Enhanced recovery after sleeve gastrectomy: earlier discharge is one part of recovery

Enhanced recovery after surgery (ERAS) is a planned pathway covering care before, during and after an operation. It usually combines several measures intended to reduce avoidable surgical stress, support symptom control and help patients regain function. Because the pathway is a bundle, a comparison of ERAS with usual care cannot show that any one measure caused the difference.

For laparoscopic sleeve gastrectomy, several randomised trials report shorter hospital stays or earlier readiness for discharge under ERAS. The studies are relatively small, use different protocols and measure recovery in different ways. They offer useful evidence about early in-hospital recovery, but they do not establish a guaranteed discharge date, prove that a patient is fully recovered, or show that every centre will reproduce the same results.

How an enhanced recovery pathway works

ERAS is a coordinated care pathway, not a single treatment. Depending on the local protocol, it may include preparation and education before surgery, anaesthetic and pain-control planning, nausea prevention, fluid and nutrition management, early movement, and clear criteria for discharge and follow-up. The specific components and their timing vary between hospitals and studies.

The intended effect is cumulative: avoiding unnecessary fasting or lines, controlling pain and nausea, supporting safe movement and intake, and planning follow-up may help a person meet recovery milestones sooner. The sleeve-gastrectomy trials evaluated their assigned bundles as a whole. They cannot identify the independent effect of one medicine, mobilisation target or other element.

What sleeve-specific randomised trials found

At one elective surgery centre in Auckland, New Zealand, Lemanu and colleagues randomised patients having primary laparoscopic sleeve gastrectomy between August 2011 and May 2012 to an ERAS pathway or the centre’s usual care. Revisional sleeve procedures were excluded. Of 106 randomised patients, 78 were included in the final randomised analysis (ERAS 40; usual care 38); a further 38 patients from 2006–2010 were selected as propensity-score-matched historical controls, making 116 analysed across all three groups, not 116 randomised patients. The ERAS bundle began before surgery and continued for 30 days. Examples included structured education and goal setting, clear fluids until 2 hours before surgery, standardised anaesthesia and multimodal symptom prevention, early oral intake and mobilisation 2 hours after return to the ward, then telephone checks after discharge and a 2-week clinic visit. Usual care was determined by individual surgeons and anaesthetists. Both randomised groups were subject to the same predetermined discharge criteria: adequate pain relief on oral non-opioid medicines, no wound problem or complication, stable specified observations, ability to walk, drinking 1 litre of water within 24 hours and tolerating oral fluids. Median index stay was 1 day with ERAS, 2 days with concurrent usual care and 3 days in historical controls; ERAS comparisons were P<0.001 and usual care versus historical care P=0.010. Thirty-day readmissions were 8 in each group, and the study found no statistically significant group difference in complications or fatigue (fatigue was assessed on the Surgical Recovery Scale before surgery and on days 1, 7 and 14). This small trial was not designed to rule out uncommon harms. Its historical comparison is non-randomised and vulnerable to changes over time; the authors also reported limited blinding and that usual-care patients received 29% of the ERAS components overall, indicating component overlap between groups. Of 106 randomised patients, 78 were included in the final analysis after post-randomisation exclusions, which may also affect interpretation. [1]

A later single-centre randomised trial at an accredited, high-volume US bariatric centre assigned 130 patients (65 per group) to standard care or an ERAS medication regimen designed to reduce post-operative pain, nausea and vomiting. Median time until patients met the study’s readiness-for-discharge measure was 28.0 hours with ERAS and 44.4 hours with standard care (P=0.001). Actual discharge on post-operative day 1 occurred in 38.5% versus 15.4% (P<0.05). Fewer ERAS patients used opioids on the ward (72.3% versus 95.4%; P<0.001), and peak pain scores were lower, although the abstract does not provide their numerical values. Rescue anti-emetic use did not differ. Thirty-day adverse events, readmissions and emergency-department visits also did not differ statistically between groups. A readiness milestone is not the same as leaving hospital, and neither measure establishes full recovery at home. Baseline demographics and comorbidities did not differ between groups. The abstract does not provide the detailed discharge criteria or confidence intervals for these outcomes. [2]

