精益思维如何改善减重手术的 ERAS 项目？

How can lean thinking improve ERAS program in bariatric surgery?

机构信息

Obesity Surgery Unit, Surgical Department, "AO Brotzu" Hospital, Cagliari, Italy.

Department of Life and Environmental Sciences, University of Cagliari, Cagliari, Italy.

出版信息

Surg Endosc. 2021 Aug;35(8):4345-4355. doi: 10.1007/s00464-020-07926-5. Epub 2020 Aug 27.

DOI:10.1007/s00464-020-07926-5

PMID:32856155

Abstract

INTRODUCTION

Enhanced recovery after bariatric surgery protocol (ERABS) decreased length of hospital stay (LOS) without influencing clinical outcomes. ERABS improved logistics aspects in operating room (OR) with OR time savings. Lean management was used to reorganize OR logistics and to improve its efficiency. This study analyzed clinical and OR logistic aspects in ERABS protocols.

METHODS

Retrospective analysis of prospectively maintained database of obese patients undergoing bariatric surgery from 2017 to 2019 was performed. Since September 2018, patients were treated with ERABS protocol (ERABS group). All patients treated with a standard protocol between January 2017 and September 2018 (control group) were compared to ERABS group. Preoperative (anthropometric data, surgical and medical history) and intraoperative (type of procedure) were analyzed in two groups. LOS was the primary outcomes parameter analyzed; complications, readmissions and reoperations within 30 days were the secondary outcomes. Logistic endpoints were evaluated in time saving and efficiency: surgical time, team work time and total anesthesia time.

RESULTS

471 patients underwent bariatric surgery: 239 patients (control group) compared to 232 patients (ERABS group). ERABS presented more previous surgical history rate (p = 0.04) compared to control group with difference of type of procedure performed (p < 0.001). Roux-en-Y gastric bypass was mainly procedure in both groups (61.1% in control group compared to 52.6% in ERABS groups). Mean LOS was shorter in ERABS (3.16 days) compared to control group (4.81 days) with no difference in clinical outcomes rate. All logistics endpoints showed a time savings in ERABS group compared to control group (surgical procedure, total anesthesia and team work time, p < 0.001). In multivariate analysis, LOS was associated to ERAS status (IRR 0.722; p < 0.0001), team work time (IRR 1.002; p = 0.002), surgical procedure time (IRR 1.002; p < 0.0001). ERAS status was not associated with complication neither readmission, but surgical procedure time was a factor associated with complication (IRR 1.011; p = 0.0008).

CONCLUSION

This study confirmed that ERABS protocol is safe and a feasible alternative with improved LOS. OR reorganization and logistic efficiency achieved using lean management helped reduce all OR times and these are likely related to the improvement in LOS and complication.

摘要

简介

减重手术后加速康复方案（ERABS）可缩短住院时间（ LOS ）而不影响临床结果。 ERABS 通过节省手术室（ OR ）时间来改善手术室的物流方面。精益管理用于重组手术室物流并提高其效率。本研究分析了 ERABS 方案中的临床和手术室物流方面。

方法

对 2017 年至 2019 年接受减重手术的肥胖患者的前瞻性维护数据库进行回顾性分析。自 2018 年 9 月起，采用 ERABS 方案（ ERABS 组）治疗患者。比较 2017 年 1 月至 2018 年 9 月期间采用标准方案治疗的所有患者（对照组）与 ERABS 组。分析两组患者的术前（人体测量数据、手术和医疗史）和术中（手术类型）。 LOS 是主要的观察指标；30 天内的并发症、再入院和再次手术是次要观察指标。以节省时间和提高效率为目标，评估了物流终点：手术时间、团队工作时间和总麻醉时间。

结果

471 例患者接受了减重手术：239 例（对照组）与 232 例（ERABS 组）。与对照组相比，ERABS 组有更多的既往手术史（ p = 0.04 ），手术类型也存在差异（ p < 0.001 ）。 Roux-en-Y 胃旁路术是两组的主要手术方式（对照组为 61.1%，ERABS 组为 52.6%）。ERABS 组的 LOS 明显短于对照组（3.16 天 vs 4.81 天），但临床结果无差异。与对照组相比，所有物流终点在 ERABS 组均显示出时间节省（手术程序、总麻醉和团队工作时间， p < 0.001 ）。多因素分析显示，LOS 与 ERAS 状态（IRR 0.722 ； p < 0.0001 ）、团队工作时间（IRR 1.002 ； p = 0.002 ）和手术时间（IRR 1.002 ； p < 0.0001 ）相关。ERAS 状态与并发症或再入院无关，但手术时间是与并发症相关的因素（IRR 1.011 ； p = 0.0008 ）。