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Vetrugno L, Deana C, Colaianni-Alfonso N, Tritapepe F, Fierro C, Maggiore SM. Noninvasive respiratory support in the perioperative setting: a narrative review. Front Med (Lausanne) 2024; 11:1364475. [PMID: 38695030 PMCID: PMC11061466 DOI: 10.3389/fmed.2024.1364475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 04/08/2024] [Indexed: 05/04/2024] Open
Abstract
The application of preoperative noninvasive respiratory support (NRS) has been expanding with increasing recognition of its potential role in this setting as a physiological optimization for patients with a high risk of developing atelectasis and postoperative pulmonary complications (PPC). The increased availability of high-performance anesthesia ventilator machines providing an easy way for NRS support in patients with reduced lung function should not be under-evaluated. This support can reduce hypoxia, restore lung volumes and theoretically reduce atelectasis formation after general anesthesia. Therapeutic purposes should also be considered in the perioperative setting, such as preoperative NRS to optimize treatment of patients' pre-existing diseases, e.g., sleep-disordered breathing. Finally, the recent guidelines for airway management suggest preoperative NRS application before anesthesia induction in difficult airway management to prolong the time needed to secure the airway with an orotracheal tube. This narrative review aims to revise all these aspects and to provide some practical notes to maximize the efficacy of perioperative noninvasive respiratory support.
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Affiliation(s)
- Luigi Vetrugno
- Department of Medical, Oral and Biotecnological Science, “G. D’Annunzio” Chieti-Pescara University, Chieti, Italy
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
| | - Cristian Deana
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | | | - Fabrizio Tritapepe
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
| | - Carmen Fierro
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
| | - Salvatore Maurizio Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
- Department of Innovative Technologies in Medicine & Dentistry, Section of Anesthesia and Intensive Care, SS. Annunziata Hospital, G. D’Annunzio University, Chieti, Italy
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Ponce de Leon-Ballesteros G, Pouwels S, Romero-Velez G, Aminian A, Angrisani L, Bhandari M, Brown W, Copaescu C, De Luca M, Fobi M, Ghanem OM, Hasenberg T, Herrera MF, Herrera-Kok JH, Himpens J, Kow L, Kroh M, Kurian M, Musella M, Narwaria M, Noel P, Pantoja JP, Ponce J, Prager G, Ramos A, Ribeiro R, Ruiz-Ucar E, Salminen P, Shikora S, Small P, Stier C, Taha S, Taskin EH, Torres A, Vaz C, Vilallonga R, Verboonen S, Zerrweck C, Zundel N, Parmar C. Metabolic and Bariatric Surgery in Patients with Obesity Class V (BMI > 60 kg/m 2): a Modified Delphi Study. Obes Surg 2024; 34:790-813. [PMID: 38238640 DOI: 10.1007/s11695-023-06990-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/28/2023] [Accepted: 12/06/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Metabolic and bariatric surgery (MBS) is the preferred method to achieve significant weight loss in patients with Obesity Class V (BMI > 60 kg/m2). However, there is no consensus regarding the best procedure(s) for this population. Additionally, these patients will likely have a higher risk of complications and mortality. The aim of this study was to achieve a consensus among a global panel of expert bariatric surgeons using a modified Delphi methodology. METHODS A total of 36 recognized opinion-makers and highly experienced metabolic and bariatric surgeons participated in the present Delphi consensus. 81 statements on preoperative management, selection of the procedure, perioperative management, weight loss parameters, follow-up, and metabolic outcomes were voted on in two rounds. A consensus was considered reached when an agreement of ≥ 70% of experts' votes was achieved. RESULTS A total of 54 out of 81 statements reached consensus. Remarkably, more than 90% of the experts agreed that patients should be notified of the greater risk of complications, the possibility of modifications to the surgical procedure, and the early start of chemical thromboprophylaxis. Regarding the choice of the procedure, SADI-S, RYGB, and OAGB were the top 3 preferred operations. However, no consensus was reached on the limb length in these operations. CONCLUSION This study represents the first attempt to reach consensus on the choice of procedures as well as perioperative management in patients with obesity class V. Although overall consensus was reached in different areas, more research is needed to better serve this high-risk population.
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Affiliation(s)
- Guillermo Ponce de Leon-Ballesteros
- Department of Surgery, Hospital Angeles Morelia, Morelia, Postal: 331, Int. B-502, Av. Montaña Monarca, Montaña Monarca, 58350, Morelia, Michoacan, Mexico.
| | - Sjaak Pouwels
- Department of General, Abdominal Surgery and Coloproctology, Helios St. Elisabeth Hospital, Oberhausen, NRW, Germany
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
- Faculty of Health, Witten/Herdecke University, Witten, Germany
| | | | - Ali Aminian
- Department of General Surgery, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Luigi Angrisani
- Department of Public Health, Federico II" University of Naples, Naples, Italy
| | | | - Wendy Brown
- Department of Surgery, Monash University, Melbourne, Australia
| | - Catalin Copaescu
- Department of Surgery, Ponderas Academic Hospital, Bucharest, Romania
| | | | | | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Till Hasenberg
- Helios Obesity Center West, Helios University Hospital Wuppertal, Wuppertal, Germany
| | - Miguel F Herrera
- Clinic for Nutrition and Obesity, The American British Cowdray Medical Center Observatorio, Mexico City, Mexico
- Department of Surgery, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Johnn H Herrera-Kok
- Department of General and Digestive Surgery, University Hospital of Leon, Leon, Spain
| | - Jacques Himpens
- Bariatric Surgery Unit, Delta CHIREC Hospital, Brussels, Belgium
| | - Lilian Kow
- Flinders Medical Centre, Adelaide, Australia
| | - Matthew Kroh
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | | | - Mario Musella
- Advanced Biomedical Sciences Department, "Federico II" University of Naples, Naples, Italy
| | | | - Patrick Noel
- Clinique Bouchard, ELSAN, Marseille, France
- Emirates Specialty Hospital, DHCC, Dubai, UAE
| | - Juan P Pantoja
- Department of Surgery, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Jaime Ponce
- CHI Memorial Hospital Chattanooga, Chattanooga, TN, USA
| | - Gerhard Prager
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Rui Ribeiro
- Department of General Surgery, Hospital Lusiadas Amadora, Amadora, Portugal
| | - Elena Ruiz-Ucar
- Department of Bariatric and Endocrine Surgery, Fuenlabrada University Hospital, Madrid, Spain
| | - Paulina Salminen
- Department of Surgery, University of Turku, Turku, Finland
- Division of Digestive Surgery and Urology, Turku University Hospital, Turku, Finland
| | - Scott Shikora
- Department of Surgery, Division of Gastrointestinal and General Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Peter Small
- Directorate of General Surgery, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Christine Stier
- Department of Interdisciplinary Endoscopy and Visceral Surgery, University Hospital Mannheim, Mannheim, Germany
| | - Safwan Taha
- Bariatric and Metabolic Surgery Center, Mediclinic Hospital Airport Road, Abu Dhabi, UAE
| | - Eren Halit Taskin
- Department of Surgery, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Antonio Torres
- General and Digestive Surgery Service, Department of Surgery, Hospital Clínico San Carlos, Complutense University Medical School, Universidad Complutense de Madrid (UCM); IdISSC, Madrid, Spain
| | - Carlos Vaz
- Obesity and Metabolic Surgery Unit, Hospital CUF Tejo, Lisbon, Portugal
| | - Ramon Vilallonga
- Department of Surgery, Enodcrine-Metabolic and Bariatric Surgery Unit, Vall Hebron Barcelona Hospital Campus, Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | - Carlos Zerrweck
- The American British Cowdray Medical Center Santa Fe, Mexico City, Mexico
| | - Natan Zundel
- Department of Surgery, University of Buffalo, Buffalo, NY, USA
| | - Chetan Parmar
- Department of Surgery, The Whittington Hospital NHS Trust, London, UK
- Apollo Hospitals Educational and Research Foundation, Hyderabad, India
- University College London, London, UK
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Bae J, Lee KT, Alohaideb N, Mun GH. Efficacy of the enhanced recovery after surgery protocol on reducing surgical disparities related to overweight/obesity in deep inferior epigastric perforator flap breast reconstruction. Microsurgery 2024; 44:e31159. [PMID: 38414011 DOI: 10.1002/micr.31159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 01/03/2024] [Accepted: 02/09/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND When choosing a method of deep inferior epigastric perforator (DIEP) flap for breast reconstruction, concerns regarding the potentially detrimental effects of obesity on postoperative recovery remain. Enhanced recovery after surgery (ERAS) is known to facilitate rapid postoperative recovery. This study aimed to examine the effect of the ERAS protocol on the disparity between normal/underweight and overweight/obese patients after DIEP flap breast reconstruction. METHODS A retrospective review of consecutive patients who underwent DIEP flap breast reconstruction between January 2015 and November 2022 was conducted. The patients were categorized into two groups: pre-ERAS and post-ERAS. In each group, associations between overweight/obese patients (BMI ≥25 kg/m2 ) and postoperative course were evaluated. RESULTS In total, 217 patients in the pre-ERAS group (including 71 overweight/obese) and 165 in the post-ERAS group (including 58 overweight/obese) were analyzed. The post-ERAS group had shorter length of stay (LOS) (8.0 versus 7.0 days, p-value <.001) and lower postoperative pain scores (5.0 versus 3.0 at postoperative day (POD) 1, p-value <.001) than the pre-ERAS group. The complication profiles did not differ according to ERAS adoption. In the pre-ERAS group, overweight/obese patients showed a significantly longer LOS (8.0 versus 9.0 days, p-value = .017) and a higher postoperative pain score (3.0 versus 4.0 at POD 2, p-value = .018) than normal/underweight patients; however, these differences disappeared in the post-ERAS group, showing similar LOS, pain scores, and analgesic consumption. CONCLUSIONS Implementation of the ERAS protocol in DIEP free-flap breast reconstruction may reduce overweight/obesity-related disparities in postoperative recovery.
