BackgroundEnhanced Recovery After Surgery (ERAS) programs have been shown to have a positive impact on outcome. The ERAS care system includes an evidence-based guideline, an implementation program, and an interactive audit system to support practice change. The purpose of this study is to describe the use of the Theoretic Domains Framework (TDF) in changing surgical care and application of the Quality Enhancement Research Initiative (QUERI) model to analyze end-to-end implementation of ERAS in colorectal surgery across multiple sites within a single health system. The ultimate intent of this work is to allow for the development of a model for spread, scale, and sustainability of ERAS in Alberta Health Services (AHS).MethodsERAS for colorectal surgery was implemented at two sites and then spread to four additional sites. The ERAS Interactive Audit System (EIAS) was used to assess compliance with the guidelines, length of stay, readmissions, and complications. Data sources informing knowledge translation included surveys, focus groups, interviews, and other qualitative data sources such as minutes and status updates. The QUERI model and TDF were used to thematically analyze 189 documents with 2188 quotes meeting the inclusion criteria. Data sources were analyzed for barriers or enablers, organized into a framework that included individual to organization impact, and areas of focus for guideline implementation.ResultsCompliance with the evidence-based guidelines for ERAS in colorectal surgery at baseline was 40%. Post implementation compliance, consistent with adoption of best practice, improved to 65%. Barriers and enablers were categorized as clinical practice (22%), individual provider (26%), organization (19%), external environment (7%), and patients (25%). In the Alberta context, 26% of barriers and enablers to ERAS implementation occurred at the site and unit levels, with a provider focus 26% of the time, a patient focus 26% of the time, and a system focus 22% of the time.ConclusionsUsing the ERAS care system and applying the QUERI model and TDF allow for identification of strategies that can support diffusion and sustainment of innovation of Enhanced Recovery After Surgery across multiple sites within a health care system.

ERAS implementation positively impacted the adoption of standardized perioperative nutrition care practices. Nutrition risk screening identified patients less able to comply with postoperative nutrition care elements and who had longer LOS.

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Reflux symptoms are significantly increased after LSG in comparison to LRYGB patients. In addition, LSG patients more frequently require initiation of reflux treatment after surgery than that of LRYGB patients. Patients reported postoperative reflux symptom relief with acid-suppressant therapies.

Background: Bariatric surgery has been shown to induce type 2 diabetes mellitus (T2DM) remission in severely obese patients. After laparoscopic Roux-en-Y gastric bypass (LRYGB), diabetes remission occurs early and independently of weight loss. Previous research has identified preoperative factors for remission, such as duration of diabetes and HbA 1c. Understanding factors that predict diabetes remission can help to select patients who will benefit most from bariatric surgery. Methods: We retrospectively reviewed all T2DM patients who underwent laparoscopic sleeve gastrectomy (LSG) or LRYGB between January 2008 and July 2014. The primary outcome was diabetes remission, defined as the absence of hypoglycemic medications, fasting blood glucose < 7.0 mmol/L and HbA 1c < 6.5%. Data were analyzed using multivariable logistic regression analysis to identify predictive factors of diabetes remission. Results: We included 207 patients in this analysis; 84 (40.6%) had LSG and 123 (59.4%) had LRYGB. Half of the patients (49.8%) achieved diabetes remission at 1 year. Multivariable logistic analysis showed that LRYGB had higher odds of diabetes remission than LSG (odds ratio [OR] 6.58, 95% confidence interval [CI] 2.79-15.50, p < 0.001). Shorter duration of diabetes (OR 0.91, 95% CI 0.83-0.99, p = 0.032) and the absence of long-acting insulin (OR 0.0011, 95% CI < 0.000-0.236, p = 0.013) predicted remission. Conclusion: Type of bariatric procedure (LRYGB v. LSG), shorter duration of diabetes and the absence of long-acting insulin were independent predictors of diabetes remission after bariatric surgery. Contexte : Il a été démontré que la chirurgie bariatrique provoque une rémission du diabète de type 2 chez les patients gravement obèses. Après la dérivation gastrique Roux-en-Y (DGRY) par laparoscopie, la rémission du diabète se produit tôt et indépendamment de la perte de poids. Des recherches antérieures ont identifié des facteurs préopératoires de rémission, notamment la durée du diabète et l'HbA 1c. Comprendre les facteurs prédictifs de la rémission du diabète peut aider à sélectionner les patients qui bénéficieront le plus de la chirurgie bariatrique. Méthodes : Nous avons examiné rétrospectivement les dossiers de tous les patients atteints de diabète de type 2 qui ont subi par laparoscopie une gastrectomie en manchon (GM) ou une DGRY entre janvier 2008 et juillet 2014. Le principal résultat a été la rémission du diabète, définie comme l'absence de médicaments hypoglycémiques, la glycémie à jeun < 7,0 mmol/L et l'HbA 1c < 6,5 %. Les données ont été soumises à une analyse de régression logistique multiple pour déterminer les facteurs prédictifs de la rémission du diabète. Résultats : Nous avons inclus 207 patients dans cette analyse; 84 (40,6 %) ont subi une GM et 123 (59,4 %), une DGRY. La moitié des patients (49,8 %) ont obtenu une rémission du diabète à 1 an. L'analyse logistique multiple a montré que la DGRY s'accompagnait de probabilités plus élevées de rémission du diabète que la GM (rapport de cotes [RC] 6,58; inter...

