Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations

Not Control but Conquest: Strategies for the Remission of Type 2 Diabetes Mellitus

A durable normoglycemic state was observed in several studies that treated type 2 diabetes mellitus (T2DM) patients through metabolic surgery, intensive therapeutic intervention, or significant lifestyle modification, and it was confirmed that the functional β-cell mass was also restored to a normal level. Therefore, expert consensus introduced the concept of remission as a common term to express this phenomenon in 2009. Throughout this article, we introduce the recently updated consensus statement on the remission of T2DM in 2021 and share our perspective on the remission of diabetes. There is a need for more research on remission in Korea as well as in Western countries. Remission appears to be prompted by proactive treatment for hyperglycemia and significant weight loss prior to irreversible β-cell changes. T2DM is not a diagnosis for vulnerable individuals to helplessly accept. We attempt to explain how remission of T2DM can be achieved through a personalized approach. It may be necessary to change the concept of T2DM towards that of an urgent condition that requires rapid intervention rather than a chronic, progressive disease. We must grasp this paradigm shift in our understanding of T2DM for the benefit of our patients as endocrine experts.

Anesthesia and Enhanced Recovery After Surgery in Bariatric Surgery

The Enhanced Recovery After Surgery Society published guidelines for bariatric surgery reviewing the evidence and providing specific care recommendations. These guidelines emphasize preoperative nutrition, multimodal analgesia, postoperative nausea and vomiting prophylaxis, anesthetic technique, nutrition, and mobilization. Several studies have since evaluated these pathways, showing them to be safe and effective at decreasing hospital length of stay and postoperative nausea and vomiting. This article emphasizes anesthetic management in the perioperative period and outlines future directions, including the application of Enhanced Recovery After Surgery principles in patients with extreme obesity, diabetes, and metabolic disease and standardization of the pathways to decrease heterogeneity.

Higher Adherence to ERAS Society® Recommendations is Associated with Shorter Hospital Stay Without an Increase in Postoperative Complications or Readmissions in Bariatric Surgery: the Association Between Use of Enhanced Recovery After Surgery Protocols and Postoperative Complications after Bariatric Surgery (POWER 3) Multicenter Observational Study

PURPOSE

The effectiveness of enhanced recovery after surgery (ERAS) pathways in patients undergoing bariatric surgery remains unclear. Our objective was to determine the effect of the ERAS elements on patient outcomes following elective bariatric surgery.

MATERIALS AND METHODS

Prospective cohort study in adult patients undergoing elective bariatric surgery. Each participating center selected a single 3-month data collection period between October 2019 and September 2020. We assessed the 24 individual components of the ERAS pathways in all patients. We used a multivariable and multilevel logistic regression model to adjust for baseline risk factors, ERAS elements, and center differences RESULTS: We included 1419 patients. One hundred and fourteen patients (8%) developed postoperative complications. There were no differences in the incidence of overall postoperative complications between the self-designated ERAS and non-ERAS groups (54 (8.7%) vs. 60 (7.6%); OR, 1.14; 95% CI, 0.73-1.79; P = .56), neither for moderate-to-severe complications, readmissions, re-interventions, mortality, or hospital stay (2 [IQR 2-3] vs. 3 [IQR 2-4] days, 0.85; 95% CI, 0.62-1.17; P = .33) Adherence to the ERAS elements in the highest adherence quartile (Q1) was greater than 72.2%, while in the lowest adherence quartile (Q4) it was less than 55%. Patients with the highest adherence rates had shorter hospital stay (2 [IQR 2-3] vs. 3 [IQR 2-4] days, 1.54; 95% CI, 1.09-2.17; P = .015), while there were no differences in the other outcomes CONCLUSIONS: Higher adherence to ERAS Society® recommendations was associated with a shorter hospital stay without an increase in postoperative complications or readmissions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03864861.

The Effects of Perioperative Factors on Early Postoperative Morbidity in Bariatric Surgery

PURPOSE

This study aims to examine the predictive role of obesity-type-related indexes and perioperative intraabdominal pressure measurements for early postoperative complications following bariatric surgery.

MATERIALS AND METHODS

Sixty-seven female patients with obesity who underwent bariatric surgery (laparoscopic sleeve gastrectomy or gastric bypass) were included in this study. Obesity-related indexes (BMI, waist/hip ratio, and waist/height ratio) were calculated using patient data. Intraoperative hemodynamic measurements and intraabdominal pressure measurements were done at the beginning and at the end of the operation. Intraabdominal pressure measurements were done using both bladder port and trocar port. Patients were followed for early postoperative complications.

RESULTS

Among 67 patients included, 22 developed early postoperative complications (32.8%), mostly pulmonary (20.9%). Trans-trocar IAP measured at the beginning of the operation emerged as the single independent predictor of postoperative complications (OR, 40.3; p = 0.002). Based on ROC analysis, AUC for predicting complications was 0.955 (p < 0.01). Optimal cutoff point (≥ 14.5 mmHg) was associated with 100% sensitivity and 82% specificity. In addition, there were weak but significant positive correlations between trans-trocar IAP-beginning and BMI (r = 0.443, p < 0.001), waist/hip ratio (r = 0.434, p < 0.001), and waist/height ratio (r = 0.539, p < 0.001).

CONCLUSION

Findings of this study suggest that a high baseline intraabdominal pressure predicts a higher risk for early postoperative complications following bariatric surgery. This information would help improve patient care. Further large studies are warranted.

Bariatric Tele-screening During the COVID-19 Pandemic: Holding Back for Direct Approval?

Purpose

Many bariatric centers were restricted from providing routine care for outpatients. Telehealth visits allowed the continued care for outpatients and thus the preoperative screening for bariatric candidates. The objective of this study was to evaluate the effect of tele-screening on the multidisciplinary obesity team’s decision (MDD) for bariatric surgery: disapproval, direct approval, or a recommendation for a prehabilitation program.

Materials and Methods

Hospital data were collected from patients who underwent face-to-face or tele-screening for bariatric surgery between April and December 2020. The tele-screening cohort was then compared with a propensity-matched cohort of patients with face-to-face consultations. A chi-square and multinomial logistic regression analyses were performed.

Results

After propensity matching, 396 patients remained for analysis. The majority received preoperative prehabilitation advice in both the tele-screening and face-to-face group (51% versus 50%). Although not significant, there were more direct approvals and fewer denials in the face-to-face group (p = 0.691). The multinomial logistic regression analysis showed no significant impact of tele-screening on the MDD result.

Conclusion

Tele-screening in bariatric centers is feasible; the multidisciplinary team’s decision was not significantly different between tele-screening and face-to-face screening which encourages the use of tele-screening in the future. An insignificant amount of fewer direct approvals and more denials were observed in the tele-screening group, which should be taken into account in future and larger case studies.

Graphical abstract

SHORTEN PREOPERATIVE FASTING AND INTRODUCING EARLY EATING ASSISTANCE IN RECOVERY AFTER GASTROJEJUNAL BYPASS?

Rational:

The metabolic response to surgical trauma is enhanced by prolonged preoperative fasting, contributing to increased insulin resistance. This manifestation is more intense on the 1^st and 2^nd postoperative days and is directly proportional to the size of the operation.