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Affiliation(s)
- Juyoung Bae
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kyeong-Tae Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Nawaf Alohaideb
- Plastic Surgery Division, Department of Surgery, Ministry of National Guard - Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Goo-Hyun Mun
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Wysocki M, Mizera M, Karpińska I, Ptaszkiewicz K, Małczak P, Pisarska-Adamczyk M, Kania M, Major P. Analysis of Changes in Glucose and Lipid Metabolism in Patients with Clinically Severe Obesity and Type 2 Diabetes Mellitus Undergoing Laparoscopic Sleeve Gastrectomy-Prospective Observational Study. Obes Surg 2024; 34:467-478. [PMID: 38105282 PMCID: PMC10811010 DOI: 10.1007/s11695-023-06991-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/07/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION We still lack studies providing analysis of changes in glucose and lipid metabolism after laparoscopic sleeve gastrectomy (LSG) in patients with type 2 diabetes mellitus (DM2). We aimed to investigate postoperative changes in glucose and lipid metabolism after LSG in patients with DM2. MATERIAL AND METHODS Prospective, observational study included patients with BMI ≥ 35 kg/m2 and ≤ 50 kg/m2, DM2 < 10 years of duration, who were qualified for LSG. Perioperative 14-day continuous glucose monitoring (CGM) began after preoperative clinical assessment and OGTT, then reassessment 1 and 12 months after LSG. Thirty-three patients in mean age of 45 ± 10 years were included in study (23 females). RESULTS EBMIL before LSG was 17 ± 11.7%, after 1 month-36.3 ± 12.8%, while after 12 months-66.1 ± 21.7%. Fifty-two percent of the patients had DM2 remission after 12 months. None required then insulin therapy. 16/33 patients initially on oral antidiabetics still required them after 12 months. Significant decrease in HbA1C was observed: 5.96 ± 0.73%; 5.71 ± 0.80; 5.54 ± 0.52%. Same with HOMA-IR: 5.34 ± 2.84; 4.62 ± 3.78; 3.20 ± 1.99. In OGTT, lower increase in blood glucose with lesser insulin concentrations needed to recover glucose homeostasis was observed during follow-ups. Overtime perioperative average glucose concentration in CGM of 5.03 ± 1.09 mmol/L significantly differed after 12 months, 4.60 ± 0.53 (p = 0.042). Significantly higher percentage of glucose concentrations above targeted compartment (3.9-6.7 mmol/L) was observed in perioperative period (7% ± 4%), than in follow-up (4 ± 6% and 2 ± 1%). HDL significantly rose, while triglyceride levels significantly decreased. CONCLUSIONS Significant improvement in glucose and lipid metabolism was observed 12 months after LSG and changes began 1 month after procedure.
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Affiliation(s)
- Michał Wysocki
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital in Cracow, Os. Zlotej Jesieni 1, 31-826, Cracow, Poland.
| | - Magdalena Mizera
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Izabela Karpińska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Kuba Ptaszkiewicz
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Piotr Małczak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | | | - Michał Kania
- Department of Metabolic Diseases and Diabetology, Jagiellonian University Medical College, Cracow, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
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El Masry MAMA, Attia MS. A comparative study between staple line reinforcement during laparoscopic sleeve gastrectomy and no reinforcement: an Egyptian experience. Surg Endosc 2023; 37:9318-9325. [PMID: 37891370 PMCID: PMC10709468 DOI: 10.1007/s00464-023-10497-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/23/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) has become an increasingly popular bariatric procedure. LSG still conveys some risks, including early staple line complications such as bleeding and leaks. It has been proposed that staple line complications can be reduced by staple line reinforcement (SLR). This study aimed to compare the short-term efficacy and safety of the SLR during LSG by oversewing versus no SLR in an Egyptian cohort over a period of 11 years. PATIENTS AND METHODS This is a retrospective study that analyzed data from patients undergoing LSG by the same surgeon over a period of 11 years. The patients' early postoperative complications were compared according to performing SLR. RESULTS The SLR group showed significantly longer surgery time (p = 0.021) and a lower rate of postoperative bleeding (p = 0.027). All leakage cases occurred in the non-SLR group (0.7% vs. 0.0%) without statistical significance (p = 0.212). The two mortality cases occurred in the non-SLR group. The LOS was comparable in the two groups (p = 0.289). CONCLUSION This study confirms the short-term benefits of SLR by oversewing during LSG in terms of a lower incidence of 30-day morbidity, particularly bleeding, and lower rates of reoperation, with a clinically questionable longer operation time.
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El Masry MAMA, Rahman IA. Perioperative Morbidity and Mortality of Laparoscopic Sleeve Gastrectomy (LSG) in a Single-Surgeon Experience on 892 Patients Over 11 Years. World J Surg 2023; 47:2809-2815. [PMID: 37548678 PMCID: PMC10545609 DOI: 10.1007/s00268-023-07123-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) has been the most frequently performed bariatric procedure since 2014, with continually growing popularity. This study aimed to present our 30-day morbidity and mortality following LSG over a period of 11 years. PATIENTS AND METHODS This is a retrospective study that was based on prospectively collected data from patients undergoing LSG by the same surgeon from July 2011 to the end of August 2022. The LSG-associated 30-day morbidity and mortality and the risk factors for 30-day morbidity were assessed. RESULTS This study included 892 patients who underwent LSG over the course of 11 years. Early postoperative adverse events were encountered in 16 patients (1.79%). Overall, twelve patients (1.35%) required blood transfusions, and two patients (0.22%) required ICU admission. The re-operation rate was 0.9% (n = 8) and the mortality rate was 0.22% (n = 2). The patient's BMI, hypertension, and revisional surgery were marginally significant/significant predictors of early postoperative morbidity. The mean EBWL% was 63.8 ± 15.55 at the 6-month follow-up. CONCLUSION This study confirms the previously reported LSG's short-term safety in terms of a low rate of 30-day postoperative morbidity and mortality. Preoperative BMI, hypertension, and revisional surgery are risk factors for 30-day morbidity and mortality.
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Affiliation(s)
| | - Islam Abdul Rahman
- General Surgery, Military Production Specialized Medical Centre, Cairo, Egypt
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Wysocki M, Ciszek K, Rymarowicz J, Zarzycki P, Walędziak M, Bartosiak K, Jaworski P, Kupczyk W, Szeliga J, Tarnowski W, Pisarska-Adamczyk M, Małczak P, Pędziwiatr M, Major P. The analysis of factors increasing the odds for type 2 diabetes mellitus remission following re-do bariatric surgery after laparoscopic sleeve gastrectomy- cohort study. Langenbecks Arch Surg 2023; 408:371. [PMID: 37736842 PMCID: PMC10516768 DOI: 10.1007/s00423-023-03102-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 09/09/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION Metabolic/bariatric surgery is the only proven treatment for type 2 diabetes mellitus (T2D) with curative intent. However, in a number of patients, the surgery is not effective or they may experience a relapse. Those patients can be offered re-do bariatric surgery (RBS). PURPOSE The study aimed to determine factors increasing the odds for T2D remission one year after RBS following primary laparoscopic sleeve gastrectomy. METHODS A multicenter retrospective cohort study was conducted between January 2010 and January 2020, which included 12 bariatric centers in Poland. The study population was divided into groups: Group 1- patients with T2D remission after RBS (n = 28) and Group 2- patients without T2D remission after RBS (n = 49). T2D remission was defined as HBA1c < 6.0% without glucose-lowering pharmacotherapy and glycemia within normal range at time of follow-up that was completed 12 months after RBS. RESULTS Fifty seven females and 20 males were included in the study. Patients who achieved BMI < 33 kg/m2 after RBS and those with %EBMIL > 60.7% had an increased chance of T2D remission (OR = 3.39, 95%CI = 1.28-8.95, p = 0.014 and OR = 12.48, 95%CI 2.67-58.42, p = 0.001, respectively). Time interval between primary LSG and RBS was significantly shorter in Group 1 than in Group 2 [1 (1-4) vs. 3 (2-4) years, p = 0.023]. CONCLUSIONS Shorter time interval between LSG and RBS may ease remission of T2D in case of lack of remission after primary procedure. Significant excess weight loss seems to be the most crucial factor for T2D remission.
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Affiliation(s)
- Michał Wysocki
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital, Cracow, Poland
| | - Karol Ciszek
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland.
| | - Justyna Rymarowicz
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland
| | - Piotr Zarzycki
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland
| | - Maciej Walędziak
- Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Katarzyna Bartosiak
- Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Paweł Jaworski
- Centre of Postgraduate Medical Education, Orlowski Hospital, Warsaw, Poland
| | - Wojciech Kupczyk
- Department of General, Gastroenterological, and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, Torun, Poland
| | - Jacek Szeliga
- Department of General, Gastroenterological, and Oncological Surgery, Collegium Medicum Nicolaus Copernicus University, Torun, Poland
| | - Wiesław Tarnowski
- Centre of Postgraduate Medical Education, Orlowski Hospital, Warsaw, Poland
| | - Magdalena Pisarska-Adamczyk
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland
| | - Piotr Małczak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2 Street, 30-688, Kraków, Poland
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Tan HS, Habib AS. Peri-operative anaesthetic management of women with obesity. Best Pract Res Clin Obstet Gynaecol 2023; 89:102335. [PMID: 37290264 DOI: 10.1016/j.bpobgyn.2023.102335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/27/2023] [Accepted: 03/31/2023] [Indexed: 06/10/2023]
Abstract
Obesity in women is prevalent and growing at an alarming pace worldwide, resulting in significant healthcare and socioeconomic consequences. Obesity is a multisystemic disease that is associated with numerous comorbidities, particularly sleep-disordered breathing, hypertension, coronary artery disease, pulmonary hypertension, thromboembolism, and diabetes mellitus. Additionally, obesity poses several peri-operative challenges including difficulty with airway management and mechanical ventilation, challenges with intravenous access or regional blocks, the need for modified anaesthetic drug dosing, the requirement for correctly sized and rated equipment, and appropriate post-operative monitoring. Therefore, early multidisciplinary planning is crucial to identify and address important peri-operative and clinical issues. Parturients with obesity are especially at high risk due to the additional physiological changes and obstetric comorbidities associated with obesity. Antenatal anaesthetic consultation along with close communication and collaboration within the multidisciplinary team are important to improve maternal and neonatal safety.
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Affiliation(s)
- Hon Sen Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore
| | - Ashraf S Habib
- Department of Anesthesiology, Duke University Medical Center, Box 3094, Durham, NC, 27710, USA. https://twitter.com/ashrafhabib5
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van den Bosch OFC, Fiset ME, Downey K, Maxwell C, Carvalho JCA. Anesthetic management of patients with class 3 obesity undergoing elective Cesarean delivery: a single-centre historical cohort study. Can J Anaesth 2023; 70:202-210. [PMID: 36447090 PMCID: PMC9957904 DOI: 10.1007/s12630-022-02365-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/20/2022] [Accepted: 08/22/2022] [Indexed: 12/02/2022] Open
Abstract
PURPOSE The preferred neuraxial anesthetic technique for patients with class 3 obesity undergoing elective Cesarean delivery is still under debate. We aimed to describe the anesthetic technique used in our tertiary institution across body mass index (BMI) groups and different surgical incisions. METHOD In this historical cohort study, we reviewed medical records of patients with a BMI ≥ 40 kg·m-2 undergoing elective Cesarean delivery between July 2014 and December 2020. We collected data on patient characteristics, anesthetic and surgical technique, and procedural times. For data analysis, we stratified patients by BMI into three different groups: 40.0-49.9 kg·m-2, 50.0-59.9 kg·m-2, and ≥ 60.0 kg·m-2. RESULTS We included 396 deliveries, distributed as follows: 258 with a BMI 40.0-49.9 kg·m-2, 112 with a BMI 50.0-59.9 kg·m-2, and 26 with a BMI ≥ 60.0 kg·m-2. For patients with a BMI 40.0-49.9 kg·m-2, the anesthetic technique of first choice was predominantly spinal anesthesia (71%), whereas for those with a BMI ≥ 60.0 kg·m-2, spinal anesthesia was never used as the anesthetic of first choice. With regard to the surgical incision, spinal anesthesia was almost exclusively used for patients undergoing Pfannenstiel incision and was rarely used for a higher supra- or infraumbilical transverse or midline incision. The overall incidence of general anesthesia was low (7/396, 1.8%). Anesthetic time, surgical time, and operating room time increased almost twofold in patients with a BMI ≥ 60.0 kg·m-2 compared with those with a BMI of 40.0-49.9 kg·m-2. CONCLUSION Neuraxial anesthesia was successfully used in approximately 98% of patients with class 3 obesity undergoing elective Cesarean delivery. The choice of regional anesthesia technique varied with increasing BMI and with the planned surgical incision. Procedural times increased with increasing BMI. This information should prove useful for comparing anesthetic choices and outcomes in this challenging population.
