Skip to main content
SpringerLink
Log in

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

  • Original Contributions
  • Published:
Obesity Surgery Aims and scope Submit manuscript

Abstract

Background

We discuss the anesthetic outcome in morbidly obese patients under the enhanced recovery after surgery (ERAS) protocol. Our evidence-based clinical pathways focused on prehabilitation and included interventions like aggressive preoperative optimization of medical comorbidities, familiarizing with perioperative protocols, thromboprophylaxis, opioid free multimodal analgesia, and early ambulation.

Methods

We did a retrospective analysis of prospectively collected data of 823 patients who underwent laparoscopic bariatric surgery. Our goal was to assess the effects of BMI on the recovery and anesthetic outcome parameters, under the categories of severely obese (SeO: BMI <39.9 kg/m2), morbidly obese (MO: BMI 40–49.9 kg/m2), super-morbidly obese (SMO: BMI 50–59.9 kg/m2), and super-super morbidly obese (SSMO: BMI >60 kg/m2). Time to ambulate (TA) was the primary variable.

Results

Requirement for non-invasive ventilation (NIV) was the only significant predictor of TA and discharge readiness (DR); the DR was further affected by functional capacity and presence of chest pain. Our analysis indicated that each unit increase in BMI (kg/m2) contributes to increase in ambulation time by 1.24 min (95 % CI: 0.648 to 1.832 min; P < 0.001) and DR by 0.52 h (95 % CI: 0.435 to 0.606 h; P < 0.001). The odds ratio for requirement for NIV (per unit change in BMI) was 1.163 (CI: 1.127/1.197; P < 0.001).

Conclusions

Aggressive preoperative optimization can avert effects of BMI on anesthetic outcome. Practice of prehabilitation and preoperative optimization of comorbidities using evidence-based clinical pathways can complement the principles of ERAS in patients undergoing bariatric surgery to facilitate their discharge readiness.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Kariv Y, Delaney CP, Senagore AJ, et al. Clinical outcomes and cost analysis of a “fast track” postoperative care pathway for ileal pouch-anal anastomosis: a case control study. Dis Colon rectum. 2007;50(2):137–46.

  2. Varadhan KK, Lobo DN, Ljungqvist O. Enhanced recovery after surgery: the future of improving surgical care. Crit Care Clin. 2010;26:527–47.

    Article  PubMed  Google Scholar 

  3. Bamgbade OA, Adeogun BO, Abbas K. Fast-track laparoscopic gastric bypass surgery: outcomes and lessons from a bariatric surgery Service in the United Kingdom. Obes Surg. 2012;22:398–02.

    Article  PubMed  Google Scholar 

  4. Chaar M, Claros L, Ejeji G, et al. Improving outcome of bariatric surgery: best practices in an accredited surgical center. Obes Surg. 2014;24:1057–63.

    PubMed  Google Scholar 

  5. Barreca M, Renzi C, Tankel J, et al. Is there a role for enhanced recovery after laparoscopic bariatric surgery? Preliminary results from a specialist obesity treatment center. Surg Obes Relat Dis. 2016;12(1):119–26.

    Article  PubMed  Google Scholar 

  6. Waldhausen JH, Schirmer BD. The effect of ambulation on recovery from postoperative ileus. Ann Surg. 1990;212(6):671–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Delaney CP, Zutshi M, Senagore AJ, et al. Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Dis Colon rectum. 2003;46(7):851–9.

  8. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108:812–21.

    Article  PubMed  Google Scholar 

  9. Mokhlesi B, Margaret D, Vekhter H, et al. Sleep-disordered breathing and postoperative outcomes after bariatric surgery: analysis of the nationwide inpatient sample. Obes Surg. 2013;23(11):1842–51.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Barbalho-Moulim MC, Miguel GP, Forti EM, et al. Effects of preoperative inspiratory muscle training in obese women undergoing open bariatric surgery: respiratory muscle strength, lung volumes, and diaphragmatic excursion. Clinics (Sao Paulo). 2011;66:1721–7.

    Article  Google Scholar 

  11. Lemanu DP, Srinivasa S, Singh PP, et al. Optimizing perioperative care in bariatric surgery patients. Obes Surj. 2012;22:979–90.

    Article  Google Scholar 

  12. Krenk L, Jennum P, Kehlet H. Sleep disturbances after fast-track hip and knee arthroplasty. Br J Anaesth. 2012;109(5):769–75.

    Article  CAS  PubMed  Google Scholar 

  13. Yue HJ, Guilleminault C. Opioid medication and sleep-disordered breathing. Med Clin North Am. 2010;94:435–46.

    Article  CAS  PubMed  Google Scholar 

  14. Casati A, Putzu M. Anesthesia in the obese patient: pharmacokinetic considerations. J Clin Anesth. 2005;17:134–45.

    Article  CAS  PubMed  Google Scholar 

  15. Bernards CM, Knowlton SL, Schmidt DF, et al. Respiratory and sleep effects of remifentanil in volunteers with moderate obstructive sleep apnea. Anesthesiology. 2009;110:41–9.

    Article  CAS  PubMed  Google Scholar 

  16. Sinha A, Jayaraman Punhani D. Efficacy of ultrasound guided TAP block for pain management after laparoscopic gastric bypass. Obes Surg. 2013;23:548–53.

    Article  PubMed  Google Scholar 

  17. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2008;133:381S–53S.