Aim:

To compare whether preoperative fasting abbreviation and early postoperative refeeding associated with intraoperative and postoperative fluid restriction interfere in the evolution of patients undergoing gastrojejunal bypass.

Methods:

Eighty patients indicated for Roux-en-Y gastrojejunal bypass were selected. They were randomly divided into two groups: Ringer Lactate (RL) group, who underwent a 6 hours solids fasting, with the administration of 50 g of maltodextrin in 100 ml of mineral water 2 hours before the beginning of anesthesia; and Physiologic Solution (PS) group, who underwent a 12 hours solids and liquids fasting. Anesthesia was standardized for both groups. During the surgical procedure, 1500 ml of ringer lactate solution was administered in the RL and 2500 ml of physiological solution (0.9% sodium chloride) in the PS. In both groups, the occurrence of bronchoaspiration was analyzed during intubation, and the residual gastric volume was measured after opening the abdominal cavity. In the postoperative period in Group RL, patients started a liquid diet 24 hours after the end of the operative procedure; whilst for PS group, fasting was maintained for the first 24 hours, it was prescripted 2000 ml of physiological solution and a restricted liquid diet after 36 hours. Each patient underwent CPK, insulin, sodium, potassium, urea, creatinine, PaCO2, pH and bicarbonate dosage in the immediate postoperative period, and 48 hours later, the exams were repeated.

Results:

There were no episodes of bronchoaspiration and gastrojejunal fistulas in either group. In the analysis of the residual gastric volume of the PS and RL groups, the mean volumes were respectively 16.5 and 8.8, which shows statistical significance between the groups. In laboratory tests, there was no difference between groups in sodium; PS group showed a higher level of serum potassium (p=0.029); whilst RL group showed a higher urea and creatinine values; CPK values were even for both; PS group demonstrated a higher insulin level; pH was higher in PS group; sodium bicarbonate showed a significant difference at all times; PaCO2 values in RL group was higher than in PS. In the analysis of the incidence of nausea and flatus, no statistical significance was observed between the groups.

Conclusions:

The abbreviation of preoperative fasting and early postoperative refeeding of Roux-en-Y gastrojejunal bypass with the application of ERAS or ACERTO Project accelerated the patient’s recovery, reducing residual gastric volume and insulin level, and do not predispose to complications.

Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update

Background

This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol.

Methods

A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations.

Results

The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries.

Conclusion

A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.

Thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs comparing 2 reduced guidelines for pharmacological prophylaxis

OBJECTIVE

To determine the thrombotic and hemorrhagic risk in bariatric surgery with multimodal rehabilitation programs, comparing two guidelines of pharmacological prophylaxis recommended in the Guide to the Spanish Society for Obesity Surgery and the Obesity Section of the AEC.

METHODS

Cohorts retrospective study from January-2010 to December-2019. Cases of vertical gastrectomy or gastric bypass were recorded, systematically applying multimodal rehabilitation protocols. Two reduced chemoprophylaxis regimens were analyzed, starting after surgery and maintained for 10 days; one with fondaparinux (Arixtra®) at a fixed dose of 2.5mg/day and the other with enoxaparin (Clexane®) with a single daily dose adjusted to BMI: 40mg/day for BMI of 35-40 and 60mg/day for BMI 40-60.

RESULTS

675 patients were included; 354 with Fondaparinux-Arixtra® during the period 2010-2015 and 321 with Enoxaparin-Clexane® during the period 2016-2019. There were no cases of DVT or clinical PE. However, the incidence of hemorrhage requiring reoperation, transfusion, or a decrease of more than 3g/dL hemoglobin was 4.7%, with no difference between groups. Mortality was nil. The average stay was 2.8 days and the outpatient follow-up was 100% during the first 6 months and 95% at 12 months.

CONCLUSIONS

The combination of multimodal rehabilitation programs and mechanical and pharmacological thromboprophylaxis by experienced teams, reduces the risk of thromboembolic events and could justify reduced chemoprophylaxis regimens to decrease the risk of postoperative bleeding.

Preoperative preparation and premedication of bariatric surgical patient

The prevalence of obesity has tripled worldwide over the past four decades. The United States has the highest rates of obesity, with 88% of the population being overweight and 36% obese. The UK has the sixth highest prevalence of obesity. The problem of obesity is not isolated to the developed world and has increasingly become an issue in the developing world as well. Obesity carries an increased risk of many serious diseases and health conditions, including type 2 diabetes, heart disease, stroke, sleep apnea, and certain cancers. Our ability to take care of this population safely throughout the perioperative period begins with a thorough and in-depth preoperative assessment and meticulous preparation. The preoperative assessment begins with being able to identify patients who suffer from obesity by using diagnostic criteria and, furthermore, being able to identify patients whose obesity is causing pathologic and physiologic changes. A detailed and thorough anesthesia assessment should be performed, and the anesthesia plan individualized and tailored to the specific patient's risk factors and comorbidities. The important components of the preoperative anesthesia assessment and patient preparation in the patient suffering from obesity include history and physical examination, airway assessment, medical comorbidities evaluation, functional status determination, risk assessment, preoperative testing, current weight loss medication, and review of any prior weight loss surgeries and their implications on the upcoming anesthetic. The preoperative evaluation of this population should occur with sufficient time before the planned operation to allow for modifications of the preoperative management without needing to delay surgery as the perioperative management of patients suffering from obesity presents significant practical and organizational challenges.

Recovery Profiles of Sevoflurane and Desflurane with or without M-Entropy Guidance in Obese Patients: A Randomized Controlled Trial

Obesity increases the risk of prolonged emergence from general anesthesia due to the delayed release of anesthetic agents from body fat. This trial aimed to evaluate the effects of sevoflurane and desflurane along with anesthetic depth monitoring on emergence time from anesthesia in obese patients. Adults with a body mass index ≥ 30 kg·m⁻² undergoing laparoscopic sleeve gastrectomy at a medical center were randomized into four groups: sevoflurane or desflurane anesthesia with or without M-Entropy guidance on anesthetic depth in a ratio of 1:1:1:1. In the M-Entropy guidance groups, the dosage of sevoflurane and desflurane was adjusted to achieve response and state entropy values between 40 and 60 during surgery. In the non-M-Entropy guidance groups, the dosage of anesthetics was titrated according to clinical signs. Primary outcome was time to spontaneous eye opening. A total of 80 participants were randomized. Compared to sevoflurane, desflurane anesthesia significantly reduced the time to spontaneous eye opening [mean difference (MD): −129 s; 95% confidence interval (CI): −211, −46], obeying commands (−160; −243, −77), tracheal extubation (−172; −266, −78), and leaving operating room (−148; −243, −54). M-Entropy guidance further reduced time to eye opening (MD: −142 s; 99.2% CI: −276, −8), tracheal extubation (−199; −379, −19), and leaving operating room (−190; −358, −23) in the desflurane but not the sevoflurane group. M-Entropy guidance significantly reduced the risk of agitation during emergence, i.e., risk difference: −0.275 (95% CI: −0.464, −0.086); and number needed to treat: 4. Compared to sevoflurane, using desflurane to maintain general anesthesia accelerated the return of consciousness in obese patients. M-Entropy guidance further hastened awakening in patients using desflurane and prevented emergence agitation.

