Enhanced Recovery after Bariatric Surgery in the Severely Obese, Morbidly Obese, Super-Morbidly Obese and Super-Super Morbidly Obese Using Evidence-Based Clinical Pathways: a Comparative Study

Sinha, Aparna; Jayaraman, Lakshmi; Punhani, Dinesh; Chowbey, Pradeep

doi:10.1007/s11695-016-2366-y

Cited by 54 publications

(29 citation statements)

References 37 publications

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“…In numerous papers, we found significant correlations of some patient-dependent factors and comorbidities on readmission rates, i.e., higher BMI and ASA class, diabetes mellitus, cardio-vascular, respiratory, renal co-morbidities, and chronic steroid intake, protein malnutrition were showed to be associated with increased risk of readmission [ 21 , 25 , 34 , 35 , 38 , 39 ]. Treating patients in accordance to ERAS protocol probably contributed to non-significant relationship of preoperative ASA class and comorbidities with the risk of postoperative readmissions in our study [ 6 , 7 , 15 , 16 , 44 ]. We, as other researchers did, determined that BMI was not found to be a predictor of readmission [ 34 , 45 , 46 ].…”

Section: Discussionmentioning

confidence: 99%

“…Patients were treated in accordance with the principles of multimodal ERAS pathway, including preoperative, intraoperative, and postoperative interventions [ 2 , 6 , 14 – 16 ]. Preoperative interventions included extensive perioperative counseling, shortened fluid fasts, preoperative high protein and carbohydrate drink, and optimized operating scheduling times.…”

Section: Methodsmentioning

confidence: 99%

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Risk Factors for Prolonged Length of Hospital Stay and Readmissions After Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-en-Y Gastric Bypass

Major

Wysocki

Torbicz³

et al. 2017

OBES SURG

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BackgroundLaparoscopic 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.MethodsThe 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.ResultsMedian 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.ConclusionsRisk 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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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Risk Factors for Prolonged Length of Hospital Stay and Readmissions After Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-en-Y Gastric Bypass

Major

Wysocki

Torbicz³

et al. 2017

OBES SURG

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“…Notwithstanding the potential benefits of improved preoperative health associated with weight loss on postoperative outcomes, taken together, these studies argue against weight loss as a prerequisite for bariatric surgery, since a likely adverse effect of failure is denial of a potentially life‐saving procedure (i.e., denial of a timely bariatric procedure). Routine prehabilitation clinical pathways that include deep breathing exercises, CPAP as appropriate, incentive spirometry, leg exercises, sips of clear liquids up to 2 hours preoperatively, H2 blocker or proton‐pump inhibitor, thromboprophylaxis, and education about perioperative protocols, in conjunction with intraoperative and postoperative ERABS protocols, are associated with improved outcomes .…”

Section: Executive Summarymentioning

confidence: 99%

“…Enhanced recovery can only be accomplished with an interdisciplinary strategy to manage key components of the early postoperative care plan to include multimodal pain management strategies , minimization of opioid use during and after surgery , goal‐directed fluid management, and tight glycemic control. Ideally, ERABS is combined with preoperative prehabilitation and comorbidity optimization, as well as evidence‐based intraoperative clinical pathways . Implementation of ERABS in patients decreases length of hospital stay without increasing morbidity, readmission rates , or postdischarge resource utilization .…”

Section: Executive Summarymentioning

confidence: 99%

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

Mechanick

Apovian

Brethauer

et al. 2020

Obesity

340

464

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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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“…Postoperative CPAP is used for patients who have an OSAS and/or OHS diagnosis, with their own nasal CPAP-apparatus. However, to create a real ERAS praxis for bariatric surgery, our cooperation with preand post-operative ward units needs further re inement [35].…”

Section: Discussionmentioning

confidence: 99%

The incidence of hemodynamic and respiratory adverse events in morbidly obese presenting for Bariatric surgery

Myrberg¹

2018

Int J Clin Anesth Res

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Context: Perioperative management of morbidly obese patients undergoing bariatric surgery is challenging. Lacking standardized perioperative protocols, complication rates may be high. This retrospective study aims to quantify the incidence of signifi cant blood pressure decreases on induction of anesthesia and intraoperative hypoxemia, before implementation of a standardized protocol designed for bariatric surgery.Design: Retrospective, observational study.Setting: A 250-bed county hospital in northern Sweden. Subjects: 219 morbidly obese patients (body mass index > 35 kg/m2) who underwent bariatric surgery between 2003 and 2008.Main outcome measures: Incidence of systolic blood pressure (SAP) falls to less than 70% of the preoperative baseline during induction of anesthesia and incidence of perioperative hypoxemia. Results:The incidence of confi rmed SAP falls to below 70% of baseline at induction of anesthesia was 56.2% (n = 123/219). This incidence rose with increasing age (p < 0.001) but not with body mass index (BMI). 3.7% (n = 8/219) of cases were marked as diffi cult intubations. A transient period of hypoxemia was observed in 6.8% (n = 15/219) and was more common with increasing BMI (p = 0.005). Fourteen different drug combinations were used in the study population. Of those administered an induction anesthetic drug, 72.6% (n = 159/193) were given an overdose when calculated by lean body weight, but this did not correlate signifi cantly to SAP falls (p = 0.468). Conclusions:The incidence of a signifi cant blood pressure fall upon induction of anesthesia was common. The incidence of airway and ventilation problems were low. Overdosing of anesthetics and excessive variation in applied anesthesia methods were found.How to cite this article: Atterhem V, Hultin M, Myrberg T. The incidence of hemodynamic and respiratory adverse events in morbidly obese presenting for Bariatric surgery. Int J Clin Anesth Res. 2018; 2: 009-017. https://dx.

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Enhanced Recovery after Bariatric Surgery in the Severely Obese, Morbidly Obese, Super-Morbidly Obese and Super-Super Morbidly Obese Using Evidence-Based Clinical Pathways: a Comparative Study

Cited by 54 publications

References 37 publications

Risk Factors for Prolonged Length of Hospital Stay and Readmissions After Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-en-Y Gastric Bypass

Risk Factors for Prolonged Length of Hospital Stay and Readmissions After Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-en-Y Gastric Bypass

The incidence of hemodynamic and respiratory adverse events in morbidly obese presenting for Bariatric surgery

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