Enhanced recovery after surgery for sleeve gastrectomies: improved patient outcomes.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) is a paradigm shift in perioperative care and incorporates patient-centered, evidence-based, and multidisciplinary team-developed pathways for a surgical specialty. ERAS pathways aim to reduce the patient's surgical stress response, optimize their physiologic function, facilitate recovery, and reduce the length of stay. The bariatric program at our institution was previously managed by many surgeons with anecdotal preferences, resulting in increased costs, lengths of stay, and opioid prescribing. OBJECTIVES: To describe a standardized ERAS pathway for patients undergoing a laparoscopic sleeve gastrectomy procedure in order to enhance perioperative care and reduce opioid usage. SETTING: ERAS bariatric program in New Jersey. METHODS: The ERAS bariatric program at our institution was implemented in January 2018. All patients who underwent sleeve gastrectomy from January 2016 to November 2017 (preimplementation) as well as from February 2018 to October 2020 (postimplementation) were included in this retrospective study, with those undergoing procedures in December 2017 and January 2018 excluded due to the transition to the ERAS protocol. Differences in lengths of stay, direct costs, and 30-day readmission rates were compared between the pre- and postimplementation periods. The primary goal of our ERAS pathway was to optimize patient care with reduced opioid usage, and the secondary goal was to reduce the costs for care. RESULTS: A total of 1988 patients who underwent sleeve gastrectomy were identified, with 789 patients in the preimplementation group and 1199 patients in the postimplementation group. In a multivariate analysis, the mean length of a hospital stay in the postimplementation period was 18% lower (95% confidence interval [CI], 14-22) than that of the preimplementation period (P < .001), while the average opioid morphine milligram equivalents administered in the postoperative period was 61% (95% CI, 57%-65%) less than that of the preimplementation period (P < .001). Average direct costs decreased by $155 (95% CI, -$358 to $48) per case in the postimplementation period (P = .133), and there was no significant difference in the 30-day readmission rate between the pre- and postimplementation periods (3.8% versus 3.0%, respectively; odds ratio, .81; 95% CI, .49-1.35; P = .413). CONCLUSION: In this study, patient outcomes after ERAS pathway implementation were significantly better than in historical cases. Implementing the bariatric ERAS program for laparoscopic sleeve gastrectomy at our institution has led to rapid postoperative recovery of patients, shorter lengths of stay, reduced opioid usage, and decreased costs per case, thereby increasing the overall cost savings to the hospital. ERAS pathways in bariatric surgery represent an opportunity to enhance patient care while decreasing overall costs. We propose that cost-effective, tailor-made ERAS pathways for sleeve gastrectomy should be implemented in all designated centers of excellence, as they can have a great economic impact on the healthcare system.

Shot by a Gun Missed by a Provider.

BACKGROUND: Botulism is a paralytic disease caused by the neurotoxin produced by Clostridium botulinum. The majority of cases are due to ingestion or injection drug use. Wound botulism from traumatic injury is exceedingly rare, with only one to two cases reported each year in the United States. CASE REPORT: A 27-year-old man presented to the Emergency Department with diplopia, dysphagia, and progressive weakness 10 days after sustaining a gunshot wound to his right lower leg. He had been evaluated for the same complaints at a different facility the day prior and was discharged. His wound appeared well-healing, but a high suspicion for wound botulism led to rapid consultation with the state Poison Control Center and the Centers for Disease Control and Prevention. The patient developed worsening respiratory insufficiency and required mechanical ventilation. Expeditious treatment with equine heptavalent botulinum antitoxin resulted in significant recovery of strength in 4 days. Serum toxin bioassay tested positive for botulinum neurotoxin type A. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Wound botulism now accounts for the majority of adult botulism in the United States. It should be considered in any patient with signs of neuromuscular disease and a recent injury, even if the wound appears uninfected.