Compliance with Enhanced Recovery After Surgery (ERAS) protocol recommendations for bariatric surgery in an obesity treatment center

INTRODUCTION

The higher risk of perioperative complications associated with obesity has made anesthesiologists increasingly concerned with the management of obese patients. Measures that improve bariatric surgery patient safety have become essential. The implementation of ERAS protocols in several surgical specialties has made it possible to achieve appropriate outcomes as to surgery safety. The aim of this study was to evaluate patient compliance with the recommendations of an ERAS protocol for Bariatric Surgery (ERABS) at a hospital specialized in obesity treatment.

METHODS

Cross-sectional study, using a medical record database, in a hospital certified as an International Center of Excellence in Bariatric and Metabolic Surgery. The definition of the variables to be assessed was based on the most recent ERABS proposed by Thorell et al. Results were analyzed using descriptive epidemiology.

RESULTS

The study evaluated all patients undergoing bariatric surgery in 2019. Mean compliance with the recommendations per participant was 42.8%, with a maximum of 55.5%, and was distributed as follows: 22.6% of compliance with preoperative recommendations, 60% to intraoperative recommendations, and 58.1% to postoperative recommendations. The anesthesiologist is the professional who provides most measures for the perioperative optimization of bariatric surgery patients. In our study we found that anesthesiologists complied with only 39.5% of ERABS recommendations.

CONCLUSIONS

Mean compliance with ERABS recommendations per participant was 42.8%. Considering that the study was carried out at a hospital certified as an international center of excellence, the need for introducing improvements in the care of patients to be submitted to bariatric surgery is evident.

Opioid Sparing Anesthesia and Enhanced Recovery After Surgery Protocol for Pancreaticoduodenectomy

Background

Opioid sparing anesthesia and enhanced recovery after surgery protocols are not innovative ideas. However, the utilization of pancreaticoduodenectomy is limited. With the rise in awareness of the opioid epidemic in the United States, we have created a multimodal approach to anesthesia and postoperative care to limit adverse effects of opioids and curb the use of opioids postoperatively.

Methods

We conducted a retrospective cohort study performed by chart review of an opioid-sparing anesthetic and enhanced recovery after surgery (ERAS) protocol initiated jointly by the anesthesiology departments and transplant surgery for pancreaticoduodenectomy from January 2017 to October 2019.

Results

Demographic data was found to be comparable between the control and protocol groups. Hospital length of stay, ICU length of stay, and opioid requirements significantly decreased in the protocol group. Hospital length of stay decreased from 8.92 to 5.72 days, ICU days decreased from 1.52 to 0.42 days, and narcotics for the first five hospital days were significantly decreased from 130.13 to 71.2 morphine milligram equivalents.

Conclusion

Proper postoperative pain management can improve patient satisfaction and decrease complication rates. Pancreaticoduodenectomy is a complicated procedure with relatively limited data regarding enhanced recovery after surgery protocols. Likewise, there is limited data regarding opioid-sparing anesthesia techniques. Our protocol produced promising hospital length of stay and reduced opioid administration during the first five hospital days without increasing 30-day readmission rates.

National Trends in Length of Stay for Microvascular Breast Reconstruction: An Evaluation of 10,465 Cases Using the American College of Surgeons National Surgical Quality Improvement Program Database

BACKGROUND

Decreasing length of stay benefits patients and hospital systems alike. This should be accomplished safely without negatively impacting patient outcomes. The authors hypothesize that in the United States, the average length of stay for patients undergoing microsurgical breast reconstruction has decreased since 2012 without a concurrent increase in complication and readmission rates.

METHODS

The authors identified female patients who underwent microvascular breast reconstruction (CPT 19364) from the 2012 to 2018 National Surgical Quality Improvement Program database. Trends in complication and readmission rates and length of stay were examined over 7 years. Multivariable logistic regression models and Mann-Kendall trend tests were used to evaluate associations between length of stay and complication and readmission rates.

RESULTS

A total of 10,465 cases were identified. The number of autologous microvascular breast reconstruction procedures performed increased annually between 2012 and 2018. Length of stay decreased significantly from 2012 to 2018 (from 4.47 days to 3.90 days) (p < 0.01). Minor and major complication rates remained constant, although major complications showed a decreasing trend (from 27 percent to 21 percent) (p = 0.07). Thirty-day readmission, surgical-site infection, and wound dehiscence rates remained consistent over the study period, whereas rates of blood transfusion or bleeding decreased (p = 0.02).

CONCLUSIONS

Using a national sample from 2012 to 2018, the authors observed a significant decrease in length of stay for patients undergoing microvascular breast reconstruction without a concurrent increase in complication and readmission rates. Current efforts to reduce length of stay have been successful without increasing complication or readmission rates.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Background for the introduction of enhanced recovery after surgery and patient outcomes

Background: To facilitate early postoperative recovery of surgical patients, various efforts have been made to develop effective treatment methods since 1990; moreover, these efforts have not been limited to surgical techniques and include multiple aspects of the entire treatment process. Enhanced recovery after surgery (ERAS) is a surgical quality improvement project that has advanced substantially since it was first introduced in 1995 and has now been firmly established in the field of perioperative care.Current Concepts: ERAS consists of many components that cover each stage before, during, and after surgery, and its clinical application changes according to the results of evidence-based research for each item. To date, more than 20 ERAS guidelines have been created for each disease, and more guidelines are expected in the future. Many studies have reported that ERAS is associated with meaningful improvements in clinical outcomes and reductions of medical costs in many surgical fields.Discussion and Conclusion: ERAS remains a work in progress, and continuous research and improvement is needed in relation to the components, areas of application, audit of compliance and results, education, and a multidisciplinary approach.

Factors affecting relapse of type 2 diabetes after bariatric surgery in Sweden 2007-2015: a registry-based cohort study

BACKGROUND

Although a large proportion of patients with type 2 diabetes (T2DM) who have undergone metabolic surgery experience initial remission some patients later suffer from relapse. While several factors associated with T2D remission are known, less is known about factors that may influence relapse.

OBJECTIVES

To identify possible risk factors for T2D relapse in patients who initially experienced remission.

SETTING

Nationwide, registry-based study.

METHODS

We conducted a nationwide registry-based retrospective cohort study including all adult patients with T2D and body mass index ≥35 kg/m² who received primary metabolic surgery with Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) in Sweden between 2007 and 2015. Patients who achieved complete diabetes remission 2 years after surgery was identified and analyzed. Main outcome measure was postoperative relapse of T2D, defined as reintroduction of diabetes medication.

