BOB Ped Surg 2023 - Wendy Jo Svetanoff, IPEG - Presentation

Thank you for the opportunity to present our work. These are our disclosures. Enhanced recovery after surgery, or ERAS protocols, have been shown to improve outcomes in many adult surgical specialties. However, reports in pediatric metabolic and bariatric surgery are limited. In 2018, our institution developed an ERAS protocol for adolescence undergoing robotically assisted vertical sleeve gastrectomy, which focused on pain management, nausea control, and early oral intake and ambulation. The aim of this presentation was to compare key outcome variables, specifically length of stay and opioid use, before and after initiation of our ERAS protocol. This was a single institution retrospective review with pre-post analysis of patients who underwent robotic sleeve gastrectomy. July 2015 to 2018 comprised the pre-ERAS group, while August 2018 to July 2021 comprised the post-ERAS group. The ERAS algorithm was developed as part of the multi-specialty quality improvement project. Our key driver diagram consists of four main areas of focus, post-operative pain, nausea, narcotic use, and oral fluid intake. Univariate analysis was performed to compare demographics, in-hospital metrics, and 30-day outcomes between pre-ERAS and post-ERAS patients. Pre-operative management included allowing a carbohydrate electrolyte drink on day of surgery, along with pre-operative pain and nausea medication. Intraoperatively, ketorolac and bilateral tap blocks were given for pain control, while metoclopramide and dexamethasone were given for nausea management. Post-operatively, the focus remained on pain and nausea control. A multimodal non-narcotic pain regimen was scheduled, while narcotic pain medication was available on an as needed basis. Patients were discharged after demonstrating tolerance of a bariatric phase one diet without nausea or vomiting and had good pain control with oral medications only. 110 patients were included in the analysis, with 60 patients in the pre-ERAS group and 50 patients in the post-ERAS group. While there was a significantly higher percentage of females in the pre-ERAS group, all other demographic characteristics were similar between the two groups. No difference was noted in operating time or total OR time between groups. Significantly, more patients in the post-ERAS group received intraoperative acetaminophen and ketorolac. Along these lines, patients in the post-ERAS group received significantly fewer opioid medications. Post-operatively, the median time to first oral intake was 1.5 hours sooner in the post-ERAS group, while the time to first ambulation was also 1 hour sooner after initiation of ERAS. Post-operative hospital stay was almost one day less in the post-ERAS group. Looking at post-operative pain management regimens, post-ERAS patients received only a median of 7.5 morphine milliequivalents of opioids compared to the pre-ERAS group who received a median of 58.1 morphine milliequivalents. More impressively, all patients in the pre-ERAS group required narcotics, while only 76% utilized narcotics in the post-ERAS group during their hospital stay, and only 64% required opioids post-operatively. There was no difference in post-operative complications between groups. Balancing measures looking specifically at nausea, vomiting, and dehydration requiring admission, were either the same or lower in the post-ERAS group, indicating that protocol implementation did not elicit added harm to the patients. In conclusion, initiation of a targeted ERAS protocol for patients undergoing a robotic assisted sleeve gastrectomy led to a significant decrease in narcotic consumption and length of stay without any change in 30-day complication rates. Expansion of this protocol, including broadening its use to other institutions may lead to improved healthcare utilization. Thank you and I'll be happy to answer any questions.