    Article  CAS  PubMed  Google Scholar 

  18. Magee CJ, Barry J, Javed S, et al. Extended thromboprophylaxis reduces incidence of postoperative venous thromboembolism in laparoscopic bariatric surgery. Surg Obes Relat Dis. 2010;6:322–5.

    Article  PubMed  Google Scholar 

  19. Raftopoulos I, Martindale C, Cronin A, et al. The effect of extended post-discharge chemical thromboprophylaxis on venous thromboembolism rates after bariatric surgery: a prospective comparison trial. Surg Endosc. 2008;22:2384–91.

    Article  PubMed  Google Scholar 

  20. Jense HG, Dubin SA, Siverstein PI, et al. Effect of obesity on safe duration of apnea in anesthetized humans. Anesth Analg. 1991;72:89–93.

    Article  CAS  PubMed  Google Scholar 

  21. Eichenberger A, Proietti S, Wicky S, et al. Morbid obesity and postoperative pulmonary atelectasis: an underestimated problem. Anesth Analg. 2002;95:1788–92.

    Article  PubMed  Google Scholar 

  22. Juvin P, Lavaut E, Dupont H, et al. Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg. 2003;97:595–600.

    Article  PubMed  Google Scholar 

  23. Brodsky JB, Lemmens HJ, Brock-Utne JG, et al. Morbid obesity and tracheal intubation. Anesth Analg. 2002;94:732–6.

    Article  PubMed  Google Scholar 

  24. Gonzalez H, Minville V, Delanoue K, et al. The importance of increased neck circumference to intubation difficulties in obese patients. Anesth Analg. 2008;106:1132–6.

    Article  PubMed  Google Scholar 

  25. Coursa M, Proeitti S, Schnyder P, et al. Prevention of atelectasis formation during the induction of anesthesia in morbidly obese patients. Anesth Analg. 2004;98:1491–5.

    Google Scholar 

  26. Talab HF, Zabani IA, Abdelrahman HA, et al. Intraoperative ventilatory strategies for prevention of pulmonary atelectasis in obese patients undergoing laparoscopic bariatric surgery. Anesth Analg. 2009;109:1511–6.

    Article  PubMed  Google Scholar 

  27. Herriger A, Frascarolo P, Spahn DR, et al. The effect of positive airway pressure during pre-oxygenation and induction of anaesthesia upon duration of non-hypoxic apnoea. Anaesthesia. 2004;59:243–7.

    Article  CAS  PubMed  Google Scholar 

  28. Gander S, Frascarolo P, Suter M, et al. Positive end-expiratory pressure during induction of general anesthesia increases duration of nonhypoxic apnea in morbidly obese patients. Anesth Analg. 2005;100:580–4.

    Article  PubMed  Google Scholar 

  29. Bostanjian D, Anthone GJ, Hamoui N, et al. Rhabdomyolysis of gluteal muscles leading to renal failure: a potentially fatal complication of surgery in the morbidly obese. Obes Surg. 2003;13:302–5.

    Article  PubMed  Google Scholar 

  30. Szewczyk D, Ovadia P, Abdullah F, et al. Pressure induced rhabdomyolysis and acute renal failure. J Trauma. 1998;44:384–8.

    Article  CAS  PubMed  Google Scholar 

  31. Mognol P, Vignes SM, Chosidow D, et al. Rhabdomyolysis after laparoscopic bariatric surgery. Obes Surg. 2004;14:91–4.

    Article  PubMed  Google Scholar 

  32. Youssef T, Abd-Elaal I, Zakaria G, et al. Bariatric surgery: rhabdomyolysis after open roux-en-Y gastric bypass: a prospective study. Int J Surg. 2010;8:484–8.

    Article  PubMed  Google Scholar 

  33. Wool DB, Lemmens HJ, Brodsky JB, et al. Intraoperative fluid replacement and postoperative creatine phosphokinase levels in laparoscopic bariatric patients. Obes Surg. 2010;20:698–01.

    Article  PubMed  Google Scholar 

  34. Flegal KM, Graubard BI, Williamson DF, et al. Excess deaths associated with underweight, overweight, and obesity. JAMA. 2005;293:1861–7.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

Attestation: Aparna Sinha has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is responsible for archiving the study files. This author designed and conducted the study, analyzed the data, and wrote the manuscript.

Attestation: Lakshmi Jayaraman has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is responsible for archiving the study files.

Attestation: Dinesh Punhani has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is responsible for archiving the study files

Attestation: Pradeep Chowbey has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is responsible for archiving the study files.

Author information

Authors and Affiliations

  1. Max Super Speciality Hospital, East Wing, 2 Press Enclave Road, Saket, New Delhi, 110017, India

    Aparna Sinha, Lakshmi Jayaraman, Dinesh Punhani & Pradeep Chowbey

Authors
  1. Aparna Sinha
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lakshmi Jayaraman
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Dinesh Punhani
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Pradeep Chowbey
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Aparna Sinha.

Ethics declarations

This study was conducted in compliance with Good Clinical Practice (GCP) and in accordance with the ethical principles that have their origin in the Declaration of Helsinki Guidelines for Ethics in Research.

Informed Consent

Informed consent was obtained from all participants in the study.

Conflict of Interest

The authors declare that they have no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sinha, A., Jayaraman, L., Punhani, D. et al. 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. OBES SURG 27, 560–568 (2017). https://doi.org/10.1007/s11695-016-2366-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11695-016-2366-y

Keywords

Search

Navigation