RESULTS

In total, 2090 patients in complete remission at 2 years after surgery were followed for a median of 5.9 years (interquartile range [IQR] 4.3-7.2 years) after surgery. The cumulative T2D relapse rate was 20.1%. Duration of diabetes (hazard ratio [HR], 1.09; 95% confidence interval [CI], 1.05-1.14; P < .001), preoperative glycosylated hemoglobin A1C (HbA1C) level (HR, 1.01; 95% CI, 1.00-1.02; P = .013), and preoperative insulin treatment (HR, 2.67; 95% CI, 1.84-3.90; P < .001) were associated with higher rates for relapse, while postoperative weight loss (HR, .93; 95% CI, .91-.96; P < .001), and male sex (HR, .65; 95% CI, .46-.91; P = .012) were associated with lower rates.

CONCLUSION

Longer duration of T2D, higher preoperative HbA1C level, less postoperative weight loss, female sex, and insulin treatment prior to surgery are risk factors for T2D relapse after initial remission.

Enhanced Recovery after Surgery in Bariatric Surgery

The enhanced recovery after surgery (ERAS) program is now widely applied in bariatric surgeries and other surgical procedures. The ERAS program in bariatric surgery consists of various components similar to that in colorectal surgery or other procedures. The major concept of the ERAS protocol relies on a multidisciplinary and multimodal approach to resolve various problems after surgical treatment. The key principles of the ERAS program in bariatric surgery include patient education, opioid-sparing multimodal pain management, prophylaxis of postoperative nausea and vomiting, goal-directed fluid therapy, and minimizing insulin resistance and catabolism. Several guidelines and studies, including randomized clinical trials and systematic reviews, have advocated for the ERAS program in bariatric surgery, which has consistently shown advantages in shortening hospital stay without increasing morbidity. The systematic application of the ERAS program in bariatric patients results in less pain and early recovery and should be routinely recommended.

ERAS reduces postoperative hospital stay and complications after bariatric surgery: A retrospective cohort study

Enhanced recovery after surgery (ERAS) is a multimodal, multidisciplinary approach for caring surgical patients. The present study aimed to compare the perioperative outcomes of laparoscopic bariatric surgery between patients with ERAS and those with conventional care.The clinical data of all patients undergoing primary laparoscopic bariatric surgery between January 2014 and June 2017 were retrospectively collected and reviewed. Patients were managed with conventional care during 2014 to 2015 (conventional care group) and with ERAS protocols during 2016 to 2017 (ERAS group). The 2 groups were compared in terms of postoperative length of hospital stay (LOS) and postoperative day 1 discharge rate.A total of 435 consecutive patients were included with 198 patients in the conventional care group and 237 patients in the ERAS group. The ERAS group had significantly shorter LOS (2.2 ± 0.9 vs 4.0 ± 2.6 days, P < .01) and significantly higher day 1 discharge rate (15.2% vs 1%, P < .01) compared with the conventional care group. During postoperative 30 days, the ERAS group had significantly less complications (2.1% vs 8.6%, P < .01) and readmissions (1.3% vs 4.5%, P = .02) compared with the conventional care group.Compared with conventional care, ERAS significantly reduces postoperative LOS, complications, and readmissions in patients undergoing laparoscopic bariatric surgery.

Metabolic surgery in treatment of obese Japanese patients with type 2 diabetes: a joint consensus statement from the Japanese Society for Treatment of Obesity, the Japan Diabetes Society, and the Japan Society for the Study of Obesity

Bariatric surgery has been shown to have a variety of metabolically beneficial effects for patients with type 2 diabetes (T2D), and is now also called metabolic surgery. At the 2nd Diabetes Surgery Summit held in 2015 in London, the indication for bariatric and metabolic surgery was included in the “algorithm for patients with type T2D”. With this background, the Japanese Society for Treatment of Obesity (JSTO), the Japan Diabetes Society (JDS) and the Japan Society for the Study of Obesity (JASSO) have formed a joint committee to develop a consensus statement regarding bariatric and metabolic surgery for the treatment of Japanese patients with T2D. Eventually, the consensus statement was announced at the joint meeting of the 38th Annual Meeting of JSTO and the 41st Annual Meeting of JASSO convened in Toyama on March 21, 2021. In preparing the consensus statement, we used Japanese data as much as possible as scientific evidence to consider the indication criteria, and set two types of recommendation grades, “recommendation” and “consideration”, for items for which recommendations are possible. We hope that this statement will be helpful in providing evidence-based high-quality care through bariatric and metabolic surgery for the treatment of obese Japanese patients with T2D.

Impact of Preoperative Weight Loss on Postoperative Weight Loss Revealed from a Large Nationwide Quality Registry

PURPOSE

Weight loss before bariatric surgery is not mandatory, but questions remain as to whether preoperative weight loss has an impact on weight loss after surgery. Most studies have small sample sizes. The objective was to evaluate the relationship between preoperative and successful postoperative weight loss defined as ≥25% total weight loss (TWL) at 1 and 2 years after primary bariatric surgery with regard to the obesity-related comorbidities.

MATERIALS AND METHODS

Data were extracted from a large nationwide quality registry of patients who underwent a sleeve gastrectomy (SG) or gastric bypass (GBP) between January 2015 and January 2018. Patients with completed screening and preoperative and postoperative data were included. A multivariate logistic regression analysis was performed for each technique and follow-up years separately.

RESULTS

In total, 8751 were included in the analysis. Patients with preoperative weight loss were more likely to achieve ≥25% postoperative TWL in both procedures. Patients with higher preoperative weight loss of 5-10% had an increased likelihood for achieving 25% TWL compared to 0-5%, OR 1.79 (CI (1.42-2.25), p < 0.001) vs 1.25 (CI (1.08-1.46), p < 0.004) for the GBP group for year 2 postoperative. This was the same for the SG group at year 2, OR 1.30 (CI (1.03-1.64), p < 0.029) vs 1.14 (CI (0.94-1.38), p < 0.198).

CONCLUSION

Patients with preoperative weight loss were more likely to achieve ≥25% postoperative TWL at 1 and 2 years after surgery in both procedures; moreover, the extent of preoperative weight loss contributes to the significance and odds of this success.

Benefits of dexmedetomidine on postoperative analgesia after bariatric surgery: a systematic review and meta-analysis

INTRODUCTION

Anesthetic management of morbidly obese patients is challenging, particularly in those undergoing bariatric surgery. Dexmedetomidine is a α2-adrenergic receptor agonist that is increasingly used in the perioperative setting for its beneficial properties including sedation, anxiolysis, analgesia with opioid-sparing effects, and minimal impact on respiration. The objective of this study was to evaluate the effect of dexmedetomidine on postoperative analgesia and recovery-related outcomes among patients undergoing bariatric surgery.

EVIDENCE ACQUISITION

We conducted a systematic review and meta-analysis of MEDLINE, EMBASE, and CENTRAL databases from conception to September 2021 for randomized controlled trials (RCTs) using dexmedetomidine in bariatric patients on postoperative outcomes. Outcomes were pooled using random effects model and presented as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CI).

