Post-operative nausea and vomiting in bariatric surgery patients: an observational study

Omentopexy versus no omentopexy in sleeve gastrectomy: an updated systematic review and meta-analysis

Laparoscopic sleeve gastrectomy with omentopexy (O-LSG) has been compared to laparoscopic sleeve gastrectomy with no-omentopexy (NO-LSG) in terms of postoperative outcomes and one-year anthropometric results. This systematic review with meta-analysis aimed to compare the utility of omentopexy in sleeve gastrectomy. We performed a systematic review with meta-analysis according to PRISMA 2020 and AMSTAR 2 guidelines. We included studies that systematically searched electronic databases and compared the O-LSG with the NO-LSG conducted through 1st March 2023. The bibliographic research yielded 13 eligible studies. These studies included 5514 patients. The O-LSG is associated with lower leakage (OR = 0.22; 95% CI [0.08, 0.55], p = 0.001), bleeding (OR = 0.33; 95% CI [0.19, 0.57], p < 0.0001), vomiting (OR = 0.50; 95% CI [0.28, 0.89], p = 0.02), twist (OR = 0.09; 95% CI [0.02, 0.39], p = 0.001), and shorter hospital stay (MD = - 0.33; 95% CI [- 0.61, - 0.05], p = 0.02) compared with NO-LSG. The O-LSG is associated with longer operative time (MD = 8.15; 95% CI [3.65, 12.64], p = 0.0004) than the NO-LSG. There were no differences between the two groups in terms of postoperative GERD (OR = 0.53; 95% CI [0.27, 1.02], p = 0.06), readmission (OR = 0.60; 95% CI [0.27, 1.37], p = 0.23), and one-year total weight loss (MD = 2.06; 95% CI [- 1.53, 5.65], p = 0.26). In the subgroup analysis including only RCTs, postoperative GERD was lower in the O-LSG (OR = 0.26; 95% CI [0.11, 0.63], p = 0.003). Our systematic review and meta-analysis concluded that omentopexy in sleeve gastrectomy is feasible and safe It reduced leakage, bleeding, and twist. It probably increased the operative time. It may reduce vomiting, GERD, and hospital stay. We don't know if it led to an additional readmission rate or one-year total weight loss.Registration The protocol was registered in PROSPERO with the ID CRD42022336790.

Erector spinae plane block versus paravertebral block on postoperative quality of recovery in obese patients undergoing laparoscopic sleeve gastrectomy: a randomized controlled trial

Purpose

To compare the impact of erector spinae plane block (ESPB) and paravertebral block (PVB) on the quality of postoperative recovery (QoR) of patients following laparoscopic sleeve gastrectomy (LSG).

Methods

A total of 110 patients who underwent elective LSG under general anesthesia were randomly assigned to receive either ultrasound-guided bilateral ESPB or PVB at T8 levels. Before anesthesia induction, 40 mL of 0.33% ropivacaine was administered. The primary outcome was the QoR-15 score at 24 hours postoperatively.

Results

At 24 hours postoperatively, the QoR-15 score was comparable between the ESPB and PVB groups (131 (112-140) vs. 124 (111-142.5), P = 0.525). Consistently, there was no significant difference in QoR-15 scores at 48 hours postoperatively, numerical rating scale (NRS) pain scores at any postoperative time points, time to first ambulation, time to first anal exhaust, postoperative cumulative oxycodone consumption, and incidence of postoperative nausea and vomiting (PONV) between the two groups (all P > 0.05). No nerve block-related complications were observed in either group.

Conclusion

In patients undergoing LSG, preoperative bilateral ultrasound-guided ESPB yields comparable postoperative recovery to preoperative bilateral ultrasound-guided PVB.

The Impact of Preoperative Dexamethasone Administration on Quality of Recovery Following Laparoscopic Sleeve Gastrectomy: A Prospective Observational Study

INTRODUCTION

Recovery from anesthesia is complex and affected by multiple factors. In patient with obesity, the increased prevalence of anxiety and depressive disorders poses a challenge in achieving optimal patient satisfaction. Therefore, strategies to enhance the quality of recovery are crucial for this population. This study aimed to investigate whether administration of dexamethasone to patients undergoing laparoscopic sleeve gastrectomy (LSG) could improve recovery outcomes.

METHODS

This prospective observational study was conducted at a tertiary university hospital in Samsun, Turkey. Thirty patients who received dexamethasone prior to LSG (group D) and 30 patients who did not (group C) were included with convenience sampling method. The quality of recovery was assessed using the Quality of Recovery 40 questionnaire (QoR-40). The primary outcome measure was the QoR-40 score at 24 h postoperatively.