A Turkish single-centre randomised trial conducted from January 2020 to March 2021 included 96 patients: 49 received ERAS and 47 traditional care. Mean ages were 37.47 ± 10.11 and 35.77 ± 9.62 years, respectively. Mean hospital stay was 30.46 ± 11.26 hours versus 52.02 ± 6.63 hours (P=0.001). Visual analogue scale (VAS) pain scores and post-operative nausea/vomiting effect scores were lower at 2 and 12 hours in the ERAS group. The abstract does not state the VAS anchors or clearly map its four reported P values to each of those measurements, so no individual score or endpoint-specific P value is inferred. Emergency-department readmission within 30 days did not differ statistically (P=0.498). The abstract describes limited blinding: one senior surgeon was blinded across the pre- and post-operative period, while another surgeon was not; it does not provide confidence intervals or enough detail to compare every pathway component with the other trials. [3]

Readiness for discharge is not the same as recovery

Hospital length of stay is an operational measure: it records time or days in hospital. Readiness for discharge is a milestone defined by a study or care team. Neither directly measures how someone feels and functions over the following weeks, whether symptoms recur after discharge, or when the person can safely return to usual activities.

The Papasavas trial is especially useful for seeing this distinction: the median time to readiness for discharge was about 28 hours in the ERAS group, while 38.5%—not all patients—were actually discharged on day 1. The Lemanu trial reported median length of stay, not a universal discharge time. The Demirpolat trial reported mean hours in hospital. These are different endpoints and should not be combined as if they were one standardised measure.

Before leaving hospital, an individual team will consider the person’s condition and the local pathway. A research abstract may not list every criterion used at a participating centre. Early discharge by itself cannot guarantee adequate pain or nausea control, hydration, complication-free recovery, confidence with the post-operative diet, or access to follow-up.

What the safety findings can and cannot show

The trials did not report statistically significant differences in their measured readmissions, complications or emergency visits. That is not proof that the approaches are equivalent or that uncommon harms cannot occur. With 96, 116 or 130 analysed participants, these studies have limited ability to detect small differences in rare outcomes. The absence of a significant difference should be read alongside the sample size, follow-up window and the specific outcome captured.

A larger sleeve-specific retrospective study compared 789 patients before and 1,199 after a pathway was introduced. After adjustment, mean hospital stay was 18% lower in the later ERAS period (95% CI 14–22%; P<0.001), and post-operative opioid morphine-milligram equivalents were 61% lower (95% CI 57–65%; P<0.001). Direct costs were estimated to decrease by $155 per case, but the confidence interval ranged from a $358 decrease to a $48 increase and the difference was not statistically significant (P=0.133). Thirty-day readmission was 3.8% before versus 3.0% after implementation (OR 0.81; 95% CI 0.49–1.35; P=0.413). This study is sleeve-specific but not randomised: the groups came from different calendar periods, so secular changes and other confounding may explain some observed differences. It cannot establish that ERAS caused the changes. [4]

How broader bariatric evidence fits

The ERAS Society’s 2021 update addresses perioperative care across bariatric surgery, not sleeve gastrectomy alone. Its evidence search ran through December 2020 and used GRADE appraisal; the authors noted that evidence quality for many ERAS interventions in bariatric surgery remained relatively low and that some practices had to be extrapolated from other operations. It can inform pathway design, but it is not a sleeve-only trial and does not guarantee a particular outcome for an individual. [5]

Likewise, a retrospective cohort of 435 patients undergoing primary laparoscopic bariatric surgery compared conventional care in 2014–2015 with ERAS in 2016–2017. Mean stay was 2.2 ± 0.9 versus 4.0 ± 2.6 days; post-operative day-one discharge was 15.2% versus 1%. Thirty-day complications were 2.1% versus 8.6%, and readmissions 1.3% versus 4.5%. The study grouped bariatric procedures, used different calendar periods and was not randomised. Its figures should not be presented as sleeve-specific effects or causal proof. [6]

Questions to discuss with the care team

• Which parts of the pathway are planned for me, and which are standard at this centre?
• How will pain, nausea, fluid intake, movement and the post-operative diet be assessed before discharge?
• What does this team mean by “ready for discharge”, and how is the decision made if recovery is slower than expected?
• Who should I contact after discharge, and what follow-up is arranged if symptoms or concerns arise?
• How should I plan time away from work and other responsibilities, given that length of stay is not a measure of complete recovery?