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Affiliation(s)
- Oscar F C van den Bosch
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, 600 University Ave, Room 7-400, Toronto, ON, M5G 1X5, Canada.
| | - Marie-Eve Fiset
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, 600 University Ave, Room 7-400, Toronto, ON, M5G 1X5, Canada
| | - Kristi Downey
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, 600 University Ave, Room 7-400, Toronto, ON, M5G 1X5, Canada
| | - Cynthia Maxwell
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Jose C A Carvalho
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, 600 University Ave, Room 7-400, Toronto, ON, M5G 1X5, Canada
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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Wysocki M, Łabul M, Małczak P, Proczko-Stepaniak M, Szymański M, Hady HR, Głuszyńska P, Myśliwiec P, Walędziak M, Zarzycki P, Rymarowicz J, Pędziwiatr M, Pisarska-Adamczyk M, Major P, Pędziwiatr M, Rymarowicz J, Zarzycki P, Stefura T, Ciszek K, Myśliwiec P, Hady HR, Głuszyńska P, Proczko-Stepaniak M, Szymański M, Walędziak M, Janik M, Kwiatkowski A, Materlak M, Bartosiak K, Czyżykowski Ł, Mawlichanów M, Kowalewski P, Szeliga J, Kupczyk W, Dowgiałło-Gornowicz N, Lech P, Harań A, Kowalski G, Łabul M, Mulek R, Kreft M, Wysocki M, Orłowski M, Franczak P, Binda A, Tarnowski W, Jaworski P, Bartosiak K, Kamiński M, Pastuszka M, Lisik W, Szymański P, Katkowski B, Leśniak M. Analysis of the risk factors for perioperative morbidity after laparoscopic revisional bariatric procedures: results from the multicenter Polish Revision Obesity Surgery Study. Surg Obes Relat Dis 2023; 19:68-75. [PMID: 36182567 DOI: 10.1016/j.soard.2022.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/12/2022] [Accepted: 08/21/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND The growing number of primary bariatric operations has led to an increase in demand for revision surgeries. Higher numbers of revisional operations are also observed in Poland, yet their safety and efficacy remain controversial because of a lack of current recommendations and guidelines. OBJECTIVE To review risk factors influencing perioperative morbidity. METHODS A retrospective study was conducted to analyze the results of surgical treatment among 12 Polish bariatric centers. Inclusion criteria were laparoscopic revisional bariatric surgeries and patients ≥18 years of age. The study included 795 patients, of whom 621 were female; the mean age was 47 years (range: 40-55 years). RESULTS Perioperative morbidity occurred in 92 patients (11.6%) enrolled in the study, including 76 women (82.6%). The median age was 45 years (range: 39-54 years). Statistically significant risk factors in univariate logistic regression models for perioperative complications were the duration of obesity, revisional surgery after Roux-en-Y gastric bypass (RYGB) or adjustable gastric band (AGB), difference in body mass index before revisional surgery and the lowest achieved after primary surgery, and postoperative morbidity of the primary surgery as the cause for revisional bariatric surgery. These factors were included in the multivariate regression model. Revisional surgery after AGB (odds ratio [OR] = 2.18; 95% confidence interval [CI]: 1.28-3.69; P = .004), revisional surgery performed after RYGB (OR = 6.52; 95% CI: 1.98-21.49; P = .002), and revisions due to complication of the primary surgery (OR = 1.89; 95% CI: 1.06-3.34; P = .030) remained independent risk factors for perioperative morbidity. CONCLUSION Revisional operations after RYGB or AGB and those performed because of postoperative morbidity after primary surgery as the main cause for revisional surgery were associated with a significantly increased risk of postoperative morbidity.
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Affiliation(s)
- Michał Wysocki
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital, Cracow, Poland
| | - Michał Łabul
- Department of General Surgery, Specialist Hospital, Legnica, Poland
| | - Piotr Małczak
- Second Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland.
| | - Monika Proczko-Stepaniak
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Gdansk, Poland
| | - Michał Szymański
- Department of General, Endocrine and Transplant Surgery, Medical University of Gdansk, Gdansk, Poland
| | - Hady Razak Hady
- First Department of General and Endocrinological Surgery, Medical University of Bialystok, Bialystok, Poland
| | - Paulina Głuszyńska
- First Department of General and Endocrinological Surgery, Medical University of Bialystok, Bialystok, Poland
| | - Piotr Myśliwiec
- First Department of General and Endocrinological Surgery, Medical University of Bialystok, Bialystok, Poland
| | - Maciej Walędziak
- Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Piotr Zarzycki
- Second Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Justyna Rymarowicz
- Second Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Michał Pędziwiatr
- Second Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | | | - Piotr Major
- Second Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
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11
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How Much Narcotics Are Really Needed After Bariatric Surgery: Results of a Prospective Study. Surg Obes Relat Dis 2022; 19:541-546. [DOI: 10.1016/j.soard.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 10/01/2022] [Accepted: 11/13/2022] [Indexed: 11/21/2022]
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12
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Marinari G, Foletto M, Nagliati C, Navarra G, Borrelli V, Bruni V, Fantola G, Moroni R, Tritapepe L, Monzani R, Sanna D, Carron M, Cataldo R. Enhanced recovery after bariatric surgery: an Italian consensus statement. Surg Endosc 2022; 36:7171-7186. [PMID: 35953683 PMCID: PMC9485178 DOI: 10.1007/s00464-022-09498-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 12/31/2021] [Indexed: 12/03/2022]
Abstract
Background Enhanced recovery after bariatric surgery (ERABS) is an approach developed to improve outcomes in obese surgical patients. Unfortunately, it is not evenly implemented in Italy. The Italian Society for the Surgery of Obesity and Metabolic Diseases and the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care joined in drafting an official statement on ERABS. Methods To assess the effectiveness and safety of ERABS and to develop evidence-based recommendations with regard to pre-, intra-, and post-operative care for obese patients undergoing ERABS, a 13-member expert task force of surgeons and anesthesiologists from Italian certified IFSO center of excellence in bariatric surgery was established and a review of English-language papers conducted. Oxford 2011 Levels of Evidence and U.S. Preventive Services Task Force Grade Definitions were used to grade the level of evidence and the strength of recommendations, respectively. The supporting evidence and recommendations were reviewed and discussed by the entire group at meetings to achieve a final consensus. Results Compared to the conventional approach, ERABS reduces the length of hospital stay and does not heighten the risk of major post-operative complications, re-operations, and hospital re-admissions, nor does it increase the overall surgical costs. A total of 25 recommendations were proposed, covering pre-operative evaluation and care (7 items), intra-operative management (1 item, 11 sub-items), and post-operative care and discharge (6 items). Conclusions ERABS is an effective and safe approach. The recommendations allow the proper management of obese patients undergoing ERABS for a better outcome.
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Affiliation(s)
- Giuseppe Marinari
- Bariatric Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Mirto Foletto
- Bariatric Surgery Unit, Azienda Ospedale Università Padova, Padua, Italy
| | - Carlo Nagliati
- Department of Surgery, San Giovanni di Dio Hospital, Gorizia, Italy
| | - Giuseppe Navarra
- Department of Human Pathology, University of Messina, Messina, Italy
| | | | - Vincenzo Bruni
- Bariatric Surgery Unit, Campus Bio Medico University of Rome, Rome, Italy
| | - Giovanni Fantola
- Bariatric Surgery Unit, ARNAS, G. Brotzu Hospital, Cagliari, Italy
| | - Roberto Moroni
- Bariatric Surgery Unit, Policlinico Sassarese, Sassari, Italy
| | - Luigi Tritapepe
- Department of Anesthesia and Intensive Care, San Camillo-Forlanini Hospital, Sapienza University of Rome, Rome, Italy
| | - Roberta Monzani
- Department of Anesthesia and Intensive Care Units, Humanitas Research Hospital, Humanitas University Milan, Rozzano, Milan, Italy
| | - Daniela Sanna
- Emergency Department, Section of Anesthesiology and Intensive Care, ARNAS, G. Brotzu Hospital, Cagliari, Italy
| | - Michele Carron
- Department of Medicine-DIMED, Section of Anesthesiology and Intensive Care, University of Padua, Via V. Gallucci, 13, 35121, Padua, Italy.
| | - Rita Cataldo
- Unit of Anesthesia, Intensive Care and Pain Management, Campus Bio Medico University of Rome, Rome, Italy
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13
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Abstract
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.
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Affiliation(s)
- Christa L Riley
- Fellow, Surgical Critical Care, Department of Anesthesiology and Critical Care, Penn Medicine, 6 Dulles, 3400 Spruce Street, Philadelphia, PA 19104, USA; Anesthesiologist & Intensivist, Department of Anesthesiology, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA.
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14
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Abiri A, Goshtasbi K, Birkenbeue JL, Lin HW, Djalilian HR, Hsu FPK, Kuan EC. Obesity as a Risk Factor for Postoperative Adverse Events in Skull Base Surgery. Ann Otol Rhinol Laryngol 2022; 131:1381-1389. [PMID: 35081772 DOI: 10.1177/00034894221074745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the implications of obesity on postoperative adverse events following skull base surgery. METHODS The 2005-2017 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for adverse events in skull base surgery cases. Patients were stratified by body mass index (BMI) into normal weight (18.5 ≤ BMI < 25), overweight (25 ≤ BMI < 30), and obese (BMI ≥ 30) cohorts. Logistic regression was used to assess the association of overweight or obese BMI with various 30-day postoperative adverse events. RESULTS A total of 2305 patients were included for analysis, of which 732 (31.8%) and 935 (40.6%) were overweight or obese, respectively. The mean age was 53.8 ± 15.3 years and 1214 (52.7%) patients were female. Obese patients were younger (P = .033) and possessed higher frailty (P < .001) and ASA scores (P < .001). Operation times and lengths of hospitalization were not significantly different across patient cohorts (all P > .05). On propensity score-adjusted multivariable analysis, only bleeding (OR = 0.42, P < .001) and deep vein thrombosis (OR = 6.46, P = .015) were significantly associated with obesity. There were no significant differences in rates of readmission, reoperation, or mortality between normal weight and obese patients (all P > .05). CONCLUSIONS Obesity was associated with decreased postoperative bleeding and increased deep vein thromboses. Obese patients were otherwise at no higher risk for medical or surgical complications. Elevated BMI did not confer an increased risk for readmission, reoperation, or death. Thus, patient obesity should not be a major determinant in offering skull base surgery in individuals who would otherwise benefit from treatment.