RESULTS

The dexamethasone group showed a significant improvement in QoR-40 scores (185.4 ± 6.0 vs. 172.0 ± 8.4, p < 0.001), exhibited reduced morphine consumption (11.8 ± 7.8 vs. 21.8 ± 10.9 mg, p < 0.001), opioid demand count (21.50 [9.50-49.00], p = 0.001), the number of patient used antiemetic drug (1 vs. 22, p < 0.001), and achieved earlier mobilization (3 [3-4] vs. 3 [3-4] h, p < 0.0001). However, no significant differences were observed between the two groups concerning intraoperative complications, postoperative wound infections, or time to discharge.

CONCLUSIONS

In patients undergoing laparoscopic sleeve gastrectomy, preoperative dexamethasone administration was associated with improved the recovery quality after discharge and reduced early postoperative need for antiemetic medications.

Effect of preoperative ondansetron on postoperative nausea in healthy dogs undergoing laparoscopic gastropexy and castration

OBJECTIVE

To investigate if preoperative ondansetron reduces postoperative nausea associated with laparoscopic gastropexy and castration in dogs.

STUDY DESIGN

Prospective clinical study.

ANIMALS

Twenty client-owned, healthy male dogs.

METHODS

Dogs were premedicated with dexmedetomidine (2-5 mcg kg-1) and methadone (0.2-0.5 mg kg-1) intramuscularly. General anesthesia was induced with propofol and maintained with an inhalant anesthetic agent. Dogs were randomized into group S (saline 0.1 mL kg-1, intravenously) or group O (ondansetron 0.2 mg kg-1, intravenously). Plasma and serum were collected before premedication and 3 hours postextubation to measure arginine vasopressin (AVP) and cortisol concentrations. Nausea scoring occurred before and 10 minutes after premedication, immediately after extubation, and at 1, 2 and 3 hours postextubation. Data were analyzed by mixed and split-plot anova with Bonferroni adjustment for the number of group comparisons. Significance was set at p < 0.05.

RESULTS

Nausea scores increased over time at 1 (p = 0.01) and 2 (p < 0.001) hours postextubation in both groups compared with before premedication. Median nausea score (0-100 mm) for groups S and O before premedication were 2.5 and 0.5 mm, respectively. At 1 and 2 hours postextubation, group S scored 7.5 and 4.0 mm and group O scored 6.0 and 5.0 mm, respectively. No significant differences in nausea scores within or between groups were observed before premedication and 3 hours postextubation. Cortisol concentrations increased significantly 3 hours postextubation in both groups (p < 0.001) compared with before premedication, with no differences between groups. AVP concentrations showed no significant differences within or between groups.

CONCLUSIONS AND CLINICAL RELEVANCE

Preoperative intravenous administration of ondansetron (0.2 mg kg-1) did not impact postoperative nausea after laparoscopic gastropexy and castration. Investigation of higher doses of ondansetron on the incidence of postoperative nausea and vomiting in dogs after surgery is warranted.

[Comparison of different prediction models for the occurrence of nausea and vomiting in the postoperative phase : A systematic qualitative comparison based on prospectively defined quality indicators]

BACKGROUND

Various prognostic prediction models exist for evaluating the risk of nausea and vomiting in the postoperative period (PONV). So far, no systematic comparison of these prognostic scores is available.

METHOD

A systematic literature search was carried out in seven medical databases to find publications on prognostic PONV models. Identified scores were assessed against prospectively defined quality criteria, including generalizability, validation and clinical relevance of the models.

RESULTS

The literature search revealed 62 relevant publications with a total of 81,834 patients which could be assigned to 8 prognostic models. The simplified Apfel score performed best, primarily because it was extensively validated. The Van den Bosch score and Sinclair score tied for second place. The simplified Koivuranta score was in third place.

CONCLUSION

The qualitative analysis highlights the strengths and weaknesses of each prediction system based on predetermined standardized quality criteria.

Implementation of Electronic Postoperative Nausea and Vomiting Assessment and Best Practice Advisory Tools to Improve Patient Care

BACKGROUND

Postoperative nausea and vomiting (PONV) affects 30% of surgical patients undergoing anesthesia. PONV is a substantial cause of increased length of stay, cost of care, and unanticipated patient admission and readmission.

LOCAL PROBLEM

Seventy percent of patients received PONV prophylaxis; PONV assessment was performed in only 63% of patients in this hospital system.

METHODS

A standardized PONV preoperative assessment checklist and a best practice advisory (BPA) were implemented in our electronic medical record (EMR) and charting system. Anesthesia providers and postanesthesia care unit (PACU) nurses completed training on patient management for PONV, including preoperative assessment and BPA use.

