Ultra Fast-Track Pathways for Bariatric Surgery

This ongoing column is authored by members of the International Society for the Perioperative Care of the Obese Patient (ISPCOP), an organization dedicated to the bariatric patient.

Column Editor: Stephanie B. Jones, MD

Dr. Jones is Associate Professor, Harvard Medical School and Vice Chair for Education, Department of
Anesthesia, Critical Care and Pain Medicine, Beth Israel
Deaconess Medical Center, Boston, Massachusetts.

This month’s installment by:  Marilu Giacalone, MD; Shantale Cyr, PhD; Nicola Pagnucci, MSN; and Thomas M. Hemmerling, MSc, MD, DEAA
Dr. Giacalone and N Pagnucci are from the Department of Anesthesia, University of Pisa, Pisa, Italy. Drs. Cyr and Hemmerling are from the Department of Anesthesia, McGill University, Montreal, Canada.

Bariatric Times. 2013;10(9):16–19.ABSTRACT
Advances in surgery and anesthesia yield bariatric surgery as a short-stay procedure. Short-stay bariatric surgery can be successfully performed applying an ultra fast-track pathway, which consists in a multidisciplinary perioperative management focused on the patient, with the aim to enhance recovery and improve outcome. Many components are involved, including adequate selection of patients, preoperative preparation, minimally invasive surgery, experienced team, dedicated facilities, possibility of follow up, and the application of several strategies that reduce surgical stress. These elements make short-stay bariatric surgery effective and safe. If correctly implemented, the ultra fast-track pathway leads to home discharge on the same day of surgery. Ultra fast-track pathways can be a real opportunity to enhance postoperative recovery of bariatric patients, decrease morbidity and mortality, and further decrease health costs.

Introduction
Bariatric surgery is an effective and acceptable therapy for obesity and related comorbidities. In the last 15 years many innovations have been introduced either to the surgical technique or to the anesthesia management to enhance the recovery and improve the outcome of bariatric surgery, without compromising patient safety. Because of these improvements and an increased need for bariatric surgery, a prolonged stay in the hospital is no longer justified.

Ultra fast-track pathways
How to do it. A fast-track pathway indicates a multidisciplinary strategy to enhance postoperative recovery and decrease morbidity by reducing surgical stress and its consequences (stress-free surgery).[1] The length of stay in the hospital is significantly reduced in comparison to traditional management strategies.[2] A further evolution is the ultra fast-track pathway, including immediate extubation at the end of the surgery, very early functional recovery,[3] and discharge from the hospital on the same day. Its application to bariatric surgery allows favorable outcomes, equivalent to traditional management strategies.[4,5] The implementation of this pathway is based on the following three elements: the features of the surgery, the particularities of patients,[2] and the optimization of all aspects of perioperative care.[6] Examples of ultra fast-track components are detailed patient information, adequate dietary preparation, specific anesthetic protocols, minimally invasive surgery, and early mobilization.[1,6] A collaboration between surgeons, anesthesiologists, nurses, and physiotherapists is essential to properly achieve this.[1] A successful outcome of ultra fast-track bariatric surgery depends on the presence of a dedicated professional team7 and an appropriate logistic organization.

Surgical aspects. Laparoscopic surgery is most suitable for ultra fast-track pathways. It has a minimally invasive approach, leading to less postoperative complications and pain,[6,7] as well as less interference with pulmonary function, thus facilitating recovery.[8] Laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (RYGB) are the surgeries most frequently associated with ultra fast-track pathways.[9] Discharge on the same day of surgery is safe and effective. A careful patient selection; an experienced surgical, anesthetic, and nursing team; and the possibility of postoperative observation and follow up are key elements to avoid complications and keep hospital readmission rates low for both LAGB[9–13] and RYBG.[,14–17] These advantages are even possible in patients with morbid obesity undergoing LAGB.18 Costs remain low.5 Ultra fast-track pathways have also been implemented in laparoscopic sleeve gastrectomy (LSG)[19] and abdominoplasty.[20,21] Other considerations include the following: short duration of the surgery, high procedure volume, and the proximity to a tertiary level hospital for the management of possible complications.

In the case of RYGB, intraoperative tests to detect leaks (i.e., dye test) do not have a high sensitivity.[22] In an ultra fast-track context the tests may not be performed routinely according to the preferences of the surgeon, the features of the patient, and their local availability. Similarly, there is evidence supporting selective rather than routine radiological tests after RYGB, for the reasons cited previously.[22] Therefore, an experienced bariatric team as well as a careful follow up after the surgery remains essential to early detection of any complication.

