GI Surgery – Bariatric Surgery
Multisociety Guidelines for Perioperative Management of GLP-1 Receptor Agonists
3 Nov, 2024 | 14:27h | UTCIntroduction: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have transformed the management of metabolic diseases such as type 2 diabetes, obesity, and heart failure by enhancing glycemic control and promoting satiety. However, their effect of delaying gastric emptying has raised perioperative safety concerns due to the risk of residual gastric contents leading to pulmonary aspiration during anesthesia. Reports of aspiration incidents and gastrointestinal side effects like nausea and vomiting have prompted the need for unified clinical guidance. This multisociety clinical practice guideline aims to provide recommendations for safely managing patients on GLP-1RAs during the perioperative period, balancing metabolic benefits with procedural risks.
Key Recommendations:
- Shared Decision-Making:
- Collaborative Approach: The continuation or discontinuation of GLP-1RAs should involve shared decision-making among the patient, surgical team, anesthesia providers, and prescribing clinicians.
- Risk Assessment: Evaluate factors that elevate the risk of delayed gastric emptying and aspiration, including:
- Dose Escalation Phase: Higher risk during dose escalation compared to maintenance.
- Higher Dosage: Increased gastrointestinal side effects with higher doses.
- Weekly Formulations: Greater side effects with weekly dosing compared to daily formulations.
- Gastrointestinal Symptoms: Presence of nausea, vomiting, abdominal pain, dyspepsia, or constipation.
- Comorbid Conditions: Conditions like gastroparesis, bowel dysmotility, or neurological disorders affecting gastric motility.
- Timing: Conduct risk assessments well in advance of surgery to allow for appropriate preoperative planning.
- Management of GLP-1RA Therapy:
- Continuation in Low-Risk Patients: GLP-1RAs may be continued preoperatively in patients without elevated risk factors.
- Balancing Risks in High-Risk Patients:
- Metabolic vs. Procedural Risks: Weigh the risks of aspiration against potential metabolic complications like hyperglycemia if GLP-1RAs are withheld.
- Avoiding Bias: Decisions should not be based solely on obesity status to prevent bias.
- Discontinuation Guidelines:
- Daily Formulations: Hold on the day of surgery.
- Weekly Formulations: Discontinue one week prior to surgery.
- Day-of-Surgery Assessment: All patients should be evaluated for symptoms of delayed gastric emptying on the day of the procedure, regardless of GLP-1RA usage.
- Minimizing Aspiration Risk:
- Preoperative Dietary Modifications:
- Liquid Diet: Implement a liquid diet for at least 24 hours before surgery, similar to protocols for colonoscopy and bariatric procedures.
- Gastric Content Assessment:
- Point-of-Care Ultrasound: Use gastric ultrasound to assess residual gastric contents when there is concern for delayed emptying, acknowledging potential limitations in resources and expertise.
- Anesthesia Plan Adjustments:
- Rapid Sequence Induction: Consider rapid sequence induction with tracheal intubation to minimize aspiration risk in patients with confirmed or suspected delayed gastric emptying.
- Procedure Continuation vs. Cancellation: Engage in shared decision-making to weigh the benefits of proceeding with the procedure against the risks, aiming to avoid unnecessary cancellations.
- Preoperative Dietary Modifications:
Conclusion: By adopting these recommendations, healthcare providers can enhance patient safety during the perioperative period for those receiving GLP-1RA therapy. The guidelines emphasize individualized care through shared decision-making, considering both metabolic benefits and procedural risks. Implementing these practices is expected to reduce aspiration incidents, optimize surgical outcomes, and ensure equitable care without bias against patients with obesity or metabolic disorders. As new evidence and medications emerge, these guidelines may be updated to reflect best practices.
