Another limitation is the rather low number of patients included. This certainly limits the validity and generalizability of our findings, despite the fact that we have observed fair validity with a similar number of patients in previous studies [11, 12].
Despite the promising recovery results, further improvements may be achievable by focusing on reducing the use of opioids. According to the PROSPECT guidelines from sleeve gastrectomy [13], this may include using pre- and postoperative COX-2 inhibitors, paracetamol, specific high-dose trocar site local anesthesia, and, based on other operations, use of low-dose or even higher doses of steroids [14, 15]. In addition, further development of TAP blocks may be of interest, while intraperitoneal local anesthetics are debatable. The median hospital stay was only 25 h. However, the recovery of the patients could have allowed a shorter stay, but the reason for the longer stay was due to logistics in our part of the world, a factor we should evaluate further.
Declarations
Conflict of interest
O. Dukhno, I. Kukeev, E. Quint, G. Sebbag, H. Kehlet, and P. Funch-Jensen declare that they have no competing interests.
Ethical standards
The study received approval from the Helsinki Ethics Committee, approval number 0489-20-SOR, at Soroka University Medical Center. Each patient included in the study provided signed informed consent. The patients’ consents and the study protocol are securely stored at the hospital where the study was conducted. Data were anonymized according to the requirements of the ethical committee.
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