Evidence-Based Clinical Pathways to Improve Anesthetic Outcomes in Bariatric Surgery

Studies have assessed the feasibility of fast-track surgery in patients undergoing bariatric surgery. However, findings from a recent study published in Obesity Surgery showed that the degree of obesity influences the postoperative course and the anesthetic outcome of patients.

Existing literature on enhanced recovery after surgery/anesthesia (ERAS) protocols focuses on surgical outcome parameters, with very limited data on anesthetic outcome for the obese, particularly for super-morbidly obese and super-super morbidly obese. This led Aparna Sinha, MBBS, Max Super Specialty Hospital (New Delhi, India), and colleagues to conduct a comparative study on anesthetic outcome data following evidence-based clinical pathways focused on prehabilitation, preoperative optimization, and ERAS.
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The retrospective analysis of 823 patients who underwent laparoscopic bariatric surgery assessed the effects of body mass index (BMI) on the recovery and anesthetic outcome parameters. Data collected from electronic medical records included age, gender, BMI, preexisting conditions, prevalence of obstructive sleep apnea (OSA), preoperative noninvasive ventilation (NIV) requirement, and functional capacity. Patients were categorized into severely obese (BMI < 39.9 kg/m2), morbidly obese (BMI 40-49.9 kg/m2), super-morbidly obese (BMI 50-59.9 kg/m2), and super-super morbidly obese (BMI > 60 kg/m2). The primary endpoint was effect of BMI on time to ambulate, and the secondary endpoint assessed and compared the outcome parameters between the BMI groups.

The groups were not significantly different for incidence of hypertension, diabetes mellitus, and osteoarthritis. However, there was significant difference in the prevalence of OSA, with 92.6% of super-super morbidly obese patients experiencing this sleep disorder. Additionally, significant difference was found in the frequency of OSA patients requiring NIV in the preoperative period across BMI groups; the overall prevalence of OSA in the study group was 54%. Anesthesia duration across the groups differed significantly, with maximum duration in the super-super morbidly obese group (159 ± 41). 

Requirement for NIV was the only significant predictor of time to ambulate and discharge readiness; the discharge readiness was further affected by functional capacity and presence of chest pain. The analysis indicated that each unit increase in BMI contributed to increase in ambulation by 1.24 minutes (95% confidence interval [CI], 0.648 to 1.832 min; P < .001) and discharge readiness by 0.52 hour (95% CI, 0.435 to 0.606 h; P < .001). The researchers said this could be attributed to greater prevalence of patients walking with support in the higher BMI groups: super-morbidly obese (11.2%) and super-super morbidly obese (10.3%). The odds ratio for requirement of NIV (per unit change in BMI) was 1.1163 (95% CI, 1.127/1.197; P < .001).

“Practice of prehabilitation and preoperative optimization of comorbidities using evidence-based clinical pathways can complement the principles of ERAS in patients undergoing bariatric surgery and contribute to improvement in the anesthetic outcomes, minimize the short-term morbidities, and facilitate discharge readiness,” concluded the researchers.—Eileen Koutnik-Fotopoulos

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Sinha A, Jayaraman L, Punhani D, Chowbey P. 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 [published online ahead of print September 6, 2016]. Obes Surg. doi:10.1007/s11695-016-2366-y.