Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery

Focus on Anesthesiology for Bariatric Surgery

Michael C. Grant, MD; Melinda M. Gibbons, MD, MSHS; Clifford Y. Ko, MD, MS, MSHS; Elizabeth C. Wick, MD; Maxime Cannesson, MD, PhD; Michael J. Scott, MBChB, FRCP, FRCA, FFICM; Matthew D. McEvoy, MD; Adam B. King, MD; Christopher L. Wu, MD

Disclosures

Anesth Analg. 2019;129(1):51-60. 

In This Article

Abstract and Introduction

Abstract

Enhanced 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.

Introduction

Enhanced recovery after surgery (ERAS) pathways have been shown to decrease length of stay (LOS), perioperative morbidity, and costs primarily after colorectal surgical procedures.[1–3] The implementation of ERAS pathways for bariatric surgery has many similarities compared to that for colorectal surgery, and systematic reviews (SRs) of bariatric ERAS pathways also indicate that they result in a decrease in LOS, perioperative opioid use, and overall costs.[4–9]

The Agency for Healthcare Research and Quality (AHRQ), together with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute (AI) for Patient Safety and Quality at Johns Hopkins, created the Safety Program for Improving Surgical Care and Recovery (ISCR). The program relies on evidence-based pathways of care to improve outcomes and enhance perioperative care and patient safety including patients undergoing bariatric surgery. The ISCR will be implemented in >750 hospitals nationwide over the next 5 years.

We have evaluated the evidence for the anesthetic components to be included in the bariatric surgery pathway. The surgical components will be reviewed and reported separately. The goals of this evidence review are to assess the current best evidence for anesthetic interventions leading to improved outcomes after bariatric surgery and to determine the anesthetic elements of the bariatric surgery protocol.

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