Post written by Chelsea D’Ascanio, DNP, MS, CRNA, from Bariendo Inc and Brigham and Women’s Hospital, Boston, Massachusetts, USA.

The focus of this pilot project was to implement an enhanced recovery perioperative protocol to reduce postoperative emergency department (ED) visits and readmissions because of postoperative nausea and vomiting (PONV) after endoscopic sleeve gastroplasty (ESG).

One in 5 patients who have undergone ESG return to the ED within 30 days, with the majority (70%) presenting with PONV. Implementing an Enhanced Recovery After Surgery protocol has been shown to reduce the incidence of PONV and the risk of readmission. The literature reveals scarce evidence of these protocols being implemented for ESG despite their positive impact in traditional metabolic and bariatric surgeries.

The Enhanced Recovery After Surgical Endoscopy (ERASE) protocol was implemented successfully with an 86.7% compliance rate. Although rates of PONV were similar between groups, there was a statistically significant reduction in postanesthesia care unit (PACU) length of stay by 17.9% (P < .001), suggesting PONV was appropriately managed with ERASE.

In addition, there was a reduction of 37.8% in the incidence of ED visits within 30 days because of PONV in the post-ERASE group, although this was not statistically significant (P = .117). The incidence of readmission within 30 days because of PONV was significantly reduced by 58.5% (P < .05) in the post-ERASE group.

In conclusion, this multidisciplinary ERASE protocol achieved a significant reduction in PACU length of stay and 30-day readmissions.

Interestingly, most ED visits and readmissions occurred within the 3-day period prescribed for postoperative oral antimicrobial therapy (metronidazole and ciprofloxacin). Nausea is a well-known side effect of antibiotics, especially metronidazole. We have since adjusted our practices to a single intraoperative dose of ceftriaxone with no postoperative antimicrobial therapy. Future studies can assess the impact of this change.

Although we did not calculate cost-effectiveness, ERASE was implied to be economically beneficial, with a successful reduction in PACU length of stay and 30-day readmissions. A future project may focus on directly calculating the financial impact of ERASE.

ERASE is now used at multiple endoscopic bariatric centers across the United States. It would be exciting to conduct a multicenter study soon.

Day of readmission pre-Enhanced Recovery After Surgical Endoscopy (ERASE) and post-ERASE implementation. The bar chart indicates the percentage of the pre- or post-ERASE group who were readmitted to the hospital on postoperative days 0 to 3, 4 to 14, or 15 to 30. For bars indicating 0.0%, no patients were readmitted during this time period.

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