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Affiliation(s)
- Arash Abiri
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Khodayar Goshtasbi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Jack L Birkenbeue
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Harrison W Lin
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Hamid R Djalilian
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA
| | - Frank P K Hsu
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, CA, USA.,Department of Neurological Surgery, University of California, Irvine, Orange, CA, USA
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15
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Ibrahim M, Elnabtity AM, Hegab A, Alnujaidi OA, El Sanea O. Combined opioid free and loco-regional anaesthesia enhances the quality of recovery in sleeve gastrectomy done under ERAS protocol: a randomized controlled trial. BMC Anesthesiol 2022; 22:29. [PMID: 35062872 PMCID: PMC8781357 DOI: 10.1186/s12871-021-01561-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 12/28/2021] [Indexed: 02/06/2023] Open
Abstract
Background It is debatable whether opioid-free anaesthesia (OFA) is better suited than multimodal analgesia (MMA) to achieve the goals of enhanced recovery after surgery (ERAS) in patients undergoing laparoscopic sleeve gastrectomy. Methods In all patients, anaesthesia was conducted with an i.v. induction with propofol (2 mg. kg-1), myorelaxation with cisatracurium (0.15 mg.kg-1), in addition to an ultrasound-guided bilateral oblique subcostal transverse abdominis plane block. In addition, patients in the OFA group (n = 51) received i.v. dexmedetomidine 0.1 μg.kg-1 and ketamine (0.5 mg. kg-1) at induction, then dexmedetomidine 0.5 μg. kg-1.h-1, ketamine 0.5 mg.kg-1.h-1, and lidocaine 1 mg. kg-1.h-1 for maintenance, while patients in the MMA group (n = 52) had only i.v. fentanyl (1 μg. kg-1) at induction. The primary outcome was the quality of recovery assessed by QoR-40, at the 6th and the 24th postoperative hour. Secondary outcomes were postoperative opioid consumption, time to ambulate, time to tolerate oral fluid, and time to readiness for discharge. Results At the 6th hour, the QoR-40 was higher in the OFA than in the MMA group (respective median [IQR] values: 180 [173–195] vs. 185 [173–191], p < 0.0001), but no longer difference was found at the 24th hour (median values = 191 in both groups). OFA also significantly reduced postoperative pain and morphine consumption (20 mg [1–21] vs. 10 mg [1–11], p = 0.005), as well as time to oral fluid tolerance (238 [151–346] vs. 175 min [98–275], p = 0.022), and readiness for discharge (505 [439–626] vs. 444 min [356–529], p = 0.001), but did not influence time to ambulate. Conclusion While regional anaesthesia achieved most of the intraoperative analgesia, avoiding intraoperative opioids with the help of this OFA protocol was able to improve several sensible parameters of postoperative functional recovery, thus improving our knowledge on the OFA effects. Clinical trial number Registration number NCT04285255.
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16
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Valvi D, Villagomez D, Shah MB, Mei X, Gupta M, Ancheta A, Marti F, Desai S, Benrajab K, Gedaly R. Perioperative Challenges in Patients Transplanted with Livers from Extreme Obese Donors. Liver Transpl 2021; 27:1824-1829. [PMID: 34097811 DOI: 10.1002/lt.26196] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/05/2021] [Accepted: 05/01/2021] [Indexed: 01/13/2023]
Abstract
The combination of rising rates of obesity and the shortage of deceased donor livers have forced the consideration of marginal liver donors in terms of body mass index (BMI) for liver transplantation (LT). To date, there are still conflicting data on the impact of donor obesity on post-LT outcomes. We analyzed all patients undergoing LT alone in the United States (US) from October 2005 through December 2019 using the United Network of Organ Sharing (UNOS) data set. We categorized donor BMI >40 kg/m2 as extremely obese (EO). Primary endpoints included 30-day perioperative mortality and early graft loss (EGL) within 7 days. A subgroup analysis was performed for the EO donor group to assess how macrovesicular steatosis (MaS) >30% affects 30-day mortality and EGL within 7 days. A total of 72,616 patients underwent LT during the study period. The 30-day perioperative mortality was significantly higher in the EO donor group (P = 0.02). On multivariate analysis, recipients undergoing LT with EO donors had a 38% higher 30-day mortality risk (odds ratio [OR], 1.38; 95% confidence interval [CI], 1.21-1.69) and 53% increased risk of EGL (OR, 1.53; 95% CI, 1.22-1.90). MaS >30% was independently associated with a 2-fold increased risk of 30-day mortality (P = 0.003) and 3.5-fold increased risk of EGL within 7 days (P < 0.001). The impact of MaS >30% in EGL was 2-fold for all patients transplanted during the study period compared with 3.5-fold in the EO donor group. There is an increased risk of EGL and 30-day perioperative mortality in recipients transplanted with EO donors. Future studies are warranted in morbid and super obese donors to assess the possible effect of obesity-related proinflammatory factors in EGL.
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Affiliation(s)
- Deepa Valvi
- Division of Transplantation, Department of Surgery, University of Kentucky, College of Medicine, Lexington, KY
| | - Diego Villagomez
- Division of Transplantation, Department of Surgery, University of Kentucky, College of Medicine, Lexington, KY
| | - Malay B Shah
- Division of Transplantation, Department of Surgery, University of Kentucky, College of Medicine, Lexington, KY
| | - Xiaonan Mei
- Division of Transplantation, Department of Surgery, University of Kentucky, College of Medicine, Lexington, KY
- Department of Surgery, Center for Biostatistics and Quality Improvement Program, Transplant Center, University of Kentucky, College of Medicine, Lexington, KY
| | - Meera Gupta
- Division of Transplantation, Department of Surgery, University of Kentucky, College of Medicine, Lexington, KY
| | - Alexandre Ancheta
- Division of Transplantation, Department of Surgery, University of Kentucky, College of Medicine, Lexington, KY
| | - Francesc Marti
- Division of Transplantation, Department of Surgery, University of Kentucky, College of Medicine, Lexington, KY
| | - Siddharth Desai
- Division of Transplantation, Department of Surgery, University of Kentucky, College of Medicine, Lexington, KY
| | - Karim Benrajab
- Division of Division of Digestive Diseases and Nutrition, Department of Medicine, University of Kentucky, College of Medicine, Lexington, KY
| | - Roberto Gedaly
- Division of Transplantation, Department of Surgery, University of Kentucky, College of Medicine, Lexington, KY
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17
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Hajmohamed S, Patel D, Apruzzese P, Kendall MC, De Oliveira G. Early Postoperative Outcomes of Super Morbid Obese Compared to Morbid Obese Patients After Ambulatory Surgery Under General Anesthesia: A Propensity-Matched Analysis of a National Database. Anesth Analg 2021; 133:1366-1373. [PMID: 34784321 DOI: 10.1213/ane.0000000000005770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Patients with body mass index (BMI) ≥50 kg/m2, defined as super morbid obesity, represent the fastest growing segment of patients with obesity in the United States. It is currently unknown if super morbid obese patients are at greater odds than morbid obese patients for poor outcomes after outpatient surgery. The main objective of the current investigation is to assess if super morbid obese patients are at increased odds for postoperative complications after outpatient surgery when compared to morbid obese patients. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2017 to 2018 was queried to extract and compare patients who underwent outpatient surgery and were defined as either morbidly obese (BMI >40 and <50 kg/m2) or super morbidly obese (BMI ≥50 kg/m2). The primary outcome was the occurrence of medical adverse events within 72 hours of discharge. In addition, we also examine death and readmissions as secondary outcomes. A propensity-matched analysis was used to evaluate the association of BMI ≥50 kg/m2 versus BMI between 40 and 50 kg/m2 and the outcomes. RESULTS A total of 661,729 outpatient surgeries were included in the 2017-2018 NSQIP database. Of those, 7160 with a BMI ≥50 kg/m2 were successfully matched to 7160 with a BMI <50 and ≥40 kg/m2. After matching, 17 of 7160 (0.24%) super morbid obese patients had 3-day medical complications compared to 15 of 7160 (0.21%) morbid obese patients (odds ratio [OR; 95% confidence interval {CI}] = 1.13 [0.57-2.27], P = .72). The rate of 3-day surgical complications in super morbid obese patients was also not different from morbid obese patients. Thirty-five of 7160 (0.48%) super morbid obese patients were readmitted within 3 days, compared to 33 of 7160 (0.46%) morbid obese patients (OR [95% CI] = 1.06 [0.66-1.71], P = .80). When evaluated in a multivariable analysis as a continuous variable (1 unit increase in BMI) in all patients, BMI ≥40 kg/m2 was not significantly associated with overall medical complications (OR [95% CI] = 1.00 [0.98-1.04], P = .87), overall surgical complication (OR [95% CI] = 1.02 [0.98-1.06], P = .23), or readmissions (OR [95% CI] = 0.99 [0.97-1.02], P = .8). CONCLUSIONS Super morbid obesity is not associated with higher rates of early postoperative complications when compared to morbid obese patients. Specifically, early pulmonary complications were very low after outpatient surgery. Super morbid obese patients should not be excluded from outpatient procedures based on a BMI cutoff alone.
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Affiliation(s)
- Sherine Hajmohamed
- From the Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Deeran Patel
- From the Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Patricia Apruzzese
- Department of Anesthesiology, Rhode Island Hospital, Providence, Rhode Island
| | - Mark C Kendall
- From the Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Gildasio De Oliveira
- From the Department of Anesthesiology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
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18
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Verhoeff K, Mocanu V, Dang J, Purich K, Switzer NJ, Birch DW, Karmali S. Five Years of MBSAQIP Data: Characteristics, Outcomes, and Trends for Patients with Super-obesity. Obes Surg 2021; 32:406-415. [PMID: 34782985 DOI: 10.1007/s11695-021-05786-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/18/2021] [Accepted: 11/08/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE Incidence of super obesity (SO; BMI ≥ 50 kg/m2) is growing rapidly and confers worse metabolic complications than non-SO (BMI 30-50 kg/m2). We aim to characterize bariatric surgery patients with SO, their postoperative complications, and treatment trends over the last 5 years in hopes of informing SO-specific treatment protocols. MATERIALS AND METHODS The MBSAQIP database was analyzed, and two cohorts were compared, those with SO and non-SO. Univariate analysis was performed to determine between-group differences. Multivariable logistic regression analysis was performed to determine if SO was independently associated with serious complications or mortality. RESULTS We evaluated 751,952 patients with 173,110 (23.0%) having SO. Patients with SO were younger (42.2 ± 11.8 SO vs 45.1 ± 12.0 years non-SO, p < 0.001) and less likely to be female (74.8% vs 81.1%, p < 0.001). While comorbidities seem to be decreasing overall in bariatric surgery patients, those with SO have worse functional capacity and more endocrine, pulmonary, and vascular comorbidities. Patients with SO also have worse 30-day postoperative complications, and SO was independently associated with severe complications (OR 1.08; CI 1.05-1.11, p < 0.001) and mortality (OR 2.49; CI 2.12-2.92, p < 0.001) CONCLUSIONS: Patients with SO have significantly increased preoperative comorbidities resulting in worse postoperative outcomes. SO remains an independent risk factor for serious complications and the greatest independent risk factor for 30-day postoperative mortality. Considering the expected increase in patients with SO, substantial work is required to optimize bariatric surgery strategies specific to these patients.