RESULTS

The PONV preoperative assessment achieved high adoption, and providers followed its recommendations in more than 90% of cases. During the 6-month implementation phase, PONV rates decreased from 56% to 43.6%.

CONCLUSIONS

Implementing a standardized, electronic PONV preoperative risk assessment checklist and a BPA effectively reduced PONV rates in this hospital system.

Perioperative use of low dose haloperidol safely reduces episodes of postoperative nausea/vomiting and length of stay following elective minimally invasive bariatric surgery

INTRODUCTION

While total intravenous anesthesia (TIVA) protocols include Dexamethasone and Ondansetron prophylaxis, bariatric patients continue to be considered at particularly high risk for postoperative nausea/vomiting (PONV). A multimodal approach for prophylaxis is recommended by the Bariatric Enhanced Recovery After Surgery (ERAS) Society however, there remains a lack of consensus on the optimal strategy to manage PONV in these patients. Haloperidol has been shown at low doses to have a therapeutic effect in treatment of refractory nausea and in PONV prophylaxis in other high risk surgical populations. We sought to investigate its efficacy as a prophylactic medication for PONV in the bariatric population and to identify which perioperative strategies were most effective at reducing episodes of PONV.

METHODS

An institutional bariatric database was created by retrospectively reviewing patients undergoing elective minimally invasive bariatric procedures from 2018 to 2022. Demographic data reviewed included age, gender, preoperative body mass index (BMI), ethnicity, and primary language. Primary endpoints included patient reported episodes of PONV, total doses of Ondansetron administered, need for a second antiemetic (rescue medication), complication rate (most commonly readmission within 30 days), and length of stay. Fisher's exact test, Mann-Whitney test, and ANOVA were used to evaluate the effect of perioperative management on various endpoints.

RESULTS

A total of 475 patients were analyzed with Haloperidol being utilized in 15.8% of all patients. Patients receiving Haloperidol were less likely to require Ondansetron outside of the immediate perioperative period (34.7% vs. 49.8%, p = 0.02), experienced less PONV (41.3% vs. 64.3%, p = 0.01) and also had a decreased median length of stay (27.3 vs. 35.8 h, p < 0.0001).

CONCLUSIONS

Addition of low dose Haloperidol to Bariatric ERAS protocols decreases incidence of PONV and the need for additional antiemetic coverage resulting in a significantly shorter length of stay, increasing the likelihood of safe discharge on postoperative day 1.

REMAP Periop: a randomised, embedded, multifactorial adaptive platform trial protocol for perioperative medicine to determine the optimal enhanced recovery pathway components in complex abdominal surgery patients within a US healthcare system

INTRODUCTION

Implementation of enhanced recovery pathways (ERPs) has resulted in improved patient-centred outcomes and decreased costs. However, there is a lack of high-level evidence for many ERP elements. We have designed a randomised, embedded, multifactorial, adaptive platform perioperative medicine (REMAP Periop) trial to evaluate the effectiveness of several perioperative therapies for patients undergoing complex abdominal surgery as part of an ERP. This trial will begin with two domains: postoperative nausea/vomiting (PONV) prophylaxis and regional/neuraxial analgesia. Patients enrolled in the trial will be randomised to arms within both domains, with the possibility of adding additional domains in the future.

METHODS AND ANALYSIS

In the PONV domain, patients are randomised to optimal versus supraoptimal prophylactic regimens. In the regional/neuraxial domain, patients are randomised to one of five different single-injection techniques/combination of techniques. The primary study endpoint is hospital-free days at 30 days, with additional domain-specific secondary endpoints of PONV incidence and postoperative opioid consumption. The efficacy of an intervention arm within a given domain will be evaluated at regular interim analyses using Bayesian statistical analysis. At the beginning of the trial, participants will have an equal probability of being allocated to any given intervention within a domain (ie, simple 1:1 randomisation), with response adaptive randomisation guiding changes to allocation ratios after interim analyses when applicable based on prespecified statistical triggers. Triggers met at interim analysis may also result in intervention dropping.

ETHICS AND DISSEMINATION

The core protocol and domain-specific appendices were approved by the University of Pittsburgh Institutional Review Board. A waiver of informed consent was obtained for this trial. Trial results will be announced to the public and healthcare providers once prespecified statistical triggers of interest are reached as described in the core protocol, and the most favourable interventions will then be implemented as a standardised institutional protocol.

TRIAL REGISTRATION NUMBER

NCT04606264.

