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Obesity is a complex chronic condition that significantly elevates the risk of numerous health issues, including type 2 diabetes, cardiovascular and cerebrovascular diseases, liver dysfunction, and depression. The treatment of obesity and its associated comorbidities places a considerable economic strain on the healthcare system. When traditional pharmacological and lifestyle approaches are ineffective, bariatric surgery can be a necessary intervention for effective obesity treatment. The perioperative care of patients undergoing bariatric surgery is inherently complex, primarily due to the patient's weight and associated comorbidities. This educational activity is designed to provide a thorough understanding of the perioperative evaluation and management of obese patients undergoing bariatric surgery. Participants in this activity will gain insights into the multifaceted roles of anesthesia providers and how they contribute to the perioperative care of patients with obesity. The activity also aims to enhance the skills and knowledge required for effective anesthetic management, ultimately improving patient outcomes following bariatric surgical procedures. Objectives: Compare expanding definitions and demographics of obesity and its impact on various organ systems. Discuss types of bariatric surgery where anesthesia providers are involved. Apply organ system knowledge to develop an anesthetic plan for perioperative care of patients undergoing bariatric surgery, utilizing the preoperative assessment. Identify bariatric patient safety concerns and how to address them in the perioperative period. Apply effective strategies to improve postoperative care coordination among interprofessional team members to facilitate positive outcomes for patients undergoing bariatric procedures. Access free multiple choice questions on this topic.

Obesity is a multifactorial condition associated with nearly every organ system. There are concomitant increases in risk for cancer (eg, uterine, colon, breast) and inflammatory diseases. Many patients suffering from obesity find that traditional methods such as diet, exercise, and pharmacologic interventions alone cannot achieve their health goals and seek the surgical alternative of bariatric surgery.[1][2][3][4] In the mid-1800s, a Belgian statistician, Adolphe Quetelet, developed the body mass index (BMI) to help catalog and index "the average man" in height versus weight ratio. Insurance company actuaries and health organizations have promoted this measurement to define obesity as an excess of adipose tissue and encouraged subclassifications. Broken into classes, overweight is a BMI of 25.0 to 29.9 kg/m², obesity class I is a BMI of 30.0 to 34.9 kg/m², and obesity class II is a BMI of 35.0 to 39.9 kg/m².[5]  Class III, or extreme obesity, is a BMI > 40 kg/m². Older classifications that used the classes morbid obesity (BMI > 40) and super-morbid obesity (BMI > 50) have been supplanted by the class system mentioned above.[6] While BMI offers a convenient estimate of body composition, it's essential to consider BMI in conjunction with other factors that contribute to a patient's overall health. Factors such as sex, age, race, and ethnicity, along with hormonal state, comorbidities, bone density, lean body weight, and the distribution and type of adipose tissue (visceral vs. subcutaneous, and variations like brown, white, and 'brite' or beige fat), provide a more comprehensive health assessment.[7] This holistic approach to understanding adiposity allows for a better appreciation of potential disease states and the associated risks, including increased comorbidities, impacts on quality of life, and potential for earlier mortality.[8]

Bariatric surgery to reduce obesity and impact obesity comorbid conditions has become safer over the past half-century as bariatric surgical societies have utilized the multidisciplinary healthcare team approach. Guidelines from the American Society for Metabolic and Bariatric Surgery, in combination with the International Federation of Surgery for Obesity (ASMBS/IFSO), were most recently updated in 2022. ERAS protocols encourage nurses and dietitians to educate patients regarding dietary and lifestyle adjustments, physical therapy, and physiotherapists to guide prehabilitation and physical fitness. Level II, III, and IV data suggest that while it may not improve morbidity, it positively impacts physical mobility at least six months after surgery. Anesthesia care team members are instrumental in providing balanced anesthetics that decrease the risk for PONV and emphasize multimodal pain control. Anesthesia providers are also helpful in continuing communication between patients, surgeons, nurses, and respiratory therapists regarding the likelihood and early treatment for airway obstruction. \Surgeons decrease the risk of infection and improve mobilization time by reducing drain placements and nasogastric tube use for decompression. Nurses, pharmacists, and therapists identify social factors in the postoperative period that may improve opioid use in this high-risk patient population. Bariatric surgery is still not without risk and requires a "whole team" approach to improve patient outcomes successfully.

Obesity, as a disease, can have a multifactorial set of causes that do not respond to one treatment alone. As such, bariatric surgery is not meant to be a stand-alone "silver bullet" for treating obesity. The American Society for Metabolic and Bariatric Surgery, in combination with the International Federation of Surgery for Obesity (ASMBS/IFSO), has supported and introduced updated guidelines for preoperative preparation to optimize patients' success in maintaining weight loss long term. It is a multidisciplinary approach focusing on the patient's overall health and decreasing wound infections and patient anxiety regarding the procedure. Patients typically self-select for bariatric procedures. Once they have engaged with a surgeon, the patient will participate in educational interventions with nurses, dietitians, social workers, or psychologists about Pre-exercise, healthy lifestyle, and dietary choices. Some programs encourage a low-calorie weight loss regimen for several weeks before surgery, driven by insurance companies ostensibly as proof of the future efficacy of bariatric surgery. A history or presence of alcohol use disorder. The patient should be in documented recovery for at least 1 to 2 years. Smoking history, with at least four weeks or more of cessation before the procedure. The goal for patients is to understand the process of living with the postoperative changes they seek and successfully implement these changes. Most of the interventions suggested have strong recommendations by the ASMBS/IFSO and ERAS societies. However, the data for the specific outcomes are questionable. Problems arise because some initial data has been extrapolated from other gastrointestinal surgeries, such as those resulting from colorectal surgery for cancer treatment. Most outcomes studied were for hard targets of postoperative physical change rather than softer targets showing the life-long change in patient behavior. Regardless of the data, multidisciplinary team interventions that treat the patient holistically can create long-lasting, effective outcomes by evaluating and managing factors that can be changed to reduce the risk of perioperative complications and improve outcomes.

Obese patients undergoing bariatric surgery are at an increased risk of respiratory depression in the postoperative period. Communication of individual patient responses to all care team members must be made clearly and thoroughly. Pain-sedation mismatch (somnolence, difficulty to arouse, signs of respiratory depression but describes intense pain when awakened) is a crucial identifier of not only increased risk for airway obstruction but of pain management requirements throughout the pre-discharge period of recovery. An increased level of monitoring may be needed throughout the patient's hospital stay. Discussion between the anesthesia care team, surgeon, nurse, and respiratory therapist can decrease the risk for adverse respiratory events in the first days after surgery. In the immediate postoperative phase, the monitoring and interventions may require a more extended stay in the PACU for an hour or more to identify the level of monitoring and intervention needed. Monitoring may decrease as the patient progresses and improved sleep architecture begins to reassert. All healthcare team members are empowered to speak on behalf of their observations to impact the patient's care and further improve their long-term success and outcome.