EVIDENCE SYNTHESIS

In total, 20 RCTs with 665 patients in the dexmedetomidine group and 671 patients in the control groups were included. Among RCTs, the dexmedetomidine group had significantly lower opioid usage at 24-hours postoperatively (MD: -5.14, 95%CI: -10.18 to -0.10; moderate certainty), reduced pain scores on a 10-point scale at PACU arrival (MD: -1.69, 95%CI: -2.79 to -0.59; moderate certainty) and 6 hours postoperatively (MD: -1.82, 95%CI: - 3.00 to -0.64; low certainty), and fewer instances of nausea (RR: 0.59, 95%CI: 0.45 to 0.75; moderate certainty) and vomiting (RR: 0.25, 95%CI: 0.15 to 0.43; moderate certainty), compared to control groups.

CONCLUSIONS

Dexmedetomidine is an efficacious anesthesia adjunct in patients undergoing bariatric surgery. These benefits of dexmedetomidine may be considered in the multi-modal analgesic management and enhanced recovery pathways in this high-risk population.

Racial disparity in causes for readmission following bariatric surgery

BACKGROUND

Readmission after bariatric surgery is not cost-effective and is a preventable quality metric within standardized practices. However, reasons for readmission among racial/ethnic bariatric cohorts are less explored and understood.

OBJECTIVE

Our study objective was designed to compare reasons for readmission among racial/ethnic cohorts of bariatric patients.

SETTING

Academic hospital.

METHODS

We performed a retrospective analysis of the 2015-2018 MBSAQIP databases to identify Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) cases. Regression analyses determined predictors of all-cause and bariatric-related readmissions. Reasons for readmission were compared between racial/ethnic cohorts using propensity score matching.

RESULTS

More than 550 000 RYGB and SG cases were analyzed. The readmission rate was 3%-4%. Black race, RYGB, robot-assisted approach, and numerous co-morbidities were independently associated with readmission (P <.05). In RYGB cases, black (versus white) patients were at decreased odds of leak-related (P < .001) and cardiovascular-related (P < .001) readmissions but at increased odds of readmissions related to renal complications (P < .001). Hispanic (versus white) patients had a higher likelihood of venous thromboembolism-related readmissions (P < .001). In SG cases, black (versus white) patients had a similar lower likelihood of readmission related to leaks or cardiovascular complications but higher odds of readmission related to renal complications (P < .001). Hispanic (versus black) patients had a higher likelihood of leak-related readmissions (P < .001).

CONCLUSION

Readmission reasons after bariatric surgery vary by race/ethnicity. Perioperative pathways to mitigate complications, including readmissions, should consider these disparate findings.

Impact of Intraoperative Ketamine on Postoperative Analgesic Requirement Following Bariatric Surgery: a Meta-analysis of Randomized Controlled Trials

This meta-analysis aimed at exploring the impact of intravenous ketamine on pain relief and analgesic consumption in patients undergoing bariatric surgery (BS). Literature searches identified nine eligible trials with 458 participants. Forest plot revealed a significantly lower pain score [mean difference (MD) =  - 1.06, p = 0.005; 390 patients) and morphine consumption (MD =  - 3.85 mg, p = 0.01; 212 patients) immediately after BS in patients with intravenous ketamine than in those without. In contrast, pooled analysis showed comparable pain score (p = 0.28), morphine consumption (p = 0.45) within 24 h, and risk of postoperative nausea/vomiting (p = 0.67) between the two groups. In conclusion, the meta-analysis demonstrated improvements in pain outcomes immediately after surgery through perioperative intravenous ketamine administration despite the absence of analgesic benefit in the late postoperative period and a positive impact on postoperative nausea/vomiting.

Updates on Wound Infiltration Use for Postoperative Pain Management: A Narrative Review

Local anesthetic wound infiltration (WI) provides anesthesia for minor surgical procedures and improves postoperative analgesia as part of multimodal analgesia after general or regional anesthesia. Although pre-incisional block is preferable, in practice WI is usually done at the end of surgery. WI performed as a continuous modality reduces analgesics, prolongs the duration of analgesia, and enhances the patient’s mobilization in some cases. WI benefits are documented in open abdominal surgeries (Caesarean section, colorectal surgery, abdominal hysterectomy, herniorrhaphy), laparoscopic cholecystectomy, oncological breast surgeries, laminectomy, hallux valgus surgery, and radical prostatectomy. Surgical site infiltration requires knowledge of anatomy and the pain origin for a procedure, systematic extensive infiltration of local anesthetic in various tissue planes under direct visualization before wound closure or subcutaneously along the incision. Because the incidence of local anesthetic systemic toxicity is 11% after subcutaneous WI, appropriate local anesthetic dosing is crucial. The risk of wound infection is related to the infection incidence after each particular surgery. For WI to fully meet patient and physician expectations, mastery of the technique, patient education, appropriate local anesthetic dosing and management of the surgical wound with “aseptic, non-touch” technique are needed.

The impact of severe postoperative complications on outcomes of bariatric surgery-multicenter case-matched study

BACKGROUND

Bariatric surgery has relatively low complication rates, especially severe postoperative complications (defined by Clavien-Dindo classification as types 3 and 4), but these rates cannot be ignored. In other than bariatric surgical disciplines, complications affect not only short-term but also long-term results. In the field of bariatric surgery, this topic has not been extensively studied.

OBJECTIVES

The aim of the study was to assess the outcomes of bariatric treatment in patients with obesity and severe postoperative complications in comparison to patients with a noneventful perioperative course.

SETTING

Six surgical units at Polish public hospitals.

METHODS

We performed a multicenter propensity score matched analysis of 206 patients from 6 Polish surgical units and assessed the outcomes of bariatric procedures. A total of 103 patients with severe postoperative complications (70 laparoscopic sleeve gastrectomy [SG] and 33 with laparoscopic Roux en Y gastric bypass [RYGB]) were compared to 103 patients with no severe complications in terms of peri- and postoperative outcomes.

RESULTS

The outcomes of bariatric treatment did not differ between compared groups. Median percentage of total weight loss 12 months after the surgery was 28.8% in the group with complications and 27.9% in patients with no severe complications (P = 0.993). Remission rates of both type 2 diabetes mellitus and arterial hypertension showed no significant difference between SG and RYGB (36% versus 42%, P = 0.927, and 41% versus 46%, P = 0.575. respectively).

CONCLUSIONS

The study suggests that severe postoperative complications had no significant influence either on weight loss effects or obesity-related diseases remission.

Obesity, metabolic syndrome, and inflammation: an update for anaesthetists caring for patients with obesity

Our understanding of chronic inflammation in obesity is evolving. Suggested mechanisms include hypoxia of adipose tissue and a subsequent increase in circulating cytokines. It is now known that adipose tissue, far from being an inert tissue, produces and secretes multiple peptides that influence inflammation and metabolism, including substrates of the renin-angiotensin-aldosterone system (RAAS). RAAS blocking antihypertensive medication and cholesterol-lowering agents are now being evaluated for their metabolic and inflammation-modulating effects. Surgery also has pro-inflammatory effects, which may be exacerbated in patients with obesity. This narrative review will summarise the recent literature surrounding obesity, metabolic syndrome, inflammation, and interplay with the RAAS, with evidence-based recommendations for the optimisation of patients with obesity, prior to surgery and anaesthesia.

Preoperative nutrition care in Enhanced Recovery After Surgery programs: are we missing an opportunity?