Patient selection. The body mass index (BMI) or absolute weight alone does not influence the feasibility of ultra fast-track surgery.[23,24] BMI should considered along with the presence of comorbidities and their level of compensation, the approach and the duration of the surgery, and the type of anesthesia and drugs.[25,26] Patients without significant comorbidities can safely undergo ultra fast-track bariatric surgery. Patients with respiratory or cardiovascular comorbidities (e.g., coronary and valvular diseases, arrhythmias, asthma, diabetes),[13] which are well controlled with therapy, can also undergo ultra fast-track surgery. Exclusion criteria for ultra-fast track bariatric surgery are summarized in Table 1. All patients undergoing bariatric surgery should be screened for the presence of obstructive sleep apnea (OSA) using specific questionnaires, such as the STOP-BANG (Snoring, Tiredness during daytime, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, Gender) questionnaire.[26,27] The risk of perioperative complications is then determined using the American Society of Anesthesiologists (ASA) score.[28] It considers the severity of obstructive sleep apnea (OSA), the invasiveness of the surgery, and the need for postoperative opioids. The ultra fast-track pathway is not advisable if the ASA score is higher than 5.[25] A resting PaCO2 greater than 50mmHg increases this score, while the presence of positive pressure ventilation therapy decreases it. Since bariatric surgery is a form of abdominal surgery to be performed under general anesthesia, in the presence of a severe OSA or an obesity hypoventilation syndrome (OHS), ultra fast-track pathway is not applicable.[25,29] Patients with OSA can undergo laparoscopic bariatric surgery with low morbidity and mortality.[30] An effective selection of patients requires a careful evaluation prior to surgery (around 1 month) in order to optimize the management of comorbidities and plan appropriate preoperative tests focused on specific patient issues.[31] An algorithm for preoperative management in day-case procedures is seen in Figure 1.[26] Patient selection also involves the patient’s acceptance of being discharged the day of the surgery and the availability of a caregiver.[31]

Perioperative management. All patients undergoing bariatric surgery should be informed of the physiological changes induced by it.[6] Patients undergoing ultra fast-track bariatric surgery should be provided with detailed information and clear explanations to increase motivation and reduce anxiety. This helps patients to be adherent and accelerate their recovery. Preoperative calorie restriction and aerobic exercise are recommended to improve cardio-respiratory reserve and facilitate the implementation of bariatric laparoscopy.[6] Smoking and alcohol cessation should be encouraged.[2]

Patients should arrive at the hospital early in the morning of the surgery, between 6:30 and 8:00AM[32] to be prepared and receive prophylactic treatments. Preoperative fasting should include two hours for clear fluids and six hours for solid foods.[1,2,33] A carbohydrate oral loading (e.g., 50mg of carbohydrates in 400mL 2 hours before surgery) can be useful to avoid dehydration and improve insulin resistance.[33] The strategies for the management of deep venous thrombosis prophylaxis vary among patients. In severely obese patients with OSA, pharmacologic and mechanic prophylaxis is recommended.[8,18] For example, dalteparin 2500 IU subcutaneous preoperatively plus 5000 IU daily during the following week, along with intraoperative, intermittent pneumatic compression.[8] In other patients, tensor bandages or antithrombosis stockings plus one preoperative dose of low-molecular-weight heparin (i.e., enoxaparin 4000 IU subcutaneous)[6] may be sufficient. The antibiotic prophylaxis should be adapted to the degree of gastrointestinal manipulation and patient tolerability. For example, metronidazole 1500mg and cefuroxim 1500mg intravenously (IV) are commonly used.[34] Premedication should include gastric secretion inhibitors to reduce the risk of aspiration (e.g., ranitidine 50mg IV35 or cimetidine 400mg oral)[19] IV sedatives are not necessary in ultra fast-track protocols.

Intraoperative management. Anesthetic management is based on the S.A.F.E. principle, which stands for short acting drugs facilitating fast emergence.[31] For the induction of general anesthesia, remifentanil, propofol and rocuronium, or cisatracurium are adequate.[12] Among opioids, remifentanil is a drug of choice because of the lack of accumulation, particularly useful for laparoscopic procedures with minimal to moderate postoperative pain. The dose is calculated using the ideal body weight (IBW)[36] (infusion: 0.1–0.5µg/kg/min). The standard inductive dose of propofol is 2–2.5mg/kg of lean body weight (LBW).[37] A target controlled infusion can also be used reaching a concentration of 6µg/mL.[34] The dose of rocuronium should be 0.6–1mg/kg of IBW.8 Succinylcholine should be administered in the case of rapid sequence induction (RSI) (1mg/kg of total body weight, TBW), in the absence of contraindications, and when sugammadex is unavailable for the reversal of rocuronium.[38] RSI is important in patients with obesity with symptomatic gastroesophageal reflux, gastroparesis, emergency surgery, and intestinal obstruction.[39] Ultra fast-track bariatric surgery is elective, patients follow a fast time and gastroesophageal reflux is optimized in the preoperative period (therapy at home, premedication). Thus, the role of succinylcholine remains limited in this context.

