Pre‐Operative Management

Pre‐Operative Management: Surgical Considerations

Sherif Awad


The increase in popularity and demand for bariatric and metabolic surgery (BMS) reflects huge efforts over the past three decades to prove the metabolic and health benefits associated with these procedures, acceptable safety profile with low incidence of post‐operative complications and rapid recovery following keyhole surgery techniques. Key to achieving excellent surgical and patient outcomes is appropriate patient selection and assessment. A holistic approach should encompass a specialist multi‐disciplinary team (MDT) assessment with appropriate liaison with medical specialists where necessary. This chapter explores surgical considerations of importance when assessing candidates for BMS.

Multi‐Disciplinary Team Assessment

Severe and complex obesity is a chronic disease of complex aetiology. Surgical intervention, which is often irreversible, should not considered a shortcut to weight loss. Long‐term weight maintenance following bariatric surgery requires lifelong commitment to significant dietary and lifestyle changes.

All patients should be assessed pre‐operatively by members of a specialist MDT, which includes bariatric surgeons, obesity physicians, specialist bariatric anaesthetists, gastrointestinal radiologists, specialist dieticians, clinical psychologists, bariatric clinical nurse specialists and physiotherapists. Ahead of the patient being seen in the surgical clinic, they should have passed MDT assessment with the aim of fulfilling the following:

  • Co‐morbidity identification and optimisation;
  • Undertake necessary pre‐operative investigations (e.g. screening bloods, endoscopy, fluoroscopy studies, CT scans and overnight oximetry [to rule in/out sleep apnoea]);
  • Counselling regarding dietary and lifestyle changes that are necessary after surgery and ensuring these changes are acceptable to patients;
  • Ruling out psychological contraindications to surgery;
  • Ensure patients adhere to being non‐smokers and do not have any alcohol or substance dependencies;
  • Demonstrate a degree of pre‐operative weight loss (e.g. 5% total body weight loss) during the medical weight management pathway. This may be considered a surrogate marker of patient commitment to the dietary and lifestyle changes necessary, which will be necessary after surgery.

Liaison with specialist teams should be undertaken regarding patient‐specific complex conditions (see examples given in Table 13.1).

Table 13.1 Examples of scenarios when specialist medical consultation pre‐operatively will be necessary to optimise and prepare patients for bariatric and metabolic surgery (BMS).

Specialist team Liaison outcome
Diabetes team Optimisation of diabetes control peri‐operatively. Peri‐operative management of insulin in type 1 and 2 patients
Nephrology team Timing of renal dialysis peri‐operatively. Medication optimisation to avoid nephrotoxic drugs peri‐operatively.
Cardiology team Optimisation of cardiac medications and pacemaker checks peri‐operatively.
Respiratory team Management of sleep apnoea and brittle asthma peri‐operatively.
Neurology team Management of ventriculoperitoneal shunts and benign intracranial hypertension.
Haematology team Management of anticoagulants, VTE risk and thrombocytopenia peri‐operatively.
Rheumatology team Management of disease‐modifying agents peri‐operatively.
Lymphoedema team Compression bandaging peri‐operatively.
Anaesthetic team Risk stratification and identification of patients who need higher levels of post‐operative care.

The Surgical Clinic

Having ensured that the MDT assessment has been completed, attention turns to assessing the patient’s suitability for BMS. The patient’s medical and surgical history, medications, allergies, social and functional history and pre‐operative investigations should be reviewed ensuring no omissions have been made during their previous assessments.

Smoking status is of importance given that smoking increases peri‐operative risks significantly following BMS. It is the Author’s practice not to operate on smokers but to instead ask them to cease smoking pre‐operatively for a period of four weeks. To gain maximal health benefits from BMS patients should be encouraged to remain non‐smoking post‐operatively, and referral should be made to local smoking cessation services to aid this. This is of particular importance in the first four to six weeks after surgery when staple lines and anastomotic healing take place.

Clinical examination should focus on accurate recording of height and weight to ensure correct calculation of body mass index (BMI

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May 14, 2023 | Posted by in GENERAL SURGERY | Comments Off on Pre‐Operative Management

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