A Postoperative Nausea and Vomiting Update: Current information on New Drugs, Old Drugs, Rescue/Treatment, Combination Therapies and Nontraditional Modalities

This article's objective is to present the latest evidence and information on the management of postoperative nausea and vomiting (PONV). PONV continues to affect 30% of the surgical population causing patient dissatisfaction, extending length of stay, and increasing overall costs. This review includes the introduction of 2 new intravenous formulations of antiemetics (amisulpride, aprepitant), updates on nontraditional therapies, suggestions for combination prophylaxis, emerging data on rescue treatment, and considerations for special populations and settings. Both of the new antiemetics provide promising options for pharmacologic interventions for PONV with favorable safety profiles.

Tension pneumocephalus following bariatric surgery: case report

Bariatric surgery is an effective treatment for patients with idiopathic intracranial hypertension (IIH), a condition that is associated with skull base defects. A 55-year-old woman presented with symptoms of intractable nausea and vomiting, followed by headache and confusion two weeks after an elective laparoscopic vertical sleeve gastrectomy procedure. She had a presumed diagnosis of IIH and a remote history of CSF oto/rhinorrhea treated with a lumbar peritoneal (LP) shunt. Computed tomography (CT) scan of the head revealed tension pneumocephalus with midline shift and dehiscence of the tegmen. The patient underwent emergent craniotomy for decompression of the air-filled temporal lobe, clamping of the LP shunt, and repair of the skull base defect. Caution should be exercised in obese patients with a history of CSF leak secondary to a middle fossa skull base defect when being evaluated for bariatric surgery.

Prevalence, Risk Factors, and Management of Postoperative Nausea and Vomiting After Laparoscopic Sleeve Gastrectomy (a Retrospective Multicentric Study)

PURPOSE

Postoperative nausea and vomiting (PONV) is a frequent unappealing laparoscopic sleeve gastrectomy (LSG) sequel. The study's purpose was to determine the prevalence, risk factors of PONV, and management of PONV after LSG.

PATIENTS AND METHODS

This multicenter retrospective study included patients with morbid obesity who had LSG between January 2022 and April 2023. The age range for LSG was 16 to 65 years, and the eligibility requirements included morbid obesity according to international guidelines.

RESULTS

PONV was experienced by 74.6% of patients who underwent LSG at 6 h postoperative. Multivariate analysis revealed that female gender, smokers, preoperative GERD, gastropexy, and severity of pain were found to be independent risk variables of the development of PONV, while antral preservation, opioid-free analgesia, and intraoperative combined analgesia were found to be independent protective variables against the development of PONV. Combined intravenous ondansetron and metoclopramide improved 92.6% of patients who developed PONV. Dexamethasone and antihistamines drugs are given for 42 cases with persistent PONV after using intravenous ondansetron and metoclopramide. Pain management postoperatively by opioid-free analgesia managed PONV. Helicobacter pylori status has no role in the development of PONV after LSG.

CONCLUSION

Female gender, smoking, presence of preoperative GERD, gastropexy, and severity of pain were found to be independent risk variables of the development of PONV, while antral preservation, opioid-free analgesia, and intraoperative combined analgesia were observed to be independent protective factors against the occurrence of PONV. Combined intravenous ondansetron and metoclopramide improved PONV. Dexamethasone and antihistamines drugs are given for persistent PONV.

Electropress Needle Stimulation for the Prevention of Postoperative Nausea and Vomiting in Patients Undergoing Laparoscopic Sleeve Gastrectomy: A Prospective, Randomized Controlled Trial

BACKGROUND

Being overweight or obese is becoming increasingly prevalent worldwide and seriously endangers human health. Laparoscopic sleeve gastrectomy (LSG) has been successfully used for the treatment of severe obesity, but the incidence of postoperative nausea and vomiting (PONV) is high. However, traditional antiemetics have limited effects on PONV. Electropress needle therapy, which can be enhanced with electrical stimulation, is a promising therapy for the prevention and treatment of PONV. However, whether the electropress needle is effective for PONV in patients with LSG remains uncertain.

METHODS

This was a prospective, randomized controlled trial. A total of 106 patients who planned to undergo elective LSG between October 2021 and July 2022 were randomly allocated to receive electropress needle stimulation combined with dexamethasone and granisetron (group A) or dexamethasone plus granisetron (group B). The primary outcome was the incidence of PONV 48 h after surgery. The secondary outcomes were PONV severity score, time to first flatus, length of hospital stay, visual analogue scale (VAS) score, and postoperative remedial medication use.

RESULTS

Compared with dexamethasone plus granisetron, electropress needle stimulation combined with dexamethasone and granisetron significantly decreased the incidence and severity of PONV (P<0.001). Patients in Group A consumed less antiemetics postoperatively (P<0.05) and had a much shorter length of postoperative hospital stay (P<0.05). There was no difference in the time to first flatus between the two groups (P > 0.05).

CONCLUSION

Electropress needle acupoint stimulation can reduce the incidence and severity of PONV in patients undergoing LSG.

