1. The Health Roundtable 3-3c_HRT1215-Session_LEMANU_CMDHB_NZ Enhanced Recovery After Laparoscopic Sleeve Gastrectomy: A Randomised Controlled Trial Presenter: Daniel Peter Lemanu 1. South Auckland Clinical School, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, NEW ZEALAND 2. Middlemore Hospital, Counties Manukau District Health Board, NEW ZEALAND Innovation Poster Session HRT1215 – Innovation Awards Sydney 11 th and 12 th Oct 2012 1

2. The Health Roundtable KEY PROBLEM  Bariatric Surgery  Treat severe obesity  Cure obesity related comorbidity  Laparoscopic Sleeve Gastrectomy offered at CMDHB  Associated with significant perioperative morbidity  Prolong convalescence  Impair surgical recovery  Enhanced Recovery After Surgery (ERAS) protocols  Multiple evidence-based perioperative care interventions to optimise and standardise perioperative care  Reduce morbidity and length of stay (LOS) in other types of surgery  Comparably less evidence in bariatric surgery 2

3. The Health Roundtable AIM OF THIS INNOVATION  Aim:  To investigate whether a bariatric specific ERAS protocol was effective at improving recovery after LSG  A randomised controlled trial was conducted to investigate the efficacy and safety of an ERAS protocol  Exposure arm (EG): Perioperative care according to ERAS  Control arm (CG): Standard perioperative care  Matched propensity scores used to generate an historical control group (HCG) to account for potential cross over as a result of inadequate blinding  Primary outcome: Reduction in LOS from 3 days to 1 day requiring 38 patients in each arm  Other outcomes: Postoperative complications, readmission rates, postoperative fatigue, protocol compliance, perioperative costs 3

4. The Health Roundtable BASELINE DATA  All procedures performed at the Manukau Surgery Centre, Auckland, New Zealand  400 patients had LSG between 2006 and 2010  Primary outcome: Reduction in LOS from 3 days to 1 day  Other outcomes: Postoperative complications, readmission rates, perioperative costs ($NZ) 4

5. The Health Roundtable KEY CHANGES IMPLEMENTED Exposure GroupControl Group Preoperative Standardised education Routine advice Formal goal setting Tour of the ward Intraoperative Clear oral fluids up to 2 hours pre surgery Care as per individual anaesthetist and surgeon CHO loading 8mg IV dexamethasone Standardised anaesthesia Intraperitoneal local anaesthetic Avoidance of prophylactic drains and NGTs 5

6. The Health Roundtable KEY CHANGES IMPLEMENTED Exposure GroupControl Group Postoperative Early instigation of oral fluid intake Care as per surgeon Mobilisation 2h after return to ward Multimodal analgesia and antiemesis Standardised thromboprophylaxis Day 1 and week 1 phone call Discharge Criteria Adequate pain relief with non opioid agentsWound satisfactory No postoperative complicationsHR<90, T ≤ 37.6, RR ≤ 20 Uneventful technical procedureAmbulatory Oral intake ≥ 1L of water/24hTolerating bariatric free oral fluids 6

7. The Health Roundtable OUTCOMES SO FAR Exposure (n=40) Control (n=38) Historic (n=38) p LOS Index Admission (IQR) 1 day (1-2) a 2 days (0) b 3 days (2-4) <0.001 Readmission8880.991 LOS Total (IQR) 1 day (1-3) a 2 days (1-2) b 3 days (2-4) <0.001 a Signficantly reduced in ERAS group compared to both non-ERAS and historical group b Signifcantly reduced in non-ERAS group compared to historical group 7

8. The Health Roundtable OUTCOMES SO FAR Exposure (n=40) Control (n=38) Historic (n=38) p Total Complications 108150.172 Major Complications 5560.906 Cost per patient (SD) $14,836.13 (13,092) a $15,566.06 (14,920) b $27,700.08 (26,976) 0.005 a Significant reduction in the Exposure Group when compared to the Historical Group b Significant reduction in the Control Group when compared to the Historical Group 8

9. The Health Roundtable LESSONS LEARNT  A bariatric specific ERAS protocol reduced LOS after surgery and was cost effective without increasing perioperative morbidity 9