Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update

Results: evidence base and recommendations

• Preoperative information and education, adapted to the individual requirements, should be given to all patientsLevel of evidence: Low; Recommendation grade: Strong
• Indications for bariatric surgery should follow updated global and national guidelinesLevel of evidence: Moderate; Recommendation grade: Strong
• 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 acknowledgedLevel of evidence: Smoking: Moderate; Recommendation grade: Strong
• Preoperative weight loss using very low or low-calorie diet prior to bariatric surgery should be recommendedLevel of evidence: Postoperative complications: Moderate; Recommendation grade: 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 diabetesLevel of evidence: Postoperative weight loss: Low; Recommendation grade: Strong
• Although prehabilitation may improve general fitness and respiratory capacity, there is insufficient data to recommend prehabilitation before bariatric surgeryLevel of evidence: Low; Recommendation grade: Weak
• 8 mg intravenous dexamethasone should be administered preferably 90 min prior to induction of anaesthesia for reduction of PONV as well as inflammatory responseLevel of evidence: Glucocorticoids: Low; Recommendation grade: 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 phaseLevel of evidence: Statins: Very low; Recommendation grade: 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 eventsLevel of evidence: Beta-adrenergic blockade: Low; Recommendation grade: Weak
• 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)Level of evidence: Low; Recommendation grade: Strong
• Patients with diabetes should follow these recommendations, but further studies are needed for patients with additional risk factors such as gastroparesisLevel of evidence: Low; Recommendation grade: Strong
• There is insufficient evidence to make a recommendation about preoperative carbohydrate loading in bariatric surgeryLevel of evidence: Low; Recommendation grade: Weak
• A multimodal approach to PONV prophylaxis should be adopted in all patientsLevel of evidence: High; Recommendation grade: Strong
• 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 strategiesLevel of evidence: Moderate; Recommendation grade: Strong
• Colloid fluids do not improve intra- and postoperative tissue oxygen tension compared with crystalloid fluids and do not reduce postoperative complicationsLevel of evidence: Low; Recommendation grade: Weak
• The current evidence does not allow recommendation of specific anaesthetic agents or techniquesLevel of evidence: Low; Recommendation grade: Weak
• Opioid-sparing anaesthesia using a multimodal approach, including local anaesthetics, should be used in order to improve postoperative recoveryLevel of evidence: High; Recommendation grade: Strong
• Whenever possible, regional anaesthetic techniques should be performed to reduce opioid requirements. Thoracic epidural analgesia should be considered in laparotomyLevel of evidence: Low; Recommendation grade: Weak
• BIS monitoring of anaesthetic depth should be considered where ETAG monitoring is not employedLevel of evidence: Low; Recommendation grade: Strong
• Anaesthetists should recognize and be prepared to handle the specific challenges in airways in patients with obesityLevel of evidence: Moderate; Recommendation grade: Strong
• Endotracheal intubation remains the main technique for intraoperative airway managementLevel of evidence: Moderate; Recommendation grade: Strong
• Lung protective ventilation should be adopted for all patients undergoing elective bariatric surgery with avoidance of high PEEP valuesLevel of evidence: Moderate; Recommendation grade: Strong
• Increases in driving pressure resulting from adjustments in PEEP should ideally be avoidedLevel of evidence: Low; Recommendation grade: Strong
• PCV or VCV can be used for patients with obesity with inverse respiratory ratio (1.5:1)Level of evidence: Low; Recommendation grade: Strong
• Positioning in a reverse Trendelenburg, flexed hips, reverse- or beach chair positioning, particularly in the presence of pneumoperitoneum, improves pulmonary mechanics and gas exchangeLevel of evidence: Low; Recommendation grade: Weak
• Deep neuromuscular blockade improves surgical performanceLevel of evidence: Low; Recommendation grade: Strong
• Ensuring full reversal of neuromuscular blockade improves patient recoveryLevel of evidence: Moderate; Recommendation grade: Strong
• Objective qualitative monitoring of neuromuscular blockade improves patient recoveryLevel of evidence: Moderate; Recommendation grade: Strong
• Laparoscopic approach whenever possibleLevel of evidence: High; Recommendation grade: Strong
• During the learning curve phase, all operations should be supervised by a senior surgeon with significant experience in bariatric surgeryLevel of evidence: Training: Low; Recommendation grade: Strong
• There is a strong association between hospital volume and surgical outcomes at least up to a threshold valueLevel of evidence: Hospital volume: Low; Recommendation grade: Strong
• Nasogastric tubes and abdominal drains should not be used routinely in bariatric surgeryLevel of evidence: Weak; Recommendation grade: Strong
• 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 distressLevel of evidence: Oxygen supplementation: Low; Recommendation grade: Strong
• Patients with OSA on home CPAP therapy should use their equipment in the immediate postoperative periodLevel of evidence: Moderate; Recommendation grade: 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 hypoxemiaLevel of evidence: Low; Recommendation grade: Strong
• Thromboprophylaxis should involve mechanical and pharmacological measures. Doses and duration of treatment should be individualizedLevel of evidence: High; Recommendation grade: Strong
• A clear liquid meal regimen can usually be initiated several hours after surgeryLevel of evidence: Moderate; Recommendation grade: 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 statusLevel of evidence: Moderate; Recommendation grade: Strong
• Patients and healthcare professionals should be aware of the risks of thiamine deficiency, especially in the early postoperative periodsLevel of evidence: Low; Recommendation grade: Strong
• A regimen of life-long vitamin and mineral supplementation and nutritional biochemical monitoring is necessaryLevel of evidence: High; Recommendation grade: Strong
• PPI prophylaxis should be considered for at least 30 days after Roux-en-Y gastric bypass surgeryLevel of evidence: RYGB: Moderate; Recommendation grade: 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 surgeryLevel of evidence: SG: Very Low; Recommendation grade: Weak
• Ursodeoxycholic acid should be considered for 6 months after bariatric surgery for patients without gallstones at the time of surgeryLevel of evidence: Moderate; Recommendation grade: Strong