Impact of Emend on Perioperative Bariatric Surgery Antiemetic Utilization, Patient Satisfaction, and Costs

PURPOSE

Postoperative nausea and vomiting (PONV) is one of the most common adverse effects of anesthesia and surgery, resulting in patient discomfort and dissatisfaction. Latest research has demonstrated the efficacy of NK-1 receptor antagonists in PONV management and its use in chemotherapy nausea prophylaxis. The authors of this article would like to provide evidence to support the use fosaprepitant, as monotherapy, in postoperative care, replacing a polypharmacological standard of care regimen.

METHODS

This was a retrospective chart review of 400 patients who received standard of care antiemetic regimen or received fosaprepitant (No-Fosaprepitant vs. Fosaprepitant groups, respectively). The primary outcome of this study is to evaluate the impact of fosaprepitant (administered intravenously) on perioperative antiemetic use, treatment cost, and patient satisfaction.

RESULTS

Total PONV medication cost decreased with the replacement of standard of care regimen for fosaprepitant, from 46.47±20.54 United States Dollars in the no-Fosaprepitant group to 25.69±14.84 United States Dollars in the Fosaprepitant group. There was a significant reduction in antiemetic doses between groups; 0.37±0.745 versus 7.61±5.202 for ondansetron ( P =0.001), 92±1.279 versus 2.21±2.399 for promethazine ( P =0.001), 0.25±0.685 versus 1.41±0.577 for scopolamine patch ( P =0.001), and 0.05±0.218 versus 1.14±0.398 for dexamethasone ( P =0.001). Patient satisfaction, measured by a questionnaire, was a 11.6% higher in the Fosaprepitant group.

CONCLUSION

Fosaprepitant is a relevant alternative in preventing and treating PONV in patients who underwent bariatric/metabolic surgical procedures.

Use of sugammadex is associated with reduced incidence and severity of postoperative nausea and vomiting in adult patients with obesity undergoing laparoscopic bariatric surgery: a post-hoc analysis

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common but troublesome complication in patients who undergo laparoscopic bariatric surgery (LBS). Whether sugammadex use is related to the persistent decrease in the occurrence of PONV during postoperative inpatient hospitalization, which is critical for the rehabilitation of patients after LBS, remains unknown.

METHODS

The study was based on a randomized controlled trial conducted in an accredited bariatric centre. A total of 205 patients who underwent LBS were included in the analysis. Univariate analysis and multivariable logistic regression model were used to identify the significant variables related to PONV. Then propensity score matching and inverse probability of treatment weighting (IPTW) were employed to compare outcomes between the sugammadex and neostigmine groups. The primary outcome was the incidence of PONV within 48 h after LBS. The secondary endpoints included the severity of PONV, time to first flatus, need for rescue antiemetic therapy, and water intake.

RESULTS

The incidence of PONV was 43.4% (89/205) within the first 48 h after LBS. In multivariable analysis, sugammadex use (OR 0.03, 95% CI 0.01-0.09, P < 0.001) was an independent protective factor of PONV. After IPTW adjustment, sugammadex use was associated with lower incidence of PONV (OR 0.54, 95% CI 0.48-0.61, P < 0.001), postoperative nausea (PON) (OR 0.77, 95% CI 0.67-0.88, P < 0.001), and postoperative vomiting (POV) (OR 0.60, 95% CI 0.53-0.68, P < 0.001) within postoperative 48 h. The severity of PON as well as the incidence and severity of POV within the first 24 h were also lower in the sugammadex group (all P < 0.05). Reduced need for rescue antiemetic therapy within the first 24 h, increased water intake for both periods, and earlier first passage of flatus were observed in the sugammadex group (all P < 0.05).

CONCLUSIONS

Compared with neostigmine, sugammadex can reduce the incidence and severity of PONV, increase postoperative water intake, and shorten the time to first flatus in bariatric patients during postoperative inpatient hospitalization, which may play a pivotal role in enhanced recovery.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2100052418, http://www.chictr.org.cn/showprojen.aspx?proj=134893 , date of registration: October 25, 2021).

The Performance of Opioid-Free Anesthesia for Bariatric Surgery in Clinical Practice

PURPOSE

Opioid-free anesthesia (OFA) is an alternative to conventional opioid-based anesthesia (OBA) in patients undergoing bariatric surgery. Several small studies and a meta-analysis have suggested advantages of OFA for bariatric surgery, but current evidence is still contradictory, and a universally accepted concept has not yet been established. The purpose of this study was to determine whether patients undergoing bariatric surgery experience less postoperative pain and better postoperative recovery when anesthetized with an OFA regimen than with an OBA regimen.

