Why is this important?

With obesity rates over 40% in many industrialised countries, and accelerating growth in bariatric surgery for more than a decade, there is need for evidence based guidelines to direct perioperative care.

This evidence review was conducted to identify protocols that achieve "superior outcomes, reduced length of hospital stay, and cost savings" for bariatric patients.

Many of the institutional protocols were founded on ERAS principals originating with colorectal surgery.

Ok, what did they identify?

The AHRQ made evidence-based anesthesia recommendations across three areas:

1. Preoperative: reduce fasting; provide carbohydrate loading; multimodal preanesthesia medication.
2. Intraoperative: standardised intraoperative anesthesia; protective ventilation; goal-directed fluid therapy (minimization); postop nausea and vomiting prophylaxis.
3. Postoperative: multimodal analgesia.

Reality check

These protocols largely reflect 'good quality modern anesthesia', and there is little here that is specific to bariatric patients.

This is not a critcism, but a reminder that it's consistent and holistic application of quality anesthesia across the perioperative period that improves outcomes – especially among higher risk patients. Interventions do not need to be fancy, just quality principles consistently applied.

summary

• Michael C Grant, Melinda M Gibbons, Clifford Y Ko, Elizabeth C Wick, Maxime Cannesson, Michael J Scott, Matthew D McEvoy, Adam B King, and Christopher L Wu.
• From the Department of Anesthesiology, The Johns Hopkins School of Medicine, Baltimore, Maryland.
• Anesth. Analg. 2019 Jul 1; 129 (1): 51-60.

AbstractEnhanced recovery after surgery protocols for bariatric surgery are increasingly being implemented, and reports suggest that they may be associated with superior outcomes, reduced length of hospital stay, and cost savings. The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery. We have conducted an evidence review to select anesthetic interventions that positively influence outcomes and facilitate recovery after bariatric surgery. A literature search was performed for each intervention, and the highest levels of available evidence were considered. Anesthesiology-related interventions for pre- (carbohydrate loading/fasting, multimodal preanesthetic medications), intra- (standardized intraoperative pathway, regional anesthesia, opioid minimization and multimodal analgesia, protective ventilation strategy, fluid minimization), and postoperative (multimodal analgesia with opioid minimization) phases of care are included. We have summarized the best available evidence to recommend the anesthetic components of care for enhanced recovery after surgery for bariatric surgery. There is evidence in the literature, and from society guidelines, to support the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery goals for bariatric surgery.

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