PURPOSE OF REVIEW

A key component of Enhanced Recovery After Surgery (ERAS) is the integration of nutrition care elements into the surgical pathway, recognizing that preoperative nutrition status affects outcomes of surgery and must be optimized for recovery. We reviewed the preoperative nutrition care recommendations included in ERAS Society guidelines for adults undergoing major surgery and their implementation.

RECENT FINDINGS

All ERAS Society guidelines reviewed recommend preoperative patient education to describe the procedures and expectations of surgery; however, only one guideline specifies inclusion of routine nutrition education before surgery. All guidelines included a recommendation for at least one of the following nutrition care elements: nutrition risk screening, nutrition assessment, and nutrition intervention. However, the impact of preoperative nutrition care could not be evaluated because it was rarely reported in recent literature for most surgical disciplines. A small number of studies reported on the preoperative nutrition care elements within their ERAS programs and found a positive impact of ERAS implementation on nutrition care practices, including increased rates of nutrition risk screening.

SUMMARY

There is an opportunity to improve the reporting of preoperative nutrition care elements within ERAS programs, which will enhance our understanding of how nutrition care elements influence patient outcomes and experiences.

Effect of Ultrasound-Guided Erector Spinae Plane Block on Postoperative Pain and Intraoperative Opioid Consumption in Bariatric Surgery

BACKGROUND

Bariatric surgery is often associated with moderate to severe pain. In patients with obesity, opioids have the potential to induce ventilatory impairment; thus, opioid use needs to be limited. This study aimed to compare the novel ultrasound-guided erector spinae plane block (ESPB) technique with controls in terms of intraoperative opioid consumption and postoperative pain control.

METHODS

A total of 63 patients with morbid obesity who underwent laparoscopic bariatric surgery were included in this randomized study. Patients were randomly assigned to the bilateral erector spinae plane block (ESPB) group or the control group. To evaluate perioperative pain and to adjust opioid dose, analgesia nociception index (ANI) was monitored during surgery. Total opioid dose was recorded for each patient. In addition, pain was evaluated using visual analogue scale (VAS) scores for 24 h following the operation.

RESULTS

Total intraoperative remifentanil dose was significantly lower in the ESPB group when compared to controls (1356.3 ± 177.8 vs. 3273.3 ± 961.9 mcg, p < 0.001). In the ESPB group, none of the patients required additional analgesia during follow-up. In contrast, all control patients required analgesia. ESPB group had significantly lower VAS scores at all postoperative time points (p < 0.001 for all).

CONCLUSION

Bilateral ultrasound-guided ESPB appears to be a simple and effective technique to improve perioperative pain control and reduce intraoperative opioid need in patients with morbid obesity undergoing bariatric surgery.

Clinical efficacy of an enhanced recovery after surgery protocol in patients undergoing robotic-assisted laparoscopic prostatectomy

Objective

To evaluate the application of an enhanced recovery after surgery (ERAS) protocol in patients undergoing robot-assisted laparoscopic prostatectomy (RALP).

Methods

We conducted a retrospective cohort study of 136 patients who underwent RALP between August 2017 and June 2018 as the control group and a prospective analysis of 106 patients who underwent RALP between January 2019 and January 2020 as the ERAS group. ERAS focused on preoperative education, nutritional intervention, electrolyte solution intake, restrictive fluid infusion, body warming, no indwelling central venous catheter, use of nonsteroidal anti-inflammatory drugs (NSAIDs), early mobilization, and eating recovery.

Results

The times from RALP to the first intake of clear liquid; first ambulation; first defecation; first fluid, semi-liquid, and general diet; drain removal; and length of hospital stay (LOS) were significantly shorter, and operative time, fluid infusion within 24 hours, postoperative day (POD) 1 albumin, POD 1 hemoglobin, and POD 2 drainage were significantly higher in the ERAS group. Five patients (3.8%) in the ERAS group developed postoperative complications (urine leakage, n = 4; intestinal obstruction, n = 1), while 1 patient (0.7%) in the control group developed intestinal obstruction.

Conclusions

ERAS effectively accelerated patient rehabilitation and reduced the LOS for patients undergoing RALP.

Prehabilitation for Bariatric Surgery: A Randomized, Controlled Trial Protocol and Pilot Study

Bariatric surgery is the most efficacious treatment for obesity, though it is not free from complications. Preoperative conditioning has proved beneficial in various clinical contexts, but the evidence is scarce on the role of prehabilitation in bariatric surgery. We describe the protocol and pilot study of a randomized (ratio 1:1), parallel, controlled trial assessing the effect of a physical conditioning and respiratory muscle training programme, added to a standard 8-week group intervention based on therapeutical education and cognitive-behavioural therapy, in patients awaiting bariatric surgery. The primary outcome is preoperative weight-loss. Secondary outcomes include associated comorbidity, eating behaviour, physical activity, quality of life, and short-term postoperative complications. A pilot sample of 15 participants has been randomized to the intervention or control groups and their baseline features and results are described. Only 5 patients completed the group programme and returned for assessment. Measures to improve adherence will be implemented and once the COVID-19 pandemic allows, the clinical trial will start. This is the first randomized, clinical trial assessing the effect of physical and respiratory prehabilitation, added to standard group education and cognitive-behavioural intervention in obese patients on the waiting list for bariatric surgery. Clinical Trial Registration: NCT0404636.

Cardiac Enhanced Recovery After Surgery: Early Outcomes in a Community Setting

BACKGROUND

Enhanced Recovery After Surgery (ERAS) programs have demonstrated improved outcomes in non-cardiac surgery. More recently, ERAS has been applied to cardiac surgery with promising results. We have implemented cardiac ERAS at our community-based program, aiming to improve all phases of care, and now report our early results.

METHODS

We retrospectively analyzed 73 consecutive patients treated with ERAS care compared to 74 patients treated prior to implementing ERAS. Our ERAS program consisted of 6 perioperative care bundles including enhanced patient education, shortened preoperative fasting period and oral carbohydrate load, postoperative nausea prophylaxis, multimodal opioid-sparing analgesia, early extubation, and early mobilization.

RESULTS

ERAS patients required significantly less opioids captured as total milligram morphine equivalents (MME; median: 35.0 versus 75.3, P < .001), less nausea as determined by fewer total ondansetron rescue doses (median 0 versus 0.5, P = .011), and less lightheadedness (P = .028) compared with pre-ERAS patients. Postoperative mobility was significantly better (POD 4: 95% vs 81%, P = .013) and postoperative length of stay was lower for ERAS care, but did not reach statistical significance (median 4 vs 5 days, P = .06). There was no difference in pain or glucose control or in early extubation.

CONCLUSIONS

Cardiac ERAS significantly decreased opioid use, nausea, lightheadedness and improved functional outcome for cardiac surgical patients in a community hospital.

Opportunities and Challenges for the Next Phase of Enhanced Recovery After Surgery: A Review

Importance

Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement initiative now firmly entrenched within the field of perioperative care. Although ERAS is associated with significant clinical outcome improvements and cost savings in numerous surgical specialties, several opportunities and challenges deserve further discussion.