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Affiliation(s)
- Kevin Verhoeff
- Department of Surgery, University of Alberta, Dvorkin Lounge Mailroom2G2 Walter C. Mackenzie Health Sciences Centre, 8440 - 112 ST NW EDMONTON AB, Edmonton, Alberta, T6G 2B7, Canada.
| | - Valentin Mocanu
- Department of Surgery, University of Alberta, Dvorkin Lounge Mailroom2G2 Walter C. Mackenzie Health Sciences Centre, 8440 - 112 ST NW EDMONTON AB, Edmonton, Alberta, T6G 2B7, Canada
| | - Jerry Dang
- Department of Surgery, University of Alberta, Dvorkin Lounge Mailroom2G2 Walter C. Mackenzie Health Sciences Centre, 8440 - 112 ST NW EDMONTON AB, Edmonton, Alberta, T6G 2B7, Canada
| | - Kieran Purich
- Department of Surgery, University of Alberta, Dvorkin Lounge Mailroom2G2 Walter C. Mackenzie Health Sciences Centre, 8440 - 112 ST NW EDMONTON AB, Edmonton, Alberta, T6G 2B7, Canada
| | - Noah J Switzer
- Department of Surgery, University of Alberta, Dvorkin Lounge Mailroom2G2 Walter C. Mackenzie Health Sciences Centre, 8440 - 112 ST NW EDMONTON AB, Edmonton, Alberta, T6G 2B7, Canada
| | - Daniel W Birch
- Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Shahzeer Karmali
- Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, Alberta, Canada
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19
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García-Delgado Y, López-Madrazo-Hernández MJ, Alvarado-Martel D, Miranda-Calderín G, Ugarte-Lopetegui A, González-Medina RA, Hernández-Lázaro A, Zamora G, Pérez-Martín N, Sánchez-Hernández RM, Ibarra-González A, Bengoa-Dolón M, Mendoza-Vega CT, Appelvik-González SM, Caballero-Díaz Y, Hernández-Hernández JR, Wägner AM. Prehabilitation for Bariatric Surgery: A Randomized, Controlled Trial Protocol and Pilot Study. Nutrients 2021; 13:2903. [PMID: 34578781 PMCID: PMC8465022 DOI: 10.3390/nu13092903] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/13/2021] [Accepted: 08/20/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Yaiza García-Delgado
- Department of Endocrinology and Nutrition, Complejo Hospitalario Universitario Insular-Materno Infantil, 35016 Gran Canaria, Spain; (M.J.L.-M.-H.); (N.P.-M.); (R.M.S.-H.); (A.I.-G.)
- Instituto Universitario de Investigaciones Biomédicas y Sanitarias, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, 35001 Las Palmas, Spain; (D.A.-M.); (G.Z.)
| | - María José López-Madrazo-Hernández
- Department of Endocrinology and Nutrition, Complejo Hospitalario Universitario Insular-Materno Infantil, 35016 Gran Canaria, Spain; (M.J.L.-M.-H.); (N.P.-M.); (R.M.S.-H.); (A.I.-G.)
- Instituto Universitario de Investigaciones Biomédicas y Sanitarias, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, 35001 Las Palmas, Spain; (D.A.-M.); (G.Z.)
| | - Dácil Alvarado-Martel
- Instituto Universitario de Investigaciones Biomédicas y Sanitarias, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, 35001 Las Palmas, Spain; (D.A.-M.); (G.Z.)
| | - Guillermo Miranda-Calderín
- Department of Rehabilitation and Physical Medicine, Complejo Hospitalario Universitario Insular-Materno Infantil, 35016 Gran Canaria, Spain; (G.M.-C.); (A.U.-L.); (C.T.M.-V.); (S.M.A.-G.)
| | - Arantza Ugarte-Lopetegui
- Department of Rehabilitation and Physical Medicine, Complejo Hospitalario Universitario Insular-Materno Infantil, 35016 Gran Canaria, Spain; (G.M.-C.); (A.U.-L.); (C.T.M.-V.); (S.M.A.-G.)
| | - Raúl Alberto González-Medina
- Internal Medicine Nursing 8th North Wing, Complejo Hospitalario Universitario Insular-Materno Infantil, 35016 Gran Canaria, Spain;
| | - Alba Hernández-Lázaro
- Department of Endocrinology and Nutrition, Hospital Universitario Dr. Negrín, 35010 Gran Canaria, Spain;
| | - Garlene Zamora
- Instituto Universitario de Investigaciones Biomédicas y Sanitarias, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, 35001 Las Palmas, Spain; (D.A.-M.); (G.Z.)
| | - Nuria Pérez-Martín
- Department of Endocrinology and Nutrition, Complejo Hospitalario Universitario Insular-Materno Infantil, 35016 Gran Canaria, Spain; (M.J.L.-M.-H.); (N.P.-M.); (R.M.S.-H.); (A.I.-G.)
| | - Rosa María Sánchez-Hernández
- Department of Endocrinology and Nutrition, Complejo Hospitalario Universitario Insular-Materno Infantil, 35016 Gran Canaria, Spain; (M.J.L.-M.-H.); (N.P.-M.); (R.M.S.-H.); (A.I.-G.)
- Instituto Universitario de Investigaciones Biomédicas y Sanitarias, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, 35001 Las Palmas, Spain; (D.A.-M.); (G.Z.)
| | - Adriana Ibarra-González
- Department of Endocrinology and Nutrition, Complejo Hospitalario Universitario Insular-Materno Infantil, 35016 Gran Canaria, Spain; (M.J.L.-M.-H.); (N.P.-M.); (R.M.S.-H.); (A.I.-G.)
- Instituto Universitario de Investigaciones Biomédicas y Sanitarias, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, 35001 Las Palmas, Spain; (D.A.-M.); (G.Z.)
| | - Mónica Bengoa-Dolón
- Department of Pneumology, Complejo Hospitalario Universitario Insular-Materno Infantil, 35016 Gran Canaria, Spain;
| | - Carmen Teresa Mendoza-Vega
- Department of Rehabilitation and Physical Medicine, Complejo Hospitalario Universitario Insular-Materno Infantil, 35016 Gran Canaria, Spain; (G.M.-C.); (A.U.-L.); (C.T.M.-V.); (S.M.A.-G.)
| | - Svein Mikael Appelvik-González
- Department of Rehabilitation and Physical Medicine, Complejo Hospitalario Universitario Insular-Materno Infantil, 35016 Gran Canaria, Spain; (G.M.-C.); (A.U.-L.); (C.T.M.-V.); (S.M.A.-G.)
| | - Yurena Caballero-Díaz
- Department of General and Digestive Surgery, Complejo Hospitalario Universitario Insular-Materno Infantil, 35016 Gran Canaria, Spain; (Y.C.-D.); (J.R.H.-H.)
| | - Juan Ramón Hernández-Hernández
- Department of General and Digestive Surgery, Complejo Hospitalario Universitario Insular-Materno Infantil, 35016 Gran Canaria, Spain; (Y.C.-D.); (J.R.H.-H.)
| | - Ana María Wägner
- Department of Endocrinology and Nutrition, Complejo Hospitalario Universitario Insular-Materno Infantil, 35016 Gran Canaria, Spain; (M.J.L.-M.-H.); (N.P.-M.); (R.M.S.-H.); (A.I.-G.)
- Instituto Universitario de Investigaciones Biomédicas y Sanitarias, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, 35001 Las Palmas, Spain; (D.A.-M.); (G.Z.)
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Pisarska-Adamczyk M, Tylec P, Gajewska N, Wierzbicka J, Przęczek K, Małczak P, Wysocki M, Pędziwiatr M, Wierdak M, Major P. Postoperative Olfaction Alteration Following Laparoscopic Bariatric Surgery. J Clin Med 2021; 10:jcm10081704. [PMID: 33920942 PMCID: PMC8071304 DOI: 10.3390/jcm10081704] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/26/2021] [Accepted: 04/13/2021] [Indexed: 12/22/2022] Open
Abstract
Introduction: Bariatric surgery is an effective method of treatment for morbid obesity that is known to change nutritional habits. Proper nutrition has an impact on postoperative recovery and outcomes. Diet preferences depend on flavour and olfaction stimuli. Some studies show long-term changes in the sense of smell after bariatric surgery, but little research has addressed olfactory function shortly after surgery. Observations of olfactory changes that occur immediately after bariatric surgery may lead to improvements in postoperative care. Aim: The aim of this study is to investigate the impact of bariatric surgery on olfactory changes in the short postoperative period. Material and methods: This is a prospective study of patients undergoing laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) between April 2018 and December 2018. The control group consists of patients who underwent various non-oncological elective surgical procedures. Patients’ olfaction was tested qualitatively and quantitatively the day before and 24 h after surgery. Sniffin Sticks test consists of three subtests: odor threshold, discrimination, and identification. Results: The study enrolled 83 patients (LSG = 39; LRYGB = 14; control = 30). Mean scores in the threshold subtest differed significantly in the bariatric group, 9.3 ± 3.9 before the surgery and 8.2 ± 3.0 a day after the surgery (p = 0.032). There were no significant differences between scores from the discrimination subtest, identification subtest and the mean total scores in the bariatric group. There was no observed change in the intensity of the smell in the control group. Analyzing the results of patients undergoing LSG and LRYGB separately, we only showed significant differences in the case of LSG. Mean score from the 1st test (9.12 ± 3.97 vs. 7.75 ± 2.98; p = 0.0339) and mean total score (32.83 ± 5.45 vs. 30.67 ± 4.88; p = 0.0173) differ between repetitive measurements in LSG patients. Conclusions: Our study shows deterioration of odor threshold in the bariatric surgery group compared to the control group 24 h after surgery. However, this change occurred only in patients undergoing LSG.
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21
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Tan HS, Habib AS. Obesity in women: anaesthetic implications for peri-operative and peripartum management. Anaesthesia 2021; 76 Suppl 4:108-117. [PMID: 33682095 DOI: 10.1111/anae.15403] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2020] [Indexed: 12/13/2022]
Abstract
The prevalence, healthcare and socio-economic impact of obesity (defined as having a body mass index of ≥ 30 kg.m-2 ) are disproportionately higher in women than men. A combination of biological and social factors, including the adaptation of energy homeostasis to the increased demands of pregnancy and lactation and poor access to healthy foods or exercise facilities, contribute to the increasing prevalence of obesity in women. Obesity-related physiological changes stem from mass loading and increased metabolism of adipose tissue, as well as secretion of bioactive substances from adipocytes leading to chronic low-grade inflammation. As a result, obesity is associated with increased risks of: infertility; malignancy; sleep-disordered breathing; cardiovascular disease; diabetes; and thromboembolism. Hence, obese women are at markedly increased risk of peri-operative morbidity and mortality and require comprehensive evaluation and targeted comorbidity optimisation by a multidisciplinary team. In addition to routine obstetric challenges, pregnancy in women with obesity further exacerbates the above risks, making multidisciplinary management starting at pre-conception even more important. Weight loss, lifestyle management and optimisation of comorbidity are the cornerstone of reducing obesity-related risks. The anaesthetist plays a vital role within the multidisciplinary team by emphasising weight loss as part of pre-operative comorbidity optimisation, formulation of individualised peri-operative management plans, supervising postoperative care in the high dependency or intensive care settings and providing safe labour analgesia and careful peripartum management for obese parturients.
