Perioperative optimization of patients undergoing bariatric surgery

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

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

Perioperative challenges in managing a morbidly obese patient with COVID-19 undergoing an elective tracheostomy

Tracheostomy is an aerosol-generating procedure and performing it in patients with COVID-19 requiring mechanical ventilation raises significant concerns of infection risk to healthcare workers. We herein report a case of tracheostomy in a critically ill patient with severe COVID-19 acute respiratory distress syndrome. This article depicts the use of personal protective equipment, highlighting the common challenges it presents and ways to address them.

Diet approach before and after bariatric surgery

Bariatric surgery (BS) is today the most effective therapy for inducing long-term weight loss and for reducing comorbidity burden and mortality in patients with severe obesity. On the other hand, BS may be associated to new clinical problems, complications and side effects, in particular in the nutritional domain. Therefore, the nutritional management of the bariatric patients requires specific nutritional skills. In this paper, a brief overview of the nutritional management of the bariatric patients will be provided from pre-operative to post-operative phase. Patients with severe obesity often display micronutrient deficiencies when compared to normal weight controls. Therefore, nutritional status should be checked in every patient and correction of deficiencies attempted before surgery. At present, evidences from randomized and retrospective studies do not support the hypothesis that pre-operative weight loss could improve weight loss after BS surgery, and the insurance-mandated policy of a preoperative weight loss as a pre-requisite for admission to surgery is not supported by medical evidence. On the contrary, some studies suggest that a modest weight loss of 5-10% in the immediate preoperative period could facilitate surgery and reduce the risk of complications. Very low calories diet (VLCD) and very low calories ketogenic diets (VLCKD) are the most frequently used methods for the induction of a pre-operative weight loss today. After surgery, nutritional counselling is recommended in order to facilitate the adaptation of the eating habits to the new gastro-intestinal physiology. Nutritional deficits may arise according to the type of bariatric procedure and they should be prevented, diagnosed and eventually treated. Finally, specific nutritional problems, like dumping syndrome and reactive hypoglycaemia, can occur and should be managed largely by nutritional manipulation. In conclusion, the nutritional management of the bariatric patients requires specific nutritional skills and the intervention of experienced nutritionists and dieticians.

Characteristics of morbid obese patients with high-risk cardiac disease undergoing laparoscopic sleeve gastrectomy surgery

Introduction

Bariatric surgery is an efficient and safe method of weight reduction among patients who have morbid obesity which cannot be treated by the conservative approach. Safety and feasibility of bariatric surgery among high-risk patients are understudied. Therefore, we aimed to report the patient-level characteristics and outcome among high-risk obese patients undergoing laparoscopic sleeve gastrectomy surgery in Saudi Arabia.

Methods

A retrospective analysis was performed among 13 morbidly obese (BMI >39 kg/m²) patients with high-risk cardiac disease, who were referred to Upper Gastro-Intestinal Surgery Clinic at King Khalid University Hospital, which is a center of excellence in bariatric surgery, for consideration for weight loss surgery. Retrospective data on preoperative weight, height, and BMI, operative details, perioperative complications, length of stay, and information on comorbidities and endocrinal disease were collected for analysis and reporting.

Results

A total of 13 patients were included in the analysis. Of the total, 61.5% were males with a mean age 40.38 (SD: 16.28) and a mean BMI 51.87 (SD: 7.69). The mean duration of surgery was 33.30 min (SD: 31.01), while the mean duration of anesthesia was 83.61 min (SD: 34.73). The mean length of stay was 6.76 days (SD: 3.89). Three patients required postoperative HDU admission with a mean length of stay of 1 day, while 5 patients required postoperative ICU admission with a length of stay ranging from 1 to 3 days. Within 30 days after discharge, only 1 patient required ER visit and none of the patients reported any postoperative morbidity and mortality.

Conclusion

Through this study, we can conclude that laparoscopic sleeve gastrectomy surgery can be considered a safe procedure. However, further studies with a large sample size and a more robust methodology are needed to build upon the findings of this study.

Obstructive sleep apnea in pediatric obesity and the effects of sleeve gastrectomy

The prevalence of severe pediatric obesity is rising and poses many adverse health risks. Children with obesity are at increased risk of several cardiovascular and metabolic diseases. They are also more likely to have obstructive sleep apnea (OSA), which increases the risk of cardiovascular and metabolic problems. In this review, we examine the relationship between OSA and obesity, improvements in OSA after non-surgical and surgical weight loss, and explore potential directions for future research.

Perioperative care of the obese patient

Background

Obesity has become an increasing problem worldwide during the past few decades. Hence, surgeons and anaesthetists will care for an increasing number of obese patients in the foreseeable future, and should be prepared to provide optimal management for these individuals. This review provides an update of recent evidence regarding perioperative strategies for obese patients.

Methods

A search for papers on the perioperative care of obese patients (English language only) was performed in July 2019 using the PubMed, Scopus, Web of Science and Cochrane Library electronic databases. The review focused on the results of RCTs, although observational studies, meta-analyses, reviews, guidelines and other reports discussing the perioperative care of obese patients were also considered. When data from obese patients were not available, relevant data from non-obese populations were used.

