Extremely Early Ambulation after Bariatric and Metabolic Surgery: A Randomized Controlled Trial

Postoperative gastrointestinal dysfunction (POGD) is common after metabolic bariatric surgery (MBS), prolonging hospitalization and increasing costs. While Enhanced Recovery After Surgery (ERAS) guidelines recommend ambulation on postoperative day one, evidence supporting extremely early ambulation commencing in the post-anesthesia care unit (PACU) remains limited.

To evaluate whether a structured, graded ambulation protocol initiated in the PACU shortens the time to first flatus after laparoscopic sleeve gastrectomy (LSG) without increasing adverse events, and to assess its impact on recovery quality.

This was a single-center, assessor-blinded, randomized controlled trial. 92 patients scheduled for elective LSG were randomized to either the experimental group (PACU ambulation) or the control group (conventional ward ambulation). The experimental group followed a structured 3-step protocol (sitting, standing, walking) initiated upon PACU arrival. The primary outcome was time to first flatus (hours). Secondary outcomes included Quality of Recovery-15(QoR-15) scores, pain scores (VAS), opioid consumption (morphine equivalents), abdominal distension, and safety outcomes (PONV, orthostatic hypotension).

Time to first flatus was significantly shorter in the experimental group compared to the control group (median18.6h[IQR 9.9-22.7]vs.24.0h[IQR 19.5-28.8]; median difference -5.4h, 95%CI: -7.6to-3.2; P< 0.001). QoR-15 scores were significantly higher in the experimental group on postoperative day POD0(median122.0vs.105.0,P< 0.001), POD1(135.0vs.122.0,P < 0.001), and POD2 (140.0 vs. 134.0, P < 0.001). The relative decline in QoR-15 on POD 0 was smaller in the experimental group (13.5% vs. 26.6%). There were no significant differences in adverse events between groups.

A structured graded ambulation protocol initiated in the PACU safely reduces the time to first flatus and improves the quality of recovery after LSG, potentially via cholinergic anti-inflammatory and gravitational mechanisms. This study provides high-quality evidence for integrating standardized early mobilization protocols into ERAS pathways for MBS patients.