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Affiliation(s)
- H S Tan
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - A S Habib
- Division of Women's Anesthesia, Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
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22
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Licina A, Silvers A, Laughlin H, Russell J, Wan C. Pathway for enhanced recovery after spinal surgery-a systematic review of evidence for use of individual components. BMC Anesthesiol 2021; 21:74. [PMID: 33691620 PMCID: PMC7944908 DOI: 10.1186/s12871-021-01281-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 02/16/2021] [Indexed: 02/07/2023] Open
Abstract
Background Enhanced recovery in spinal surgery (ERSS) has shown promising improvements in clinical and economical outcomes. We have proposed an ERSS pathway based on available evidence. We aimed to delineate the clinical efficacy of individual pathway components in ERSS through a systematic narrative review. Methods We included systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled studies, and observational studies in adults and pediatric patients evaluating any one of the 22 pre-defined components. Our primary outcomes included all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). Following databases (1990 onwards) were searched: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two authors screened the citations, full-text articles, and extracted data. A narrative synthesis was provided. We constructed Evidence Profile (EP) tables for each component of the pathway, where appropriate information was available. Due to clinical and methodological heterogeneity, we did not conduct a meta-analyses. GRADE system was used to classify confidence in cumulative evidence for each component of the pathway. Results We identified 5423 relevant studies excluding duplicates as relating to the 22 pre-defined components of enhanced recovery in spinal surgery. We included 664 studies in the systematic review. We identified specific evidence within the context of spinal surgery for 14/22 proposed components. Evidence was summarized in EP tables where suitable. We performed thematic synthesis without EP for 6/22 elements. We identified appropriate societal guidelines for the remainder of the components. Conclusions We identified the following components with high quality of evidence as per GRADE system: pre-emptive analgesia, peri-operative blood conservation (antifibrinolytic use), surgical site preparation and antibiotic prophylaxis. There was moderate level of evidence for implementation of prehabilitation, minimally invasive surgery, multimodal perioperative analgesia, intravenous lignocaine and ketamine use as well as early mobilization. This review allows for the first formalized evidence-based unified protocol in the field of ERSS. Further studies validating the multimodal ERSS framework are essential to guide the future evolution of care in patients undergoing spinal surgery. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01281-1.
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Affiliation(s)
- Ana Licina
- Austin Health, 145 Studley Road, Heidelberg, Victoria, 3084, Australia.
| | - Andrew Silvers
- Monash Health, Clayton, Australia, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
| | | | - Jeremy Russell
- Department of Neurosurgery, Austin Health, Melbourne, Victoria, Australia
| | - Crispin Wan
- Royal Hobart Hospital, Hobart, Tasmania, Australia.,St Vincent's Hospital, Melbourne, Australia
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Goswami J, Lal J, Bhosale GP, Sinha A, Madhavi J. Exploring new frontiers: Organ transplant anaesthesia or bariatric anaesthesia. Indian J Anaesth 2021; 65:23-28. [PMID: 33767499 PMCID: PMC7980247 DOI: 10.4103/ija.ija_1449_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/17/2020] [Accepted: 12/30/2020] [Indexed: 11/21/2022] Open
Abstract
Unlike previous years, Anaesthesiology today is a major speciality encompassing many areas of modern medicine. Advent of various surgical sub-specialities resulted into the emergence of anaesthesia sub-specialities, as every group of surgery has specific need. Choosing the best-suited speciality is a complex matter. For that, one needs to have an idea about each one of them. A postgraduate anaesthesiology student does not have adequate exposure to choose the speciality. This article will give an overview of two important sub-specialities i.e., Organ Transplant Anaesthesia and Bariatric Anaesthesia.
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Affiliation(s)
- Jyotsna Goswami
- Department of Anaesthesia, Critical Care and Pain, Tata Medical Center, Kolkata, West Bengal, India
| | - Jatin Lal
- Department of Anaesthesiology and Critical Care, Pt. B. D. Sharma PGIMS, Rohtak, Haryana, India
| | - Guruprasad P Bhosale
- Department of Anaesthesia and Critical Care, Institute of Kidney Diseases and Research Centre, Civil Hospital Campus, Ahmedabad, Gujarat, India
| | - Aparna Sinha
- Anesthesia Division, Max Institute of Laparoscopy Endoscopy and Bariatric Surgery, Max Hospital, Saket, New Delhi, India
| | - Julakanti Madhavi
- Upgraded Department of Anaesthesiology and Critical Care, Osmania Medical College, Hyderabad, Telangana, India
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The Application of Enhanced Recovery After Surgery (ERAS) for Patients Undergoing Bariatric Surgery: a Systematic Review and Meta-analysis. Obes Surg 2021; 31:1321-1331. [PMID: 33420977 DOI: 10.1007/s11695-020-05209-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 12/12/2022]
Abstract
To systematically evaluate the effectiveness and safety of the enhanced recovery after surgery (ERAS) pathway in bariatric surgery. A literature search was conducted using PubMed, Medline, EMBASE, OVID, World Health Organization International Trial Register, and Cochrane Library identifying all eligible studies comparing ERAS protocols with standard care (SC) in bariatric surgery through May 2020. Relevant perioperative parameters were extracted from the resulting studies for meta-analysis. The primary outcome was the length of hospital stay, and secondary outcomes included operation time, postoperative nausea, and vomiting (PONV), postoperative complications, readmission, reoperation, and subsequent emergency room visits. Postoperative complications were categorized according to the Clavien-Dindo classification. Final analysis included five randomized controlled trials (RCTs) and twelve observational studies which included 4964 patients in the ERAS group and 3218 patients in the SC group. The length of the hospital stay was significantly decreased (p < 0.01) after ERAS protocol management, as did the incidence of POVN (p < 0.01). No significant differences were observed between the ERAS group and SC group in terms of operation time (p = 0.37), postoperative complications (p = 0.18), readmission (p = 0.17), reoperation (p = 0.34), or emergency room visits (p = 0.65). The application of ERAS protocols in bariatric surgery is safe and feasible, effectively shortening the length of a hospital stay without compromising morbidity, and accelerating patient recovery.
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25
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Barros LM, Gomes FADV, Carneiro FN, Galindo Neto NM, Frota NM, Caetano JÁ. Knowledge and attitude of candidates to gastroplasty about perioperative: randomized clinical trial. Rev Bras Enferm 2020; 73:e20180869. [PMID: 32965318 DOI: 10.1590/0034-7167-2018-0869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 06/10/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES to evaluate the effectiveness of educational intervention in the knowledge and attitude of candidates for gastroplasty. METHODS randomized controlled clinical trial with 56 preoperative patients (intervention=28; control=28). The control group received routine care from the health institution and the intervention group participated in a book-mediated educational intervention. Forms were used for clinical-epidemiological characterization and evaluation of knowledge/attitude about bariatric surgery, which were reapplied seven weeks after intervention. RBR-297fzx. RESULTS in the pre-test there was no significant difference between the groups (p=0.254). In the post-test, the group that received verbal guidance had a mean score of 19.5 (± 6.17) and the group reading the booklet averaged 31.1 (± 2.96), p=0.000. The attitude is adequate, especially for care such as vitamin supplement intake, water intake and physical activity practice. CONCLUSIONS the educational intervention mediated by booklet was effective in improving knowledge and attitude when compared to verbal guidance. Thus, it can be replicated during the preoperative preparation.
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Affiliation(s)
- Lívia Moreira Barros
- Universidade da Integração Internacional da Lusofonia Afro-Brazileira. Redenção, Ceará, Brazil
| | | | | | | | - Natasha Marques Frota
- Universidade da Integração Internacional da Lusofonia Afro-Brazileira. Redenção, Ceará, Brazil
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Gupta M, Dugan A, Chacon E, Davenport DL, Shah MB, Marti F, Roth JS, Bernard A, Zwischenberger JB, Gedaly R. Detailed perioperative risk among patients with extreme obesity undergoing nonbariatric general surgery. Surgery 2020; 168:462-470. [DOI: 10.1016/j.surg.2020.03.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/28/2020] [Accepted: 03/21/2020] [Indexed: 12/23/2022]
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27
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Romero-Velez G, Pechman DM, Muñoz Flores F, Moran-Atkin E, Choi J, Camacho DR. Bariatric surgery in the super-super morbidly obese: outcome analysis of patients with BMI >70 using the ACS-NSQIP database. Surg Obes Relat Dis 2020; 16:894-899. [PMID: 32371037 DOI: 10.1016/j.soard.2020.03.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/17/2020] [Accepted: 03/15/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Bariatric surgery offers patients short- and long-term benefits to their health and quality of life. Currently, we see more patients with superior body mass index (BMI) looking for these benefits. Evidence-based medicine is integral in the evaluation of risks versus benefit; however, data are lacking in this high-risk population. OBJECTIVES To assess the morbidity and mortality of patients with BMI ≥70 undergoing bariatric surgery. SETTING University Hospital, Bronx, New York, United States using national database. METHODS Using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database for years 2005 to 2016, we identified patients who underwent primary laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass. Patients with BMI ≥70 were assigned to the BMI >70 (BMI70+) cohort and less obese patients were assigned to the BMI <70 (U70) cohort. Length of stay and 30-day morbidity and mortality were compared. RESULTS A total of 163,413 patients underwent non-revisional bariatric surgery. Of those, 2322 had a BMI ≥70. BMI70+ was associated with increased mortality (.4% versus .1%, P = .0001), deep vein thrombosis (.6% versus .3%, P = .007), pulmonary (1.9% versus .5%, P = .0001), renal (.9% versus .2%, P = .0001), and infectious complications (1.1% versus .4%, P = .0001). BMI70+ patients had longer mean length of stay (2.6 versus 2.1 d, P = .0001) and operative time (126.1 versus 114.5 min, P = .0001). There was no statistically significant difference in the number of myocardial infarctions (.1% versus .1%, P = .319), pulmonary embolisms (.3% versus .2%, P = .596), and transfusion requirements (.1% versus .1%, P = .105) between groups. CONCLUSIONS Evaluation of risk and benefit is performed on a case-by-case basis, but evidence-based medicine is critical in empowering surgeons and patients to make informed decisions. The overall rate of morbidity and mortality for BMI70+ patients undergoing bariatric surgery was increased over U70 patients but was still relatively low. Our study will allow surgeons to incorporate objective data into their assessment of risk for super-obese patients pursuing bariatric surgery.
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Affiliation(s)
| | | | | | | | - Jenny Choi
- Montefiore Medical Center, Bronx, New York
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28
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Mechanick JI, Apovian C, Brethauer S, Timothy Garvey W, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Obesity (Silver Spring) 2020; 28:O1-O58. [PMID: 32202076 DOI: 10.1002/oby.22719] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 10/09/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists. METHODS Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. RESULTS New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). CONCLUSIONS Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.