Results and conclusion

Obese patients require comprehensive preoperative evaluation. Experienced medical teams, appropriate equipment and monitoring, careful anaesthetic management, and an adequate perioperative ventilation strategy may improve postoperative outcomes. Additional perioperative precautions are necessary in patients with severe morbid obesity, metabolic syndrome, untreated or severe obstructive sleep apnoea syndrome, or obesity hypoventilation syndrome; patients receiving home ventilatory support or postoperative opioid therapy; and obese patients undergoing open operations, long procedures or revisional surgery.

The safety and efficiency of a fast-track protocol for sleeve gastrectomy: a team approach

BACKGROUND

Increasing numbers of morbid obese patients has led to increased numbers of bariatric procedures. Fast-track protocols are being developed to enhance the available resources, while maintaining a safe procedure. Reported results on safety merely apply to a mixed bariatric population. The objective was to evaluate safety and efficiency of the fast-track principles in patients undergoing sleeve gastrectomy.

METHODS

Retrospective observational study including patients undergoing primary sleeve gastrectomy at the Obesity Centre of the Catharina Hospital Eindhoven, the Netherlands. Conventional perioperative care (CC) (2008-2011) versus a fast-track protocol (FT) (2011-2013), using short-acting anesthetic agents, a multi-modal pain protocol to reduce opioids, and early mobilization. The main parameters for safety were intraoperative, early and late postoperative complications. Procedure time and hospital stay were used to evaluate efficiency.

RESULTS

This study included 805 patients, 494 patients were subjected to the conventional care and 318 patients to fast-track protocol. A reduction of median operation time from 60 (CC) to 40 minutes (FT) (P<0.001) and a reduction in median length of hospital stay from three to two days (P=0.001), with a significant reduction in early postoperative complications (9.9% [CC] vs. 5% [FT], P=0.016) was achieved. The amount of late complications was comparable for both groups (5.1% [CC] vs. 4.4% [FT] [P=0.738]).

CONCLUSIONS

Implementation of a fast-track protocol for sleeve gastrectomy is safe and efficient. It effectively reduces operation time and length of hospital stay, while improving postoperative outcome. This pleads for standard implementation of the fast-track protocol in sleeve gastrectomy.

Very low-carbohydrate ketogenic diet before bariatric surgery: prospective evaluation of a sequential diet

BACKGROUND

We evaluated the effectiveness of a sequential diet regimen termed the obese preoperative diet (OPOD) in morbidly obese patients with and without type 2 diabetes mellitus (T2DM) scheduled for laparoscopic bariatric surgery.

METHODS

Fifty patients (body mass index 53.5 ± 8.4 kg/m(2)) scheduled for bariatric surgery, including 14 with T2DM, were prospectively enrolled and followed the OPOD regimen: a very low-calorie ketogenic diet for 10 days, followed by a very low-calorie diet for 10 days, and then a low-calorie diet for 10 days. Patients were evaluated at baseline (T0) and after 10 days (T1), 20 days (T2), and 30 days (T3).

RESULTS

Body weight, body mass index, waist circumference, and neck circumference were significantly lower at T1, T2, and T3 than at T0 in the 48 patients who completed the OPOD. Two patients discontinued the OPOD after 4-7 days. In patients with T2DM, fasting plasma glucose levels decreased significantly, enabling reduction of diabetic medications. Plasma and urine ketone levels increased at T1 but were all <1 mmol/L, and hunger decreased during the diet period.

CONCLUSIONS

OPOD, including 10 days of a VLCKD, was safe and effective in morbidly obese patients, and it seems to be promising in morbidly obese patients with and without T2DM scheduled for laparoscopic bariatric surgery.

Identificação dos diagnósticos de enfermagem da classe de respostas cardiovasculares/pulmonares em pacientes submetidos à cirurgia bariátrica

O objetivo deste estudo foi identificar as respostas humanas apresentadas por pacientes no pós-operatório de cirurgia bariátrica que se configurem como diagnósticos de enfermagem da classe respostas cardiovasculares/pulmonares. Estudo observacional de caráter transversal realizado no período de julho de 2010 a maio de 2011, em um hospital referência em cirurgia bariátrica em Fortaleza-CE. Os diagnósticos de enfermagem identificados foram: risco de perfusão gastrintestinal ineficaz (87,9%), risco de intolerância à atividade (70,7%), perfusão tissular periférica ineficaz (67,2%), risco de choque (63,8%), débito cardíaco diminuído (60,3%), risco de perfusão tissular cardíaca diminuída (58,6%), intolerância à atividade (51,7%), risco de perfusão tissular cerebral ineficaz (48,3%), ventilação espontânea prejudicada (46,5%), risco de perfusão renal ineficaz (43,1%), padrão respiratório ineficaz (37,9%) e resposta disfuncional ao desmame ventilatório (36,2%). Assim, com base nesses resultados será possível direcionar a assistência de enfermagem prestada aos pacientes submetidos à cirurgia bariátrica e, consequentemente, reduzir complicações pós-operatórias.