Reference: Kindel TL, Wang AY, Wadhwa A, et al. Multisociety clinical practice guidance for the safe use of glucagon-like peptide-1 receptor agonists in the perioperative period. Surgery for Obesity and Related Diseases. 2024; In Press. https://doi.org/10.1016/j.soard.2024.08.033
Study | Gastric bypass linked to increased risk of non-alcohol substance use disorder
7 Aug, 2023 | 14:23h | UTCNews Release: Gastric bypass surgery associated with non-alcohol substance use disorder – Obesity – The Obesity Society
RCT | Liraglutide aids weight management in patients with suboptimal weight loss post metabolic surgery
28 Jul, 2023 | 14:05h | UTCSee also: Visual Abstract
Clinical Trial Update | Mesenteric defects closure in bariatric surgery cuts reoperation rate due to bowel obstruction
29 May, 2023 | 10:49h | UTCLong-term Safety and Efficacy of Closure of Mesenteric Defects in Laparoscopic Gastric Bypass Surgery: A Randomized Clinical Trial – JAMA Surgery (link to abstract – $ for full-text)
See also: Visual Abstract
RCT | Bariatric–metabolic surgery is more effective than lifestyle intervention plus best medical care in non-alcoholic steatohepatitis
24 Apr, 2023 | 14:03h | UTCNews Release: Surgery most effective treatment of metabolic liver disease – King’s College London
Commentary on Twitter
New @TheLancet – Verrastro et al – Bariatric–metabolic surgery versus lifestyle intervention plus best medical care in non-alcoholic steatohepatitis (BRAVES): a multicentre, open-label, randomised trialhttps://t.co/pCWahvbReQ#NASH #NAFLD #fattyliver #livertwitter pic.twitter.com/xNMsAskJF9
— The Lancet Gastroenterology & Hepatology (@LancetGastroHep) April 21, 2023
Cohort Study | Preoperative depression has minimal impact on 5-year bariatric surgery outcomes
4 Apr, 2023 | 13:23h | UTC
Review | Choosing the best endoscopic approach for post-bariatric surgical leaks and fistulas
20 Mar, 2023 | 13:23h | UTC
ESGE Position Statement | Curriculum for bariatric endoscopy and endoscopic treatment of the complications of bariatric surgery
17 Mar, 2023 | 13:06h | UTC
M-A | Risk of non-hormonal cancer after bariatric surgery
2 Feb, 2023 | 14:37h | UTCRisk of non-hormonal cancer after bariatric surgery: meta-analysis of retrospective observational studies – British Journal of Surgery (link to abstract – $ for full-text)
Commentary: Bariatric Surgery May Reduce the Risk of Some Common Cancers – National Cancer Institute
Cohort Study | Alcohol-related problems before and after metabolic and bariatric surgery in adolescents
26 Jan, 2023 | 12:01h | UTCA Prospective Cohort of Alcohol use and Alcohol-related Problems Before and After Metabolic and Bariatric Surgery in Adolescents – Annals of Surgery (link to abstract – $ for full-text)
News Release: Problems with Alcohol Increase After Weight-Loss Surgery in Adolescence – Ann & Robert H. Lurie Children’s Hospital of Chicago
Related Study: Association Between Bariatric Surgery and Alcohol Use–Related Hospitalization and All-Cause Mortality in a Veterans Affairs Cohort – JAMA Surgery (link to abstract – $ for full-text)
Opinion | The American Academy of Pediatrics is pushing drugs and surgery for obesity
17 Jan, 2023 | 13:27h | UTCThe American Academy of Pediatrics is Pushing Drugs & Surgery for Obesity – Sensible Medicine
Original article and commentaries: AAP Guideline | Evaluation and treatment of children and adolescents with obesity
M-A | Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy effects on obesity comorbidities
12 Jan, 2023 | 13:00h | UTC
AAP Guideline | Evaluation and treatment of children and adolescents with obesity
10 Jan, 2023 | 14:54h | UTCExecutive Summary: Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity – Pediatrics
Commentaries:
Childhood obesity requires early, aggressive treatment, new guidelines say – NPR
New guidance: Use drugs, surgery early for obesity in kids – Associated Press
Cohort Study | Association between bariatric surgery and alcohol use–related hospitalization and all-cause mortality.
16 Dec, 2022 | 13:44h | UTCAssociation Between Bariatric Surgery and Alcohol Use–Related Hospitalization and All-Cause Mortality in a Veterans Affairs Cohort – JAMA Surgery (link to abstract – $ for full-text)
SR | Pharmacological interventions for preventing venous thromboembolism in people undergoing bariatric surgery.
24 Nov, 2022 | 13:21h | UTC
Guideline | Operative management of acute abdomen after bariatric surgery in the emergency setting.
3 Oct, 2022 | 13:59h | UTC
Cohort Study | A 7-year study of the durability of improvements in pain, physical function, and work productivity after Roux-en-Y gastric bypass and sleeve gastrectomy.