MATERIALS AND METHODS

This prospective observational cohort study, conducted between October 2020 and July 2021, compared patients receiving OFA with patients receiving OBA. Patients were visited 24 and 48 h after the surgical procedure and asked about their postoperative pain using the visual analogue scale (VAS). Additionally, the quality of recovery-40 questionnaire (QoR-40) and the postoperative opioid requirements were recorded.

RESULTS

Ninety-nine patients were included and analyzed in this study (OFA: N = 50; OBA: N = 49). The OFA cohort exhibited less postoperative pain than the OBA cohort within 24 h (VAS median [interquartile range (IQR)]: 2.2 [1-4.4] vs. 4.1 [2-6.5]; P ≤ 0.001) and 48 h (VAS median [IQR]: 1.9 [0.4-4.1] vs. 3.1 [1.4-5.8]; P ≤ 0.001) postoperatively. Additionally, the OFA cohort had higher QoR-40 scores and required less opioid therapy postoperatively.

CONCLUSION

Based on our results the use of OFA for bariatric surgery results in less pain, reduced opioid requirements, and improved postoperative recovery-adding additional evidence regarding the use of OFA in everyday clinical practice.

Effects of ondansetron, metoclopramide and granisetron on perioperative nausea and vomiting in patients undergone bariatric surgery: a randomized clinical trial

INTRODUCTION

Post-operative nausea and vomiting (PONV) is a common problem after sleeve gastrectomy. In recent years, following the increase in the number of such operations, special attention has been paid to preventing PONV. Additionally, several prophylaxis methods have been developed, including enhanced recovery after surgery (ERAS) and preventive antiemetics. Nevertheless, PONV has not been completely eliminated, and the clinicians are trying to reduce the incidence of PONV yet.

METHODS

After successful ERAS implementation, patients were divided into five groups, including control and experimental groups. Metoclopramide (MA), ondansetron (OA), granisetron (GA), and a combination of metoclopramide and ondansetron (MO) were used as antiemetics for each group. The frequency of PONV during the first and second days of admission was recorded using a subjective PONV scale.

RESULTS

A total of 130 patients were enrolled in this study. The MO group showed a lower incidence of PONV (46.1%) compared to the control group (53.8%) and other groups. Furthermore, the MO group did not require rescue antiemetics, however, one-third of control cases used rescue antiemetics (0 vs. 34%).

CONCLUSION

Using the combination of metoclopramide and ondansetron is recommended as the antiemetic regimen for the reduction of PONV after sleeve gastrectomy. This combination is more helpful when implemented alongside ERAS protocols.

Incidence and risk factors of postoperative nausea and vomiting following laparoscopic sleeve gastrectomy and its relationship with Helicobacter pylori: A propensity score matching analysis

BACKGROUND

Postoperative nausea and vomiting (PONV) are common after laparoscopic sleeve gastrectomy (LSG), affecting patient satisfaction and postoperative recovery. The purpose of this study was to investigate the incidence and severity of PONV after LSG and the relationship between Helicobacter pylori (HP) and PONV.

METHODS

Patients undergoing LSG in our center from June 1, 2018, to May 31, 2022, were divided into HP-positive and HP-negative groups for retrospective analysis. The independent risk factors of PONV were determined by univariate and binary logistic regression analysis using a 1:1 propensity score matching (PSM) method.

RESULTS

A total of 656 patients was enrolled, and 193 pairs of HP-positive and negative groups were matched after PSM. Both groups of patients had similar clinical features and surgical procedures. PONV occurred in 232 patients (60.1%) after LSG, and the incidence of PONV in HP-positive patients was 61.10%. The incidence and severity of PONV were statistically similar in both groups (P=0.815). Multivariate analysis showed that the female sex (OR=1.644, P=0.042), postoperative pain (OR=2.203, P=0.001) and use of postoperative opioid (OR=2.229, P=0.000) were independent risk factors for PONV after LSG, whereas T2DM (OR=0.510, P=0.009) and OSAS (OR=0.545, P=0.008) independently reduced the incidence rate of PONV. There was no difference either in smoking (P=0.255) or alcohol drinking (P=0.801). HP infection did not affect PONV (P=0.678).

CONCLUSIONS

The incidence of PONV following LSG was relatively high. Female sex, postoperative pain and use of postoperative opioid predicted a higher incidence of PONV. Patients with T2DM and OSAS were less likely to have PONV. There was no clear association between HP infection and PONV after LSG.