Preoxygenation and endotracheal intubation should be performed in the 25-degree, head-up position or the head elevated laryngoscopy position (HELP).[8] These measures, along with the delivery of 100-percent oxygen and a positive end expiratory pressure (PEEP) of 10cm H2O during preoxygenation, reduce post-intubation atelectasis and improve oxygenation.[8] It has been reported an increased incidence of aspiration associated to the use of laryngeal mask airway (LMA) in patients.[40] Today, ultrasonography offers the possibility to rapidly detect the presence of gastric fluid[41] as well as the correct placement of an LMA.[42] The use of an LMA could not be excluded a priori, especially that of the most recent models in selected patients (i.e., no severe obesity, no evidence of gastroesophageal reflux, no increased reactivity of airways). Any additional equipment for difficult intubation should always be present in the operating room. Pressure-controlled ventilation with tidal volumes based on IBW (e.g., 6–8mL/kg) and a PEEP of 10 to 15cm H2O helps to preserve pulmonary function in laparoscopic bariatric surgery.[8] The maintenance of general anesthesia is based on propofol (50–200µg/kg/min)[5] or desflurane (3–6%),34 titrated to maintain a bispectral index of 40 to 50.

Other intraoperative strategies, which reduce stress and systemic inflammation, include the following: goal-directed fluid therapy, warming, avoidance of routine nasogastric tube and abdominal drainages, postoperative nausea vomiting (PONV) prophylaxis, and glucocorticoid administration.[1,6] Goal-direct fluid therapy indicates the optimization of IV fluid administration based on variations of hemodynamic parameters.[6] The gold standard is the use of esophageal Doppler,[2] but this is not applicable in an ultra-fast track setting. Fluid therapy should be administered according to clinically available parameters, such as noninvasive blood pressure, heart rate, oxygen saturation, spontaneous diuresis and sense of thirsty. PONV prophylaxis is important to promote an early gastrointestinal recovery and oral intake. Either a restriction or an excess of fluids should be avoided, as well as conventional reversal. An example of pharmacologic prophylaxis is dexamethasone 8mg and ondansetron 4 to 8mg, both IV;[6] metoclopramide (10mg IV) or low-dose droperidol (0.625mg IV) can be added in high-risk patients or in case of necessity.[8] Propofol anesthesia reduces the incidence of PONV significantly. A multimodal and opioid-sparing approach for postoperative analgesia is recommended to promote an early mobilization, less respiratory complications, PONV and paralytic ileus.[2,6] When remifentanil is used, pre-emptive analgesia—application of opioid/NSAID before the end of surgery—is necessary. A combination of nonsteroidal agents, acetaminophen, and local anesthetics, possibly associated with adjuvants, such as low-dose glucocorticoids and ketamin, is a reasonable choice.[12] This regimen does allow the use of opioids as rescue analgesia.[25] Examples are (IV): ketorolac 30mg,43 parecoxib 40mg,34 or acetaminophen 1g.[5,19] These drugs are administered intraoperatively, and they can be continued postoperatively and replaced by oral analgesics as soon as possible. Wound infiltration is suitably performed with long-acting agents, such as ropivacaine 150mg19 or bupivacaine 150 to 200mg.[34]

Postoperative management. Patients should be extubated at the end of surgery and transferred awake to the recovery room—very often, patients are awake enough to be able to transfer themselves from the operating table.[31] In the recovery room, they should be placed in a 25- to 30-degree head-up position, monitored and provided with supplemental oxygen, (e.g., using nasal cannulae). In patients with OSA, the duration of the monitoring should be three hours longer than non-OSA patients.[27] Patients should be encouraged and assisted in the implementation of physiotherapy exercises. Early mobilization and respiratory exercises are milestones of the ultra fast-track rehabilitation. Early mobilization improves patient recovery and outcome in terms of reduced length of stay, respiratory complications and need for analgesics.[44] Similarly, respiratory exercise helps to prevent pulmonary complications and promote lung function recovery in any form of bariatric surgery.[45] The beneficial effects of physiotherapy are obtained in the presence of an adequate antalgic control. Since opioids may cause orthostatic instability and respiratory depression, multimodal and opioid-sparing analgesia is a necessary prerequisite for ultra fast-track pathways.[44] Examples of physiotherapy for ultra fast-track bariatric surgery are shown in Table 2. If the course is uneventful, after around three hours patients can be mobilized with the help of some members of the staff.[32] They can also be allowed to drink some tea or water; before this, they should be hydrated with IV fluids.[32] Thereafter, patients could begin a fluid oral intake and be tested for a short walk (e.g., walking outside of the recovery room or going to the restroom).[34] If problems arise in this phase, such as dysphagia or more pain than expected, surgeons should be alerted and perform a clinical evaluation. The patient should possibly be assessed by instrumental tests (e.g., contrast tests). Criteria for the discharge home are no signs of airway obstruction, saturation at the preoperative level with room air,25 sufficient control of pain and no PONV, full oral liquid intake, ability to ambulate, possibility of a follow up (by telephone and presence during the following days).[46] Patients should also be provided with appropriate postoperative instructions.

Conclusion
Ultra fast-track bariatric surgery (Figure 2) requires dedicated facilities, as well as the involvement of several experienced professionals. The minimally invasive, stress- and pain-free approach allows for an early mobilization and recovery of physiological functions. If correctly implemented, and patients adequately selected, it can be successfully used in the majority of patients undergoing bariatric surgery, with good short- and long-term outcomes and decreased costs for the health care system.

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Funding: No funding was provided.

Disclosures: The authors do not have any conflicts of interest relevant to the content of this article.

Category: Anesthetic Aspects of Bariatric Surgery, Past Articles