15 Sep, 2022 | 13:03h | UTCNews Release: Beyond weight loss: Improvements in pain, mobility persist long after bariatric surgery – University of Pittsburgh
Author Interview: Long-term Changes in Pain, Physical Function, and Work Productivity After Bariatric Surgery – JAMA
Systematic Review | Surgery for the treatment of obesity in children and adolescents.
11 Sep, 2022 | 22:29h | UTCSurgery for the treatment of obesity in children and adolescents – Cochrane Library
Summary: Surgery for the treatment of obesity in children and adolescents – Cochrane Library
Consensus Statement | Enhanced recovery after bariatric surgery.
12 Aug, 2022 | 14:52h | UTCEnhanced recovery after bariatric surgery: an Italian consensus statement – Surgical Endoscopy
Related Guidelines:
ERAS Guidelines for perioperative care in bariatric surgery.
Consensus Statement: Enhanced Recovery After Surgery in Bariatric Surgery
Review | Anesthesia for bariatric surgery.
10 Aug, 2022 | 12:11h | UTCAnaesthesia for bariatric surgery – BJA Education
Cohort Study | Bariatric surgery linked to doubling chance of marriage or divorce.
4 Aug, 2022 | 14:16h | UTCNews Release: Bariatric Surgery Linked to Doubling Chance of Marriage or Divorce – University of Pittsburgh
Commentary: Spouse Getting Weight Loss Surgery? Your Marriage Might Be in Trouble – HealthDay
RCT: Effect of banded Roux-en-Y gastric bypass versus sleeve gastrectomy on diabetes remission at 5 years among patients with obesity and type 2 diabetes.
24 Jun, 2022 | 11:10h | UTCEffect of Banded Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy on Diabetes Remission at 5 Years Among Patients With Obesity and Type 2 Diabetes: A Blinded Randomized Clinical Trial – Diabetes Care (link to abstract – $ for full-text)
RCT: Effect of laparoscopic sleeve gastrectomy vs Roux-en-Y Gastric bypass on weight loss, comorbidities, and reflux at 10 years in adult patients with obesity.
23 Jun, 2022 | 10:17h | UTCEffect of Laparoscopic Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass on Weight Loss, Comorbidities, and Reflux at 10 Years in Adult Patients With Obesity: The SLEEVEPASS Randomized Clinical Trial – JAMA Surgery (free for a limited period)
Commentary on Twitter
10-year follow-up of the SLEEVEPASS RCT: both sleeve and gastric bypass resulted in good #weightloss. Reflux was more prevalent after sleeve. The incidence of #Barrettesophagus was much lower than in previous trials, and similar after both procedures. https://t.co/zRLzB6Nf7a
— JAMA Surgery (@JAMASurgery) June 22, 2022
Safety of bariatric surgery in patients with previous acute coronary events or heart failure: nationwide cohort study.
21 Jun, 2022 | 10:44h | UTC
Commentary on Twitter
#Bariatric surgery improves metabolic health of patients, but what are the risks if they have had MI before surgery?
National dataset matched 16000 pts🇸🇪
Heart dis assoc w/🔼 cardiac events post op, plus 🔼risk of SBO and stricture.#SoMe4Surgery https://t.co/iHsZiHIgdG pic.twitter.com/v2SXMpcZd3— BJS Open (@BjsOpen) June 17, 2022
#ADA2022 – Retrospective Cohort Study: Association of bariatric surgery with cancer risk and mortality in adults with obesity.
6 Jun, 2022 | 11:54h | UTCAssociation of Bariatric Surgery With Cancer Risk and Mortality in Adults With Obesity – JAMA (free for a limited period)
Editorial: Bariatric Surgery and Cancer Risk – JAMA (free for a limited period)
News Release: Weight loss with bariatric surgery cuts the risk of developing cancer and death from cancer – Cleveland Clinic
Commentaries on Twitter
In this study, among adults with #obesity, #bariatricsurgery compared with no surgery was associated with a significantly lower incidence of obesity-associated #cancer and cancer-related mortality. https://t.co/x2gz3RUdra
— JAMA (@JAMA_current) June 3, 2022
Retrospective cohort presented at the @AmDiabetesAssn: incidence rate of 3.0 events vs 4.6 events per 1,000 person-years, resp, & a 32% reduced risk for developing obesity-related cancer following weight loss via surgery. @ClevelandClinic
https://t.co/6jLDmhgJbR @JAMA_current
— Karl Nadolsky (@DrKarlNadolsky) June 4, 2022