Observations

Uptake and implementation of ERAS Society guidelines, together with ERAS-related research, have increased exponentially since the inception of the ERAS movement. Opportunities to further improve patient outcomes include addressing frailty, optimizing nutrition, prehabilitation, correcting preoperative anemia, and improving uptake of ERAS worldwide, including in low- and middle-income countries. Challenges facing enhanced recovery today include implementation, carbohydrate loading, reversal of neuromuscular blockade, and bowel preparation. The COVID-19 pandemic poses both a challenge and an opportunity for ERAS.

Conclusions and Relevance

To date, ERAS has achieved significant benefit for patients and health systems; however, improvements are still needed, particularly in the areas of patient optimization and systematic implementation. During this time of global crisis, the ERAS method of delivering care is required to take surgery and anesthesia to the next level and bring improvements in outcomes to both patients and health systems.

Perioperative nutrition care and dietetic practices in the scope of bariatric surgery in Saudi Arabia using adapted protocols for evaluation

Objectives:

This study evaluates the availability of perioperative nutritional care protocols and the practices of bariatric registered dietitians in Saudi Arabia. The primary outcomes of the study were conducted using an adapted American survey “with permission.”

Methods:

A cross-sectional survey of a selected 32 dietitians providing bariatric services completed a self-administered online questionnaire from 12 hospitals in Jeddah, Saudi Arabia.

Results:

All surveyed dietitians were females, mainly Saudi nationals (93.9%, n = 30), and accredited by the Saudi Commission for Health Specialties (93.8%, n = 30). Only 37.5% (n = 6) of the dietitians were specialized in bariatric surgery. Perioperative common practices of dietitians included a conduct of screening for nutrition risk before (44%, n = 14) and after surgery (62.5%, n = 20) and applied a nutrition management protocol that is mainly based on the application of nutrition care process (62.5%, n = 20). Dietitians (81%, n = 26) reported the importance of having standardized protocols for nutritional management of patients undoing bariatric surgery, where 69% (n = 22) confirmed the availability of pre-operative written protocols in hospitals and 75% (n = 24) confirmed the existence of post-operative protocols. Pre-operative practices included using approaches for weight loss before surgery, for example, very low and low-calorie diet. Dietitians (25%, n = 8) see two to ten patients per month. The sleeve gastrectomy procedure is the most often performed surgery.

Conclusion:

This is the first study to evaluate the perioperative nutrition care protocols and practices related to bariatric surgery in Saudi Arabia. Perioperative bariatric protocols are available, but some dietitians are not aware of their availability and contents. Researchers emphasize the importance of creating national protocols by the Saudi Credentials Body to standardize practices within the field.

Levels of Evidence Supporting the North American and European Perioperative Care Guidelines for Anesthesiologists between 2010 and 2020: A Systematic Review

BACKGROUND

Although there are thousands of published recommendations in anesthesiology clinical practice guidelines, the extent to which these are supported by high levels of evidence is not known. This study hypothesized that most recommendations in clinical practice guidelines are supported by a low level of evidence.

METHODS

A registered (Prospero CRD42020202932) systematic review was conducted of anesthesia evidence-based recommendations from the major North American and European anesthesiology societies between January 2010 and September 2020 in PubMed and EMBASE. The level of evidence A, B, or C and the strength of recommendation (strong or weak) for each recommendation was mapped using the American College of Cardiology/American Heart Association classification system or the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The outcome of interest was the proportion of recommendations supported by levels of evidence A, B, and C. Changes in the level of evidence over time were examined. Risk of bias was assessed using Appraisal of Guidelines for Research and Evaluation (AGREE) II.

RESULTS

In total, 60 guidelines comprising 2,280 recommendations were reviewed. Level of evidence A supported 16% (363 of 2,280) of total recommendations and 19% (288 of 1,506) of strong recommendations. Level of evidence C supported 51% (1,160 of 2,280) of all recommendations and 50% (756 of 1,506) of strong recommendations. Of all the guidelines, 73% (44 of 60) had a low risk of bias. The proportion of recommendations supported by level of evidence A versus level of evidence C (relative risk ratio, 0.93; 95% CI, 0.18 to 4.74; P = 0.933) or level of evidence B versus level of evidence C (relative risk ratio, 1.63; 95% CI, 0.72 to 3.72; P = 0.243) did not increase in guidelines that were revised. Year of publication was also not associated with increases in the proportion of recommendations supported by level of evidence A (relative risk ratio, 1.07; 95% CI, 0.93 to 1.23; P = 0.340) or level of evidence B (relative risk ratio, 1.05; 95% CI, 0.96 to 1.15; P = 0.283) compared to level of evidence C.

CONCLUSIONS

Half of the recommendations in anesthesiology clinical practice guidelines are based on a low level of evidence, and this did not change over time. These findings highlight the need for additional efforts to increase the quality of evidence used to guide decision-making in anesthesiology.

EDITOR’S PERSPECTIVE

Safety and Outcomes of Laparoscopic Sleeve Gastrectomy in a General Surgery Residency Program

Background:

With the escalation of surgical treatment of morbid obesity, there is a growing interest in the training of bariatric surgeons. Laparoscopic sleeve gastrectomy (LSG) gained popularity both as a first-stage approach and as a stand-alone procedure.

Objectives:

The aim of this study was to assess detectable differences in LSG with intra-operative resident involvement.

Methods:

We reviewed obese patients, who had undergone LSG between January 1, 2017 and January 31, 2020. Collected data reported demographic factors, operative time, postoperative complications, and outcomes.

Results:

Among 313 patients who met the inclusion criteria, 94 were men and 219 were women. The procedures were performed either by an expert bariatric surgeon (group 1), or a general surgery resident (group 2), respectively in 228 and 85 cases. Mean operative time of the first group was 65.3 ± 18.8 minutes, while it was 74.3 ± 17.2 among trainees (p < 0.001). Perioperative complications were diagnosed in 13 patients (10 in group 1 and 3 in group 2). Mean excess body weight loss after 12 months was 87.7 ± 28.2% in the first group and 81.1 ± 31.6% in the residents group. Between the two groups, we found no differences in the incidence of perioperative complications and in surgical outcomes. Trainee involvement was associated with increased operative time, with no correlation with a worse postoperative course.

Conclusions:

Residents can safely perform LSG in referral centers under the supervision of an expert bariatric surgeon. Trainee involvement is not related to increased leak rate, nor to suboptimal short-term outcome.