Paragastric Autonomic Neural Blockade to Prevent Early Visceral Pain and Associated Symptoms After Laparoscopic Sleeve Gastrectomy: a Randomized Clinical Trial

Background

Visceral pain (VP) following laparoscopic sleeve gastrectomy remains a substantial problem. VP is associated with autonomic symptoms, especially nausea and vomiting, and is unresponsive to traditional pain management algorithms aimed at alleviating somatic (incisional) pain. The present study was performed to evaluate the safety and effectiveness of laparoscopic paragastric autonomic neural blockade (PG-ANB) in managing the symptoms associated with VP following sleeve gastrectomy.

Study Design

This prospective, double-blinded, randomized clinical trial involved patients undergoing laparoscopic sleeve gastrectomy at two high-volume institutions. The patients were randomized to laparoscopic transversus abdominis plane block with or without PG-ANB. The primary outcome was patient-reported pain scores assessed at 1, 8, and 24 h postoperatively. The secondary outcome measures were analgesic requirements, nausea, vomiting, hiccups, and hemodynamic changes immediately after PG-ANB and postoperatively.

Results

In total, 145 patients (block group, n = 72; control group, n = 73) were included in the study. The heart rate and mean arterial pressure significantly decreased 10 min after PG-ANB. The visual analog scale score for pain was significantly lower in the PG-ANB than in the control group at 1 h postoperatively (p < 0.001) and 8 h postoperatively (p < 0.001). Vomiting, nausea, sialorrhea, and hiccups were significantly less prevalent in the PG-ANB group. Patients in the PG-ANB group received fewer cumulative doses of analgesics at 1 h postoperatively (p = 0.003) and 8 h postoperatively (p < 0.001). No differences between the groups were detected at 24 h (p = 0.298). No complications related to PG-ANB occurred.

Conclusion

PG-ANB safely and effectively reduces early VP, associated autonomic symptoms, and analgesic requirements after laparoscopic sleeve gastrectomy.

Graphical abstract

Effect of Dexmedetomidine Compared to Remifentanil During Bariatric Surgery on Postoperative Nausea and Vomiting: a Retrospective Study

PURPOSE

Postoperative nausea and vomiting (PONV) occurs frequently after bariatric surgery and is a major cause of adverse outcomes. This retrospective study investigated whether opioid-restricted total intravenous anesthesia using dexmedetomidine as a substitute for remifentanil can reduce PONV in bariatric surgery.

MATERIALS AND METHODS

The electronic medical records of adult patients who underwent laparoscopic bariatric surgery between January and December 2019 were reviewed. The patients were divided into two groups according to the agents used for anesthesia: Group D, propofol and dexmedetomidine; Group R, propofol and remifentanil.

RESULTS

A total of 134 patients were included in the analyses. The frequency of postoperative nausea was significantly lower in Group D than that in Group R until 2 h after discharge from the postanesthesia care unit (PACU) (P = 0.005 in the PACU, P = 0.010 at 2 h after PACU discharge) but failed to significantly reduce the overall high incidence rates of 60.5% and 65.5%, respectively (P = 0.592). Postoperative pain score was significantly lower in Group D until 6 h after PACU discharge. The rates of rescue antiemetic and analgesic agent administration in the PACU were significantly lower in Group D than those in Group R.

CONCLUSION

Opioid-restricted total intravenous anesthesia using dexmedetomidine reduces postoperative nausea, pain score, antiemetic, and analgesic requirements in the immediate postoperative period after bariatric surgery.

A Randomised Study To Compare Palonosetron With Ondansetron for Prophylaxis of Postoperative Nausea and Vomiting (PONV) Following Laparoscopic Gynecological Surgeries

Background

Incidence of postoperative nausea and vomiting (PONV) in susceptible patients can be unacceptably high (70-80% reported incidence). This study was designed to evaluate the effect of palonosetron and ondansetron in preventing PONV in high-risk patients undergoing gynecological laparoscopic surgery.

Methodology

In this randomized, controlled, double-blind trial, non-smoking females aged 18-70 years, weighing 40-90 kg, and posted for elective laparoscopic gynecological surgeries were enrolled into ondansetron (Group A, n = 65) and palonosetron (Group B, n = 65) groups. Palonosetron (1 mcg/kg IV) or ondansetron (0.1 mg/kg IV) were administered just before induction. Postoperatively, the incidence of nausea, vomiting, PONV (scored on a scale of 0-3), need for rescue antiemetic, complete response, patient satisfaction, and adverse effects were evaluated up to 48 h following surgery. Normally distributed continuous variables were compared using Student’s t-test. In addition, the Chi-squared test or Fisher’s exact test were used to compare nominal categorical data as deemed appropriate. P-value <0.05 was observed as statistically significant.