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Affiliation(s)
- Jeffrey I Mechanick
- Guideline Task Force Chair (AACE); Professor of Medicine, Medical Director, Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart; Director, Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York; Past President, AACE and ACE
| | - Caroline Apovian
- Guideline Task Force Co-Chair (TOS); Professor of Medicine and Director, Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Stacy Brethauer
- Guideline Task Force Co-Chair (ASMBS); Professor of Surgery, Vice Chair of Surgery, Quality and Patient Safety; Medical Director, Supply Chain Management, Ohio State University, Columbus, Ohio
| | - W Timothy Garvey
- Guideline Task Force Co-Chair (AACE); Butterworth Professor, Department of Nutrition Sciences, GRECC Investigator and Staff Physician, Birmingham VAMC; Director, UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- Guideline Task Force Co-Chair (ASA); Professor of Anesthesiology, Service Chief, Otolaryngology, Oral, Maxillofacial, and Urologic Surgeries, Associate Medical Director, Respiratory Care, University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Guideline Task Force Co-Chair (ASMBS); Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Guideline Task Force Co-Chair (TOS); Professor of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Richard Lindquist
- Guideline Task Force Co-Chair (OMA); Director, Medical Weight Management, Swedish Medical Center; Director, Medical Weight Management, Providence Health Services; Obesity Medicine Consultant, Seattle, Washington
| | - Rachel Pessah-Pollack
- Guideline Task Force Co-Chair (AACE); Clinical Associate Professor of Medicine, Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Guideline Task Force Co-Chair (OMA); Adjunct Assistant Professor, Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | - Richard D Urman
- Guideline Task Force Co-Chair (ASA); Associate Professor of Anesthesia, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stephanie Adams
- Writer (AACE); AACE Director of Clinical Practice Guidelines Development, Jacksonville, Florida
| | - John B Cleek
- Writer (TOS); Associate Professor, Department of Nutrition Sciences, University of Alabama, Birmingham, Alabama
| | - Riccardo Correa
- Technical Analysis (AACE); Assistant Professor of Medicine and Endocrinology, Diabetes and Metabolism Fellowship Director, University of Arizona College of Medicine, Phoenix, Arizona
| | - M Kathleen Figaro
- Technical Analysis (AACE); Board-certified Endocrinologist, Heartland Endocrine Group, Davenport, Iowa
| | - Karen Flanders
- Writer (ASMBS); Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Writer (AACE); Associate Professor, Department of Surgery, University of Alabama at Birmingham; Staff Surgeon, Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Writer (AACE); Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Shanu Kothari
- Writer (ASMBS); Fellowship Director of MIS/Bariatric Surgery, Gundersen Health System, La Crosse, Wisconsin
| | - Michael V Seger
- Writer (OMA); Bariatric Medical Institute of Texas, San Antonio, Texas, Clinical Assistant Professor, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Writer (TOS); Medical Director, Center for Nutrition and Weight Management Director, Geisinger Obesity Institute; Medical Director, Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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Sinha A, Jayaraman L, Punhani D. Predictors of difficult airway in the obese are closely related to safe apnea time! J Anaesthesiol Clin Pharmacol 2020; 36:25-30. [PMID: 32174653 PMCID: PMC7047673 DOI: 10.4103/joacp.joacp_164_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/19/2019] [Indexed: 11/04/2022] Open
Abstract
Background and Aims: We aimed to redefine the preoperative factors that may challenge the airway and safe apnea time (SAT) in the obese. Material and Methods: We analyzed 834 patients with body mass index (BMI) >35 kg/m2 for their difficult airway score (DASc). DASc is a consolidation of measures of difficult airway like mask ventilation, difficult intubation, change of device, and number of personnel required. DASc varied from “0” no difficulty to “12” serious difficulty and DASc ≥6 was considered difficult. Preoperative parameters – neck circumference (NC), BMI, STOPBANG score, Mallampati score, obstructive sleep apnea grade, and waist circumference– were assessed. Results: Receiver operating characteristic curve was used to identify risk factors for obese patients at DASc ≥6. The Youden index (for the best threshold, with highest sensitivity and specificity) was BMI 45 kg/m2 and NC 44.5 cm. Their absence had an 81% negative predictive value to include a difficult airway, while their presence had a positive predictive value of 55%. This further has sensitivity of 66% and specificity of 73%. The mean SAT (256 ± 6 s) was inversely related to DASc (P < 0.001). Conclusion: This study demonstrates that BMI and NC have a strong association with difficult airway in obese patients and are inversely related to SAT. Amongst these NC is the single most important predictor of difficult airway in obese and should be used as a screening tool.
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Affiliation(s)
- Aparna Sinha
- Department of Anesthesia, Institute of Minimal Access, Metabolic and Bariatric Surgery, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Lakshmi Jayaraman
- Department of Anesthesia, Institute of Minimal Access, Metabolic and Bariatric Surgery, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Dinesh Punhani
- Department of Anesthesia, Institute of Minimal Access, Metabolic and Bariatric Surgery, Max Super Speciality Hospital, Saket, New Delhi, India
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Knight P, Chou J, Dusseljee M, Verseman S, Elian A. Effective reduction in stress induced postoperative hyperglycemia in bariatric surgery by better carb loading. Am J Surg 2019; 219:396-398. [PMID: 31757437 DOI: 10.1016/j.amjsurg.2019.10.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 10/21/2019] [Accepted: 10/23/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Preoperative carbohydrate loading is a recommended component of enhanced recovery protocols (ERP's), however the impact on postoperative stress-induced insulin resistance remains poorly studied in both diabetics and non-diabetics. METHODS Using our ERP, a preoperative grape juice group (Grape) was compared to the use of 25 g maltodextrin/3 g citrulline (G.E.D.™, SOF Health, LLC) for carbohydrate loading. RESULTS The population included 171 patients (Grape n = 96; GED n = 75). Glycemic variability was significantly worse for the Grape group on POD 0 in both non-diabetic (70% vs 41%; p < 0.05) and diabetic patients (66% vs 34%; p < 0.05). Significantly more Grape patients required postoperative insulin regardless of diabetic status. CONCLUSION Following bariatric surgery, the impact of stress induced hyperglycemia is primarily on POD 0 in non-diabetics whereas the effect extends into POD 1 for diabetics. Preoperative loading with G.E.D.™ versus grape juice is associated with a significantly lower rate of glycemic variation and postoperative insulin requirement, demonstrating that drink composition and treatment process reduces the severity of postoperative stress induced hyperglycemia in bariatric surgery patients.
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Affiliation(s)
- Patrick Knight
- Western Michigan University Homer Stryker M.D. School of Medicine, Department of General Surgery, 1000 Oakland Dr, Kalamazoo, MI, 49008, USA.
| | - Jesse Chou
- Western Michigan University Homer Stryker M.D. School of Medicine, Department of General Surgery, 1000 Oakland Dr, Kalamazoo, MI, 49008, USA
| | - Melissa Dusseljee
- Western Michigan University Homer Stryker M.D. School of Medicine, Department of General Surgery, 1000 Oakland Dr, Kalamazoo, MI, 49008, USA
| | - Stuart Verseman
- Western Michigan University Homer Stryker M.D. School of Medicine, Department of General Surgery, 1000 Oakland Dr, Kalamazoo, MI, 49008, USA
| | - Alain Elian
- Western Michigan University Homer Stryker M.D. School of Medicine, Department of General Surgery, 1000 Oakland Dr, Kalamazoo, MI, 49008, USA
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Taylor CR, Dominguez JE, Habib AS. Obesity And Obstetric Anesthesia: Current Insights. Local Reg Anesth 2019; 12:111-124. [PMID: 31819609 PMCID: PMC6873959 DOI: 10.2147/lra.s186530] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/18/2019] [Indexed: 12/26/2022] Open
Abstract
Obesity is a significant global health problem. It results in a higher incidence of complications for pregnant women and their neonates. Cesarean deliveries are more common in obese parturients as well. The increased burden of comorbidities seen in this population, such as obstructive sleep apnea, necessitates antepartum anesthetic consultation. These patients pose unique challenges for the practicing anesthesiologist and may benefit from optimization prior to delivery. Complications from anesthesia and overall morbidity and mortality are higher in this population. Neuraxial anesthesia can be challenging to place in the obese parturient, but is the preferred anesthetic for cesarean delivery to avoid airway manipulation, minimize aspiration risk, prevent fetal exposure to volatile anesthetic, and decrease risk of post-partum hemorrhage from volatile anesthetic exposure. Monitoring and positioning of these patients for surgery may pose specific challenges. Functional labor epidural catheters can be topped up to provide conditions suitable for surgery. In the absence of a working epidural catheter, a combined spinal epidural anesthetic is often the technique of choice due to relative ease of placement versus a single shot spinal technique as well as the ability to extend the anesthetic through the epidural portion. For cesarean delivery with a vertical supraumbilical skin incision, a two-catheter technique may be beneficial. Concern for thromboembolism necessitates early mobilization and a multimodal analgesic regimen can help accomplish this. In addition, thromboprophylaxis is recommended in this population after delivery—especially cesarean delivery. These patients also need close monitoring in the post-partum period when they are at increased risk for several complications.
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Affiliation(s)
- Cameron R Taylor
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University, Durham, NC 27710, USA
| | - Jennifer E Dominguez
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University, Durham, NC 27710, USA
| | - Ashraf S Habib
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University, Durham, NC 27710, USA
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Mechanick JI, Apovian C, Brethauer S, Garvey WT, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Surg Obes Relat Dis 2019; 16:175-247. [PMID: 31917200 DOI: 10.1016/j.soard.2019.10.025] [Citation(s) in RCA: 235] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists. METHODS Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. RESULTS New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). CONCLUSIONS Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.
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Affiliation(s)
- Jeffrey I Mechanick
- Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart, New York, New York; Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Caroline Apovian
- Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | | | - W Timothy Garvey
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama; UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Rachel Pessah-Pollack
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | | | - Stephanie Adams
- American Association of Clinical Endocrinologists, Jacksonville, Florida
| | - John B Cleek
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama
| | | | | | - Karen Flanders
- Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama; Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | | | - Michael V Seger
- Bariatric Medical Institute of Texas, San Antonio, Texas, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Center for Nutrition and Weight Management Director, Geisinger Obesity Institute, Danville, Pennsylvania; Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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Reduction of opioid use after implementation of enhanced recovery after bariatric surgery (ERABS). Surg Endosc 2019; 34:2184-2190. [DOI: 10.1007/s00464-019-07006-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 07/19/2019] [Indexed: 12/19/2022]
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Smolders EJ, Willemse SB, El-Sherif O, Khoo S, Burger DM. The Observed Effect of Gastric Bypass Surgery on Direct-acting Antiviral Treatment: a Case Report. Ann Hepatol 2019; 17:525-529. [PMID: 29735803 DOI: 10.5604/01.3001.0011.7398] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Chronic hepatitis C virus (HCV) infection can be cured with treatment using direct-acting antivirals (DAAs). Although these drugs have been widely studied, information about certain special populations is missing. In this case report we describe a treatment-experienced patient with chronic HCV infection genotype 1b, treated with 150 mg/day simeprevir, 400 mg/day sofosbuvir, and 1,000 mg/ day ribavirin for 24 weeks, after a Roux-and-Y gastric bypass. At steady-state a pharmacokinetic curve was recorded of sofosbuvir, GS-331007, and simeprevir. Ribavirin trough plasma concentration (Ctrough) was determined. The simeprevir area under the-concentration time curve (AUClast) and Ctrough were 9.42 h.mg/L and 0.046 mg/L, respectively. Compared to what was described in the literature, simeprevir exposure was low and therefore the simeprevir dose was increased to 300 mg/day. The increased dose of simeprevir was well tolerated and Ctrough was 0.532 mg/L. Sofosbuvir AUClast and Ctrough were 0.63 h.mg/L and 0.0013 mg/L. GS-331007 AUClast and Ctrough were 21.02 h.mg/L and 0.35 mg/L. Ribavirin Ctrough was 2.5 mg/L. Sofosbuvir, GS-331007, and ribavirin exposure were comparable with levels described in literature. The patient achieved a sustained virological response twelve weeks after the completion of treatment.
