Sherif Awad Despite huge need and demand for bariatric and metabolic surgery (BMS), worldwide only a relatively small percentage of patients who are eligible and willing to undergo surgery actually do so (in the United Kingdom <0.5% of eligible patients undergo BMS). There is therefore huge unmet need for these procedures, and it is likely that the numbers of procedures performed will increase significantly in future. Outcomes following BMS are related to case volume with clear evidence that high volume centres are associated with lower post‐operative morbidity and mortality. Various accreditation and quality control programs around the world seek to accredit bariatric centres and recognise those centres with the best clinical outcomes. What is clear is that BMS procedures should be performed in specialist centres with a fully functioning multi‐disciplinary team (MDT) supported by dedicated inpatient, radiology, operating theatre and critical care facilities. Regular audit of clinical outcomes should be undertaken, and indeed many National Bariatric Societies have been reporting systems to capture this data (e.g. National Bariatric Surgery Registry [NBSR] in the UK and Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program [MBSAQIP®] in the USA). This chapter discusses the key aspects of post‐operative management of patients who have undergone BMS with the aim of describing clinically relevant “real‐life” interventions. Early and late problems that may be picked up during follow‐up are also discussed. A key advancement in post‐operative management of patients who have undergone BMS is the implementation and use of enhanced recovery after surgery (ERAS) protocols. Originally designed for use after open colorectal surgery, these protocols sought to speed recovery and reduce length of hospital stay by avoiding interventions that delayed recovery. ERAS protocols have been adopted and are widely utilised within BMS programs (Figure 20.1). Traditional thought would be that high body mass index (BMI) patients with numerous co‐morbidities and mobility issues would not tolerate these fast‐track protocols. However, in reality, ERAS protocols suit this high‐risk patient cohort, and numerous studies have demonstrated their safe adoption into routine clinical practice. Of importance is ensuring that patients are counselled pre‐operatively on what to expect within the ERAS pathway. Key interventions from the ERAS pathway are discussed. Figure 20.1 Enhanced recovery after bariatric surgery (ERABS) commonly utilised within bariatric and metabolic surgery centres. Source: Awad et al. (2014) / Springer Nature/CC BY 4.0. Early and regular mobilisation is key to help reduce complications post BMS. The author’s practice is to advise patient are sat up in a chair within two hours of surgery and mobilise an hour later. Hourly mobilisation around the ward continues to midnight post‐operatively. This helps re‐expand the lung bases (reduces atelectasis) following general anaesthesia, improves circulation in the lower limbs (reduces venous thromboembolic risk), improves gut function (reduced occurrence of paralytic ileus) and helps absorb ‘trapped wind’ and ‘gas pains’ that patients experience after laparoscopic procedures due to CO2 insufflation. This advice is tailored in patients unable to mobilise due to arthritis or other conditions. For these patients, we advise regular standing out of bed/chair and undertaking a standing march instead of mobilising around the ward. Use of incentive spirometry devices (Figure 20.2) helps expand the lung bases and reduces occurrence of atelectasis following general anaesthesia, thereby reducing the risk of post‐operative pneumonia. Patients are taught to use the spirometer (by the physiotherapist or bariatric clinical nurse specialist) during the pre‐operative assessment clinic or on admission to hospital. Patients should aim to use the spirometer twice every 30 minutes post‐operatively, again to midnight. It is the author’s practice that incentive spirometry is used for at least 48 hours after BMS. Figure 20.2 Incentive spirometry device (Spiro‐Ball® Incentive Exerciser, Leventon S.A.U., Spain) utilised within the author’s institution. Intraoperative use of intermittent pneumatic compression devices (e.g. Flowtron®) is recommended to improve blood flow, thereby reducing venous stasis, through the deep veins during surgery. Patients are also encouraged to wear antiembolism stockings (if these fit) and continue wearing for two weeks post‐operatively. Despite the lack of randomised clinical trial evidence supporting the use of low molecular heparin for pharmacological thromboprophylaxis against venous thromboembolism (VTE
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Post‐Operative Management and Follow‐Up
Introduction
Enhanced Recovery After Surgery (ERAS)
Early Mobilisation
Incentive Spirometry
Venous Thromboembolism Thromboprophylaxis
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