Results

The overall PONV scores and postoperative nausea scores during 0-2 and 24-48 hours were comparable, but PONV scores (p = 0.023) and postoperative nausea scores (p = 0.010) during 2-24 hours were significantly lesser in Group B compared to Group A. There was no statistically significant difference in the postoperative vomiting score or retching during 0-48 hours. The amount of first-line rescue antiemetic used during 2-24 hours was significantly higher in Group A (56%) than in Group B (31%) (p = 0.012; p <0.05). A complete response to the drug during 2-24 hours was significantly higher (p = 0.023) in Group B (63%) compared to Group A (40%), whereas response was comparable during 0-2 and 24-48 hours. Both groups had a comparable incidence of adverse effects and patient satisfaction scores.

Conclusion

Palonosetron has a superior anti-nausea effect, less need for rescue antiemetics, and lesser incidence of total PONV compared to ondansetron during 2-24h and comparable effect to ondansetron during 0-2h and 24-48h postoperative period in high-risk patients undergoing gynecological laparoscopic surgery.

Sleeve gastrectomy in the surgical management of obesity in Cameroon (a sub-Saharan country): A single-institute retrospective review of 30-day postoperative morbidity and mortality

BACKGROUND

METHODS

RESULTS

CONCLUSION

•

Sleeve gastrectomy is a safe procedure in a sub-Saharan African low setting.

•

Bleeding is the only intraoperative complication encountered in 14.3% of cases.

•

The prevalence of 30-day postoperative morbidity of sleeve gastrectomy is 38.1%.

•

Postoperative 30-day complications after sleeve gastrectomy are minor.

•

The 30-day postoperative mortality after sleeve gastrectomy is nil.

Effect of intravenous scopolamine before stapling, on postoperative nausea and vomiting in sleeve gastrectomy patients: a randomized controlled trial

INTRODUCTION

Postoperative nausea and vomiting (PONV) is a common complication of general anesthesia that is further potentiated in an obese patient undergoing a bariatric procedure. Literature shows trials of myriad of drugs used alone or in combination, as a prophylaxis for this cohort of patients with varied benefits.

OBJECTIVE

The objective of the study was to determine the effect of intravenous scopolamine prior to stapling in obese patients undergoing sleeve gastrectomy.

METHODOLOGY

A prospective randomized controlled trial of consecutive patients with BMI > 35 kg/m², undergoing laparoscopic sleeve gastrectomy (LSG) was performed after approval of the hospital's ethical committee, explanation of trial to the patients and obtaining a consent. Patients were randomized into two groups; patients receiving intravenous scopolamine just before firing first stapler (Group 1) and patients receiving placebo (Group 2). Primary outcome parameter was PONV. The secondary outcome parameters were use of rescue antiemetic and time to oral intake.

RESULTS

In our study, out of 100 cases of patients undergoing LSG, 50 received scopolamine before stapling and 50 were assigned to the control group. There was no significant difference between the two groups in terms of PONV. The group receiving scopolamine had lesser use of rescue antiemetic but no difference in time to oral intake.

CONCLUSION

We concluded that incidence of PONV in obese patients undergoing LSG is not affected by scopolamine. Further trials are needed to validate the results.

Preoperative reflux or regurgitation symptoms are independent predictors of postoperative nausea and vomiting (PONV) in patients undergoing bariatric surgery: a propensity score matching analysis

BACKGROUND

Postoperative nausea and vomiting (PONV) is common side effect after gastrointestinal surgery. It causses discomfort, increase risk of incision disruption, bleeding and airway blockage. This study aimed to investigate the incidence and severity of PONV and determine whether preoperative reflux or regurgitation symptoms influence PONV in patients undergoing bariatric surgery.

METHODS

Patients with obesity underwent laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in our center between January 2016 and December 2018 were divided into PONV and NoPONV group and analyzed retrospectively. PONV and postoperative pain visual analogue scale (VAS) were analyzed after surgery. A 1:1 propensity score matching (PSM) method was performed, and multivariable logistic regression analyses were used to identify predictors for PONV.

RESULTS

There were 483 patients enrolled, with a mean age of 30.19 ± 9.96 years, and 134 pairs of matched patients were selected from PONV group and NoPONV group after PSM. PONV occurred in 288 (59.6%) patients after bariatric surgery (77.4% after LSG vs 21.5% after LRYGB, p < 0.001). In PONV group, 210 (72.9%) were female, preoperative reflux or regurgitation symptoms were 128 (33.6%). Multivariable analysis found that preoperative reflux or regurgitation symptoms were independent risk factors for PONV after LSG, with an OR of 2.78 (95% CI: 1.12-6.93, p = 0.028).

CONCLUSIONS

Incidence of PONV after bariatric surgery is high. For the first time, this study valued preoperative reflux or regurgitation symptoms as risk factors that may promote PONV after bariatric surgery. Patients with preoperative symptoms undergoing LSG have a higher risk of