Seek prompt medical advice from the treating service if recovery concerns arise; a research summary cannot assess symptoms or decide whether urgent care is needed.

The extent of surgery and what is included in a quotation can affect cost comparisons, so ask for the planned procedure and included services in writing. Our gastric sleeve cost guide for Turkey gives commercial price context; it cannot determine clinical suitability or predict an individual bill.

When discussing the pathway, also clarify who will check on you after discharge, how to reach the treating service, and what follow-up is included. The gastric sleeve package details describe a commercial offer, not evidence that a particular follow-up arrangement is medically appropriate.

Limitations and take-away

The sleeve-specific randomised trials consistently suggest earlier hospital readiness or shorter stay, with some evidence of lower early pain, nausea or opioid use. They tested different bundles and different outcomes, so their numbers are not interchangeable. The studies are too small to rule out modest differences in uncommon complications, and the abstracts do not always report full protocol details, confidence intervals or discharge criteria. Retrospective comparisons add confounding by time and case mix.

ERAS is best understood as a structured care pathway whose components should be adapted and delivered by the treating team. Earlier discharge can be one sign of progress within that pathway; it is not a promise of uncomplicated recovery, fitness for work or travel, or proof that a particular centre’s care is superior.

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References

1. Lemanu DP, Singh PP, Berridge K, Burr M, Birch C, Babor R, MacCormick AD, Arroll B, Hill AG. Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy. British Journal of Surgery. 2013;100(4):482–489. Published online 21 January 2013. doi: 10.1002/bjs.9026. PMID: 23339040.
2. Papasavas P, Seip RL, McLaughlin T, Staff I, Thompson S, Mogor I, Sweeney J, Gannon R, Waberski W, Tishler D. A randomized controlled trial of an enhanced recovery after surgery protocol in patients undergoing laparoscopic sleeve gastrectomy. Surgical Endoscopy. 2023;37(2):921–931. Published online 1 September 2022. doi: 10.1007/s00464-022-09512-3. PMID: 36050610.
3. Demirpolat MT, Şişik A, Yildirak MK, Basak F. Enhanced Recovery After Surgery Promotes Recovery in Sleeve Gastrectomy: A Randomized Controlled Trial. Journal of Laparoendoscopic & Advanced Surgical Techniques. 2023;33(5):452–458. Published online 26 December 2022. doi: 10.1089/lap.2022.0494. PMID: 36576984.
4. Sapin A, Hilden P, Cinicolo L, Stein J, Turner A, Pitera R, Yodicei P, Paragi PR. Enhanced recovery after surgery for sleeve gastrectomies: improved patient outcomes. Surgery for Obesity and Related Diseases. 2021;17(9):1541–1547. Published online 3 May 2021. doi: 10.1016/j.soard.2021.04.017. PMID: 34120829.
5. Stenberg E, dos Reis Falcão LF, O’Kane M, Liem R, Pournaras DJ, Salminen P, Urman RD, Wadhwa A, Gustafsson UO, Thorell A. Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update. World Journal of Surgery. 2022;46(4):729–751. Published online 4 January 2022; conflict-of-interest statement corrected online 29 January 2022 (issue page 752). doi: 10.1007/s00268-021-06394-9. PMID: 34984504; PMCID: PMC8885505.
6. Zhou B, Ji H, Liu Y, Chen Z, Zhang N, Cao X, Meng H. ERAS reduces postoperative hospital stay and complications after bariatric surgery: A retrospective cohort study. Medicine (Baltimore). 2021;100(47):e27831. Published 24 November 2021. doi: 10.1097/MD.0000000000027831. PMID: 34964750; PMCID: PMC8615334.