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Affiliation(s)
- Elise J Smolders
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Sophie B Willemse
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Omar El-Sherif
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Saye Khoo
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - David M Burger
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
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Ruiz-Tovar J, Garcia A, Ferrigni C, Gonzalez J, Castellon C, Duran M. Impact of implementation of an enhanced recovery after surgery (ERAS) program in laparoscopic Roux-en-Y gastric bypass: a prospective randomized clinical trial. Surg Obes Relat Dis 2018; 15:228-235. [PMID: 30606469 DOI: 10.1016/j.soard.2018.11.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 11/02/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND The essence of enhanced recovery after surgery (ERAS) program is the multimodal approach, and many authors have demonstrated safety and feasibility in fast-track bariatric surgery. OBJECTIVES The aim of this study was to evaluate the postoperative pain after the implementation of an ERAS protocol in Roux-en-Y gastric bypass and to compare it with the application of a standard care protocol. SETTING University Hospital Rey Juan Carlos, Madrid, Spain. METHODS A prospective randomized clinical trial of all the patients undergoing Roux-en-Y gastric bypass was performed. Patients were randomized into the following 2 groups: those patients after an ERAS program and those patients after a standard care protocol. Postoperative pain, nausea or vomiting, morbidity, mortality, hospital stay, and analytic acute phase reactants 24 hours after surgery were evaluated. RESULTS One hundred eighty patients were included in the study, 90 in each group. Postoperative pain (16 versus 37 mm; P < .001), nausea or vomiting (8.9% versus 2.2%; P = .0498), and hospital stay (1.7 versus 2.8 d; P < .001) were significantly lower in the ERAS group. There were no significant differences in complications, mortality, and readmission rates. White blood cell count, serum fibrinogen, and C reactive protein levels were significantly lower in the ERAS group 24 hours after surgery. CONCLUSION The implementation of an ERAS protocol was associated with lower postoperative pain, reduced incidence of postoperative nausea or vomiting, lower levels of acute phase reactants, and earlier hospital discharge. Complications, reinterventions, mortality, and readmission rates were similar to that obtained after a standard care protocol.
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Affiliation(s)
- Jaime Ruiz-Tovar
- Centro de Excelencia para el Estudio y Tratamiento de la Obesidad, Valladolid, Spain; Department of Surgery. Bariatric Surgery Unit. University Hospital Rey Juan Carlos, Madrid, Spain.
| | - Alejandro Garcia
- Department of Surgery. Bariatric Surgery Unit. University Hospital Rey Juan Carlos, Madrid, Spain
| | - Carlos Ferrigni
- Department of Surgery. Bariatric Surgery Unit. University Hospital Rey Juan Carlos, Madrid, Spain
| | - Juan Gonzalez
- Department of Surgery. Bariatric Surgery Unit. University Hospital Rey Juan Carlos, Madrid, Spain
| | - Camilo Castellon
- Department of Surgery. Bariatric Surgery Unit. University Hospital Rey Juan Carlos, Madrid, Spain
| | - Manuel Duran
- Department of Surgery. Bariatric Surgery Unit. University Hospital Rey Juan Carlos, Madrid, Spain
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Major P, Wysocki M, Torbicz G, Gajewska N, Dudek A, Małczak P, Pędziwiatr M, Pisarska M, Radkowiak D, Budzyński A. Risk Factors for Prolonged Length of Hospital Stay and Readmissions After Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg 2018; 28:323-332. [PMID: 28762024 PMCID: PMC5778173 DOI: 10.1007/s11695-017-2844-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass (LRYGB) are most commonly performed bariatric procedures. Laparoscopic approach and enhanced recovery after surgery (ERAS) protocols managed to decrease length of hospital and morbidity. However, there are patients in whom, despite adherence to the protocol, the length of stay (LOS) remains longer than targeted. This study aimed to assess potential risk factors for prolonged LOS and readmissions. Methods The study was a prospective observation with a post-hoc analysis of bariatric patients in a tertiary referral university teaching hospital. Inclusion criteria were undergoing laparoscopic bariatric surgery. Exclusion criteria were occurrence of perioperative complications, prior bariatric procedures, and lack of necessary data. The primary endpoints were the evaluations of risk factors for prolonged LOS and readmissions. Results Median LOS was 3 (2–4) days. LOS > 3 days occurred in 145 (29.47%) patients, 79 after LSG (25.82%) and 66 after LRYGB (35.48%; p = 0.008). Factors significantly prolonging LOS were low oral fluid intake, high intravenous volume of fluids administered on POD0, and every additional 50 km distance from habitual residence to bariatric center. The risk of hospital readmission rises with occurrence of intraoperative adverse events and low oral fluid intake on the day of surgery on. Conclusions Risk factors for prolonged LOS are low oral fluid intake, high intravenous volume of fluids administered on POD0, and every additional 50 km distance from habitual residence. Risk factors for hospital readmission are intraoperative adverse events and low oral fluid intake on the day of surgery.
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Affiliation(s)
- Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Krakow, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Krakow, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Michał Wysocki
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Krakow, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Grzegorz Torbicz
- Students' Scientific Group at 2nd Department of Surgery, JUMC, Krakow, Poland
| | - Natalia Gajewska
- Students' Scientific Group at 2nd Department of Surgery, JUMC, Krakow, Poland
| | - Alicja Dudek
- Students' Scientific Group at 2nd Department of Surgery, JUMC, Krakow, Poland
| | - Piotr Małczak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Krakow, Poland. .,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Krakow, Poland. .,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland.
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Krakow, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Krakow, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Magdalena Pisarska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Krakow, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Krakow, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Dorota Radkowiak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Krakow, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Krakow, Poland
| | - Andrzej Budzyński
- 2nd Department of General Surgery, Jagiellonian University Medical College, Kopernika 21 St., 31-501, Krakow, Poland.,Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Krakow, Poland.,Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
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Precision Surgery for Obesity. Am J Ther 2018; 27:e491-e494. [PMID: 29782345 DOI: 10.1097/mjt.0000000000000783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Precision medicine is targeted towards improving the effectiveness of treatment, reducing the side effects of drugs and reducing medical costs. The application of precision surgery for obesity is a new concept that involves 2 stages: the first stage is to attain a precise obesity surgery, and the second stage is to achieve individualized obese gene therapy. In this article, we discuss the value of precision surgery for obesity, its stages and its future application to improve obesity surgery. Due to recent advancements in medical technologies, genetics, surgical and clinical research; precision surgery for obesity will lead the future of obesity surgery.
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Mahmood F, Sharples AJ, Rotundo A, Balaji N, Rao VSR. Factors Predicting Length of Stay Following Bariatric Surgery: Retrospective Review of a Single UK Tertiary Centre Experience. Obes Surg 2018; 28:1924-1930. [DOI: 10.1007/s11695-017-3105-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Ibrahim AM, Ghaferi AA, Thumma JR, Dimick JB. Variation in Outcomes at Bariatric Surgery Centers of Excellence. JAMA Surg 2017; 152:629-636. [PMID: 28445566 DOI: 10.1001/jamasurg.2017.0542] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance In the United States, reports about perioperative complications associated with bariatric surgery led to the establishment of accreditation criteria for bariatric centers of excellence and many bariatric centers obtaining accreditation. Currently, most bariatric procedures occur at these centers, but to what extent they uniformly provide high-quality care remains unknown. Objective To describe the variation in surgical outcomes across bariatric centers of excellence and the geographic availability of high-quality centers. Design, Setting, and Participants This retrospective review analyzed the claims data of 145 527 patients who underwent bariatric surgery at bariatric centers of excellence between January 1, 2010, and December 31, 2013. Data were obtained from the Healthcare Cost and Utilization Project's State Inpatient Database. This database included unique hospital identification numbers in 12 states (Arkansas, Arizona, Florida, Iowa, Massachusetts, Maryland, North Carolina, Nebraska, New Jersey, New York, Washington, and Wisconsin), allowing comparisons among 165 centers of excellence located in those states. Participants were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Those included in the study cohort were patients with a primary diagnosis of morbid obesity and who underwent laparoscopic Roux-en-Y gastric bypass, open Roux-en-Y gastric bypass, laparoscopic gastric band placement, or laparoscopic sleeve gastrectomy. Excluded from the cohort were patients younger than 18 years or who had an abdominal malignant neoplasm. Data were analyzed July 1, 2016, through January 10, 2017. Main Outcomes and Measures Risk-adjusted and reliability-adjusted serious complication rates within 30 days of the index operation were calculated for each center. Centers were stratified by geographic location and operative volume. Results In this analysis of claims data from 145 527 patients, wide variation in quality was found across 165 bariatric centers of excellence, both nationwide and statewide. At the national level, the risk-adjusted and reliability-adjusted serious complication rates at each center varied 17-fold, ranging from 0.6% to 10.3%. At the state level, variation ranged from 2.1-fold (Wisconsin decile range, 1.5%-3.3%) to 9.5-fold (Nebraska decile range, 1.0%-10.3%). After dividing hospitals into quintiles of quality on the basis of their adjusted complication rates, 38 of 132 (28.8%) had a center in a higher quintile of quality located within the same hospital service area. Variation in rates of complications existed at centers with low volume (annual mean [SD] procedure volume, 156 [20] patients; complication range, 0.6%-6.4%; 9.8-fold variation), medium volume (annual mean [SD] procedure volume, 239 [27] patients; complication range, 0.6%-10.3%; 17.5-fold variation), and high volume (annual mean [SD] procedure volume, 448 [131] patients; complication range, 0.6%-4.9%; 7.5-fold variation). Conclusions and Relevance Even among accredited bariatric surgery centers, wide variation exists in rates of postoperative serious complications across geographic location and operative volumes. Given that a large proportion of centers are geographically located near higher-performing centers, opportunities for improvement through regional collaboratives or selective referral should be considered.
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Affiliation(s)
- Andrew M Ibrahim
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Amir A Ghaferi
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Jyothi R Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor2Surgical Innovation Editor, JAMA Surgery
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