According to a new American study, after undergoing bariatric surgery, obese people should be followed by an assisted recovery protocol in order to stay in hospital for less time and have fewer long-term complications.
In the world, 1.9 billion adults are obese (BMI equal to or greater than 30). To avoid the health problems associated with this affliction such as cardiovascular disease or type 2 diabetes, many patients are offered bariatric surgeries. This is an operation consisting of restricting the absorption of food, thereby reducing the daily calorie intake. This technique is cumbersome and risky. Also, people who follow an intervention of this nature must meet an endocrinologist, a surgeon, a psychiatrist or psychologist and a dietitian-nutritionist, before and after the surgical act. Unfortunately, the quality of the follow-up varies according to the teams and we often see non-compliance with protocols and contraindications, leading to physical and/or psychological complications in patients. For example, it has been identified that many patients who have undergone this type of intervention have a tendency to fall into alcohol, perhaps due to a transfer of dependence.
In the United States, a country particularly affected by obesity (two out of five adults are affected), a protocol, known as the assisted recovery program (PRA), has been in place for about twenty years. And, according to a large-scale study published in the journal Surgery for Obesity and Related Diseases, this technique is said to have reduced the rates of prolonged hospitalization after bariatric surgery by nearly half.
During this study, the researchers compared the results of 8,946 bariatric operations before the implementation of the protocol with 9,102 operations after. And the scientists measured 26 different methods aimed at improving results after weight loss operations. They were thus able to observe that the rate of stays of more than four days in hospital after hospitalization fell from 8.1% before PRA to 4.5% after. “This result was achieved without increasing readmission rates,” the researchers explain. In centers that complied with at least 23 of the 26 measures of the PRA process, this rate even fell to 2.3%, compared to 5.4% in those who had followed 19 or 20 measures.
“The main finding of this study is that the more a program adhered to all protocol measures, the greater the reduction in length of extended stay for their patients,” notes Stacy A. Brethauer, MD, FACS, professor of surgery. at Ohio State University, Columbus, lead author of the study.
Avoid opioids as much as possible
In detail, ARPs aim to maintain the normal physiological state of the patient as much as possible throughout the operation and recovery process. “This goal is achieved by allowing patients to arrive for surgery in a physiologically ‘nourished’ state after drinking a carbohydrate drink two hours before the procedure, minimizing fluid overload during and after the procedure, maintaining tight blood sugar control, applying multimodal pain management strategies that allow opioids to minimize the emotional and physical stress that can accompany major surgery,” says Dr. Brethauer.
The protocol also eliminates urinary catheters and catheters, encourages activity right after surgery, and non-opioid medications to treat pain. “Routine use of patient-controlled analgesics with opioids was not permitted,” Brethauer recalls.
“Patient education is critical to the success of an enhanced recovery program (…) It is important to set expectations and outline pain management strategies that spare patients opioids prior to surgery surgery and to help them understand their role in their recovery,” he continues.
“All of these measures improve recovery by reducing nausea, postoperative ileus (bowel obstruction) and other opioid-related adverse effects. Also, as fewer patients are exposed to opioids after bariatric surgery, there will likely be fewer of patients who will become addicted and continue to use opioids after their recovery period”.
Implement this technique on a large scale
Based on the results of this study, Brethauer encourages all accredited centers to adopt assisted recovery protocols in their surgical practice. “Enhanced recovery can and should be implemented widely in bariatric surgery with the goal of reducing variation in care, eliminating practices that are not evidence-based, and improving clinical outcomes” , he explains.
The next national project of its kind will focus on prescribing opioids after bariatric surgery. “This project will involve many more centers, and in-hospital and discharge opioid-sparing strategies will be implemented and measured for a year in hopes of reducing our patients’ exposure to opioids and minimize the number of opioid prescriptions in the community”, explains Dr. Brethauer while in the United States, a country ravaged by the opioid crisis, 130 people die of an overdose every day.
In France, the HAS very cautious on the subject
In France, according to the Ministry of Health “more than 500 overdose deaths, of which nearly 80% related to opioids identified in 2017, could have been avoided”. Over the past ten years, the prescription of strong opioids (oxycodone, morphine, fentanyl) has increased by 150% in ten years in France. However, we are still far from the crisis that the United States is undergoing.
On the other hand, obesity is a growing problem. In France, the proportion of obese people rose from 8.5% to 14.5% between 1997 and 2009. Also, bariatric surgery is experiencing unprecedented development in the country. According to the Ameli website, 240,000 operations were carried out between 2006 and 2014. But because of the possible dangers of this surgery, the High Authority for Health (HAS) wants it to be reserved for morbid obesity (body mass index greater than 40) or people with a BMI of 35 or more and at risk because of their excess weight. Moreover, this intervention should only be carried out after the failure of other means, in particular dietetic, recalls the HAS. A few days ago, she spoke out against reimbursement bypass, the technique most used during this operation.
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