Perioperative optimisation in low- and middle-income countries (LMICs): A systematic review and meta-analysis of enhanced recovery after surgery (ERAS).

Background: Enhanced recovery after surgery (ERAS) protocols have largely been incorporated into practice in high-income settings due to proven improvement in perioperative outcomes. We aimed to review the implementation of ERAS protocols and other perioperative optimisation strategies in low- and middle-income countries (LMICs) and their impact on length of hospital stay (LOS). Methods: We searched MEDLINE, PubMed, Global Health (CABI), WHO Global Index Medicus, Index Medicus, and Latin American and Caribbean Health Sciences Literature (LILACS) for studies incorporating ERAS or other prehabilitation approaches in LMICs. We conducted a pooled analysis of LOS using a random-effects model to evaluate the impact of such programs. This systematic review was pre-registered on PROSPERO. Results: We screened 1205 studies and included 70 for a full-text review; six were eligible for inclusion and five for quantitative analysis, two of which were randomised controlled trials. ERAS was compared to routine practice in all included studies, while none implemented prehabilitation or other preoperative optimisation strategies. Pooled analysis of 290 patients showed reduced LOS in the ERAS group with a standardised mean difference of -2.18 (95% confidence interval (CI) = -4.13, -.0.05, P < 0.01). The prediction interval was wide (95% CI = -7.85, 3.48) with substantial heterogeneity (I2 = 94%). Conclusions: Perioperative optimisation is feasible in LMICs and appears to reduce LOS, despite high levels of between-study heterogeneity. There is a need for high-quality data on perioperative practice in LMICs and supplementary qualitative analysis to further understand barriers to perioperative optimisation implementation. Registration: PROSPERO: CRD42021279053.

Low socioeconomic status is associated with lower weight-loss outcomes 10-years after Roux-en-Y gastric bypass.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is the criterion standard operation for weight loss. Low socioeconomic status (SES) is common in the Veteran population undergoing bariatric surgery, but the impact of SES on long-term weight-loss outcomes is not known. We hypothesize that low socioeconomic status is associated with less weight loss after gastric bypass in long-term follow-up. METHODS: We performed a retrospective review of patients undergoing RYGB at a single Veterans Affairs (VA) hospital. Patients with at least 10 years of follow-up data in the electronic health record were included in the analysis. Weight loss was measured as percent excess body mass index loss (%EBMIL). The primary predictor variable, median household income, was determined using zip codes of patient residences matched to publicly available 2010 U.S. census data. Univariate relationships between income, weight loss, and other patient characteristics were evaluated. We calculated a multivariate generalized linear model of %EBMIL to estimate independent relationships with median household income quartile while controlling for patients' age, race, sex, and VA distance. RESULTS: Complete 10-year follow-up data were available for 83 of 92 patients (90.2%) who underwent RYGB between 2001 and 2007 and survived at least 10 years. The majority of patients were male (79.5%) and white (73.5%). The mean 10-year %EBMIL was 57.8% (SD: 29.5%, range - 36.0% - 132.8%). In univariate analysis, income was significantly associated with race (p < 0.001) and median distance to the VA bariatric center (p = 0.034), but income did not differ by gender (p = 0.73) or age (p = 0.45). Multivariate analysis revealed significantly lower 10-year %EBMIL for patients with the lowest income compared to patients with low-mid income (p = 0.03) and mid-high income (p = 0.01), after controlling for gender, race, age, and VA distance. CONCLUSIONS: Low socioeconomic status is associated with lower weight-loss outcomes, 10 years after RYGB. Durable weight loss is observed in all income groups.