Introduction
Methods
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Grading of evidence and recommendations
Results: evidence base and recommendations
Element | Recommendation | Level of evidence | Recommendation grade |
---|---|---|---|
1. Information, education and counselling | Preoperative information and education, adapted to the individual requirements, should be given to all patients | Low | Strong |
2. Indications and contraindications for surgery | Indications for bariatric surgery should follow updated global and national guidelines | Moderate | Strong |
3a. Smoking and alcohol cessation | All patients should be screened for alcohol and tobacco use. Tobacco smoking should be stopped at least 4 weeks before surgery. For patients with alcohol abuse, abstinence should be strictly adhered to for 1–2 years. Moreover, the risk for relapse after bariatric surgery should be acknowledged | Smoking: Moderate | Strong |
Alcohol: Low | Strong | ||
3b. Preoperative weight loss | Preoperative weight loss using very low or low-calorie diet prior to bariatric surgery should be recommended | Postoperative complications: Moderate | Strong |
While feasible, patients with diabetes and treatment with glucose-lowering drugs should closely monitor treatment effects, and be aware of the risk for hypoglycaemia. Very low calorie diet improves insulin sensitivity in patients with diabetes | Postoperative weight loss: Low | Strong | |
Diabetes: Low | Strong | ||
4. Prehabilitation and exercise | Although prehabilitation may improve general fitness and respiratory capacity, there is insufficient data to recommend prehabilitation before bariatric surgery | Low | Weak |
Element | Recommendation | Level of evidence | Recommendation grade |
---|---|---|---|
5. Supportive pharmacological intervention | 8 mg intravenous dexamethasone should be administered preferably 90 min prior to induction of anaesthesia for reduction of PONV as well as inflammatory response | Glucocorticoids: Low | Weak |
There is insufficient evidence to support perioperative statins for statin-naive patients in bariatric surgery. Patients on statins can safely continue the treatment during the perioperative phase | Statins: Very low | Weak | |
Beta-adrenergic blockade does not influence the risk for adverse outcomes in bariatric surgery, but can be safely continued during the perioperative phase for patients at high risk of cardiovascular events | Beta-adrenergic blockade: Low | Weak | |
6. Preoperative fasting | Solids until 6 h before induction and clear liquids until 2 h before induction for elective bariatric surgery assuming no contraindications (e.g., gastroparesis, bowel obstruction) | Low | Strong |
Patients with diabetes should follow these recommendations, but further studies are needed for patients with additional risk factors such as gastroparesis | Low | Strong | |
7. Carbohydrate loading | There is insufficient evidence to make a recommendation about preoperative carbohydrate loading in bariatric surgery | Low | Weak |
8. PONV | A multimodal approach to PONV prophylaxis should be adopted in all patients | High | Strong |
Element | Recommendation | Level of evidence | Recommendation grade |
---|---|---|---|
8. Perioperative fluid management | The goal of perioperative fluid management is to maintain normovolemia and optimize tissue perfusion and oxygenation. Individual goal-directed fluid therapy is the most effective strategy, avoiding both restrictive or liberal strategies | Moderate | Strong |
Colloid fluids do not improve intra- and postoperative tissue oxygen tension compared with crystalloid fluids and do not reduce postoperative complications | Low | Weak | |
9. Standardized anaesthetic protocol | The current evidence does not allow recommendation of specific anaesthetic agents or techniques | Low | Weak |
Opioid-sparing anaesthesia using a multimodal approach, including local anaesthetics, should be used in order to improve postoperative recovery | High | Strong | |
Whenever possible, regional anaesthetic techniques should be performed to reduce opioid requirements. Thoracic epidural analgesia should be considered in laparotomy | Low | Weak | |
BIS monitoring of anaesthetic depth should be considered where ETAG monitoring is not employed | Low | Strong | |
10 Airway management | Anaesthetists should recognize and be prepared to handle the specific challenges in airways in patients with obesity | Moderate | Strong |
Endotracheal intubation remains the main technique for intraoperative airway management | Moderate | Strong | |
11. Ventilation strategies | Lung protective ventilation should be adopted for all patients undergoing elective bariatric surgery with avoidance of high PEEP values | Moderate | Strong |
Increases in driving pressure resulting from adjustments in PEEP should ideally be avoided | Low | Strong | |
PCV or VCV can be used for patients with obesity with inverse respiratory ratio (1.5:1) | Low | Strong | |
Positioning in a reverse Trendelenburg, flexed hips, reverse- or beach chair positioning, particularly in the presence of pneumoperitoneum, improves pulmonary mechanics and gas exchange | Low | Weak | |
12. Neuromuscular blockade | Deep neuromuscular blockade improves surgical performance | Low | Strong |
Ensuring full reversal of neuromuscular blockade improves patient recovery | Moderate | Strong | |
Objective qualitative monitoring of neuromuscular blockade improves patient recovery | Moderate | Strong | |
14. Surgical technique, volume and training | Laparoscopic approach whenever possible | High | Strong |
During the learning curve phase, all operations should be supervised by a senior surgeon with significant experience in bariatric surgery | Training: Low | Strong | |
There is a strong association between hospital volume and surgical outcomes at least up to a threshold value | Hospital volume: Low | Strong | |
15. Abdominal drainage and nasogastric decompression | Nasogastric tubes and abdominal drains should not be used routinely in bariatric surgery | Weak | Strong |
Element | Recommendation | Level of evidence | Recommendation grade |
---|---|---|---|
16. Postoperative oxygenation | Patients without OSA or with uncomplicated OSA should be supplemented with oxygen prophylactically in a head-elevated or semi-sitting position. Both groups can be safely monitored in a surgical ward after the initial PACU stay. A low threshold for non-invasive positive pressure ventilation should be maintained in the presence of signs of respiratory distress | Oxygen supplementation: Low | Strong |
Position in the postoperative period: High | |||
Patients with OSA on home CPAP therapy should use their equipment in the immediate postoperative period | Moderate | Strong | |
Patients with obesity hypoventilation syndrome (OHS) are at higher risk of respiratory adverse events. Postoperative BiPAP/NIV should be considered liberally during the immediate postoperative period, in particular in the presence of hypoxemia | Low | Strong | |
17. Thromboprophylaxis | Thromboprophylaxis should involve mechanical and pharmacological measures. Doses and duration of treatment should be individualized | High | Strong |
18. Early postoperative nutritional care | A clear liquid meal regimen can usually be initiated several hours after surgery | Moderate | Strong |
All patients should have access to a comprehensive nutrition and dietetic assessment with counselling on the macronutrient and micronutrient content of the diet based on the surgical procedure and the patient’s nutritional status | Moderate | Strong | |
Patients and healthcare professionals should be aware of the risks of thiamine deficiency, especially in the early postoperative periods | Low | Strong | |
19. Supplementation of vitamins and minerals | A regimen of life-long vitamin and mineral supplementation and nutritional biochemical monitoring is necessary | High | Strong |
20a. PPI prophylaxis | PPI prophylaxis should be considered for at least 30 days after Roux-en-Y gastric bypass surgery | RYGB: Moderate | Strong |
There is not enough evidence to provide a recommendation of PPI prophylaxis for sleeve gastrectomy, but given the high numbers of patients with gastroesophageal reflux after this procedure, it may be considered for at least 30 days after surgery | SG: Very Low | Weak | |
20b. Gallstone prevention | Ursodeoxycholic acid should be considered for 6 months after bariatric surgery for patients without gallstones at the time of surgery | Moderate | Strong |