Background. Obesity is well known for being associated with significant economic repercussions. Bariatric surgery is the only evidence-based solution to this problem as well as a cost-effective method of addressing the concern. Numerous authors have calculated the cost effectiveness and cost savings of bariatric surgery; however, to date the economic impact of weight regain as a component of overall cost has not been addressed. Methods. The literature search was conducted to elucidate the direct costs of obesity and primary bariatric surgery, the rate of weight recidivism and surgical revision, and any costs therein. Results. The quoted cost of obesity in Canada was $2.0 billion–$6.7 billion in 2013 CAD. The median percentage of bariatric procedures that fail due to weight gain or insufficient weight loss is 20% (average: 21.1% ± 10.1%, range: 5.2–39, n = 10). Revision of primary surgeries on average ranges from 2.5% to 18.4%, and depending on the procedure accounts for an additional cost between $14,000 and $50,000 USD per patient. Discussion. There was a significant deficit of the literature pertaining to the cost of revision surgery as compared with primary bariatric surgery. As such, the cycle of weight recidivism and bariatric revisions has not as of yet been introduced into any previous cost analysis of bariatric surgery.

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A comparison of revisional and primary bariatric surgeryBackground: Revisional surgery is an important component of addressing weight regain and complications following primary bariatric surgery. Owing to provincial need and the complexity of this patient population, a specialized multidisciplinary revision clinic was developed. We sought to characterize patients who undergo revision surgery and compare their outcomes with primary bariatric surgery clinic data. Methods:We completed a retrospective chart review of bariatric revision clinic patients compared with primary bariatric surgery patients from December 2009 to June 2014. Results:We reviewed the charts of 2769 primary bariatric clinic patients, 886 of whom had bariatric surgery, and 534 revision bariatric clinic patients, 83 of whom had revision surgery. Fewer revision clinic patients underwent surgery than primary clinic patients (22% v. 32%). The mean preoperative body mass index (BMI) was 44.7 ± 9.5 in revision patients compared with 45.7 ± 7.6 in primary bariatric surgery patients. Most revision patients had a prior vertical banded gastroplasty (VBG; 48%) or a laparoscopic adjustable gastric band (LAGB; 24%). Bands were removed in 36% of all LAGB patients presenting to clinic. Of the 134 procedures performed in the revision clinic, 83 were bariatric weight loss surgeries, and 51 were band removals. Revision clinic patients experienced a significant decrease in BMI (from 44.7 ± 9.5 to 33.8 ± 7.5, p < 0.001); their BMI at 12-month follow-up was similar to that of primary clinic patients (34.5 ± 7.0, p = 0.7). Complications were significantly more frequent in revision patients than primary patients (41% v. 15%, p < 0.001). Conclusion:A bariatric revision clinic manages a wide variety of complex patients distinct from those seen in a primary clinic. Operative candidates at the revision clinic are chosen based on favourable medical, anatomic and psychosocial factors, keeping in mind the resource constraints of a public health care system. Contexte : La chirurgie de révision est une intervention importante lors d'une reprise de poids ou lors de complications à la suite d'une chirurgie bariatrique primaire. Compte tenu des besoins provinciaux et de la complexité de cette population de patients, une clinique de révision multidisciplinaire spécialisée a été créée. Nous avons voulu caractériser les patients qui subissent une chirurgie de révision et comparer leurs résultats aux données de la clinique de chirurgie bariatrique primaire.Méthodes : Nous avons procédé à un examen rétrospectif des dossiers des patients de la clinique de révision bariatrique par rapport aux patients ayant subi une chirurgie bariatrique primaire entre décembre 2009 et juin 2014.Résultats : Nous avons examiné les dossiers de 2769 patients de la clinique bariatrique primaire, dont 886 avaient subi une chirurgie bariatrique, et 534 patients de la clinique de révision, dont 83 avaient subi une chirurgie de révision. Un moins grand nombre de patients de la clinique de révision ont subi une c...