Intraoperative Monitoring of the Obese Patient Undergoing Surgery: A Narrative Review

With the increasing prevalence of obesity in the population, anaesthetists must confidently manage both the pathophysiological and technical challenges presented in bariatric and non-bariatric surgery. The intraoperative period represents an important opportunity to optimise and mitigate risk. However, there is little formal guidance on what intraoperative monitoring techniques should be used in this population. This narrative review collates the existing evidence for intraoperative monitoring devices in the obese patients. Although a number of non-invasive blood pressure monitors have been tested, an invasive arterial line remains the most reliable monitor if accurate, continuous monitoring is required. Goal-directed fluid therapy is recommended by clinical practice guidelines, but the methods tested to assess this had guarded applicability to the obese population. Transcutaneous carbon dioxide (CO₂) monitoring may offer additional benefit to standard capnography in this population. Individually titrated positive end expiratory pressure (PEEP) and recruitment manoeuvres improved intraoperative mechanics but yielded no benefit in the immediate postoperative period. Depth of anaesthesia monitoring appears to be beneficial in the perioperative period regarding recovery times and complications. Objective confirmation of reversal of neuromuscular blockade continues to be a central tenet of anaesthesia practice, particularly relevant to this group who have been characterised as an "at risk" extubation group. Where deep neuromuscular blockade is used, continuous neuromuscular blockade is suggested. Both obesity and the intraoperative context represent somewhat unstable search terms, as the clinical implications of the obesity phenotype are not uniform, and the type and urgency of surgery have significant impact on the intraoperative setting. This renders the generation of summary conclusions around what intraoperative monitoring techniques are suitable in this population highly challenging.

ESPEN practical guideline: Clinical nutrition in surgery

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.

Enhanced Recovery After Cardiac Surgery: Where Do We Stand?

Purpose of Review

Enhanced recovery after surgery (ERAS) protocols are multimodal and multi-professional strategies to enhance postoperative convalescence and thereby reduce the length of hospital stay and hospital-associated complications. This review provides an up-to-date overview about basic principles of enhanced recovery after surgery protocols, their transfer into cardiac surgery, and their current state of evidence. It is supposed to offer clinical implications for further adaptations and implementations of such protocols in cardiac surgery.

Recent Findings

ERAS protocols are a story of success in numerous surgical disciplines and led to a paradigm shift in perioperative care and the establishment of ERAS Cardiac Society, a non-profit organization that provides evidence-based guidelines and recommendations for further development of enhanced recovery protocols, trying to harmonize the many existing efforts of individual approaches for cardiac surgery.

Summary

Promising results from comprehensive ERAS protocols in cardiac surgery emerged. Nevertheless, there is a paucity of high-quality data about holistic approaches in cardiac surgery and further efforts need to be promoted.

Practices concerning sleeve gastrectomy in Turkey: A survey of surgeons

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric surgical procedure. LSG is a restrictive procedure and in this operation stomach volume is greatly reduced. When the details of the procedure are examined, it is seen that there are many different methods surgery.

AIM

To analyze approaches of surgeons performing LSG.

METHODS

A questionnaire consist of 44 questions was sent by e-mail to the surgeons performing bariatric surgery. Approaches of surgery about preoperative period, surgical techniques and postoperative period was questioned.

RESULTS

Different approaches about antibiotic prophylaxis, stapler line reinforcement utilization, application of intraoperative and postoperative leakage test, approach to the crus and hiatal hernia repair were detected. It was observed that a few partipicipants applied contrary to the guidelines of antibiotic prophlaxis and thromboembolism prophylaxis. Approaches about other subjects were generally similar.

CONCLUSION

In this study, approaches about LSG that most common bariatric surgical procedure in our country was learned. According to these results, knowing the approaches in our country will be beneficial in terms of determining the training programs in bariatric surgery, improving surgical results and reducing the complications.

Outcomes of Enhanced Recovery After Surgery Protocols Versus Conventional Management in Patients Undergoing Bariatric Surgery

Background: Enhanced recovery after surgery (ERAS) pathways focus on decreasing surgical stress and promoting return to normal function for patients undergoing surgical procedures. The aim of our study was to evaluate the impact of an ERAS protocol on outcomes of patients undergoing primary sleeve gastrectomy and Roux-en-Y gastric bypass. Outcomes included hospital length of stay (LOS), and management of postoperative pain and postoperative nausea and vomiting (PONV) measured by pain medications and antiemetic use, respectively. Incidence of 90-day emergency department (ED) visits, readmissions, and complications were also analyzed. Methods: A retrospective review was performed from October 1, 2016 to October 31, 2018 of patients enrolled in the ERAS versus the conventional pathway. Patient baseline characteristics, pain and nausea scores, LOS, and postoperative outcome variables were collected. Results: Non-ERAS (n = 193) and ERAS (n = 173) groups had similar patient characteristics. Fewer ERAS patients required postoperative opioids and antiemetics (P < .01), with a significant difference in postoperative nausea control in favor of ERAS patients (P < .05). There was a decreasing trend in median LOS (2 versus 1, P = .28), 90-day postoperative readmissions (10.4% versus 8.1%, P = .47), and major adverse events (5.2% versus 1.7%, P = .07) after ERAS implementation. The ED visits and postoperative need for intravenous fluid for dehydration were significantly lower in the ERAS group (P = .01). Conclusion: Implementation of ERAS pathway for bariatric surgery was associated with less opioid usage, PONV, ED visits, and postoperative need for intravenous fluids, without increasing LOS, 90-day readmission or rates of adverse effects.

Opioid-free anesthesia with a mixture of dexmedetomidine, ketamine, and lidocaine in one syringe for surgery in obese patients

Recently, there has been a trend toward minimizing opioid use in obese patients to prevent opioid-related postoperative complications. Moreover, the use of opioid-free anesthesia has received growing interest. This case series reports the use of simple opioid-free anesthesia consisting of a mixture of dexmedetomidine, ketamine, and lidocaine in an obese male patient undergoing laparoscopic bariatric surgery and an obese pregnant woman undergoing cesarean section. These cases indicate that opioid-free anesthesia can be safely administered to obese patients and provides effective pain control without any postoperative adverse outcomes.

Infection prevention plan to decrease surgical site infections in bariatric surgery patients

BACKGROUND

Surgical site infections (SSI) are one of the most common complications of bariatric surgery. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement (QI) Program (MBSAQIP) allows accredited programs to develop processes for quality improvement based on data collection. The objective of this study was to decrease SSI rates in patients undergoing bariatric surgery at an accredited MBSAQIP center.

METHODS

Using the MBSAQIP semiannual report, SSI rates were retrospectively reviewed. Baseline SSI rates were collected from 01/01/2014-12/31/2015. On 01/01/2016, the first infection prevention protocol (IPP-1) was created that included 4% chlorhexidine gluconate (CHG) showers, CHG wipes immediately prior to surgery, and routine cultures of SSIs. An updated IPP (IPP-2) was implemented on 09/01/2016, which discontinued routine surgical drain placement and broadened antibiotic coverage for penicillin allergic patients.

RESULTS

During baseline data collection, SSI rates were 5.1%. After the implementation of IPP-1, SSI rates trended down to 2.5%. After implementation of IPP-2, SSI rates decreased significantly to 1.5%, a 66% relative risk reduction in SSIs from baseline. On multivariate regression analysis, the perioperative factors associated with an increased risk for SSIs included diabetes mellitus, intraoperative surgical drain placement, the number of hypertension medications prior to bariatric surgery, and an open approach.

CONCLUSIONS

Our study demonstrates that the implementation of a specific protocol for reducing SSIs is safe and feasible in patients undergoing bariatric surgery. We also identified that the success of the IPP is likely centered on the elimination of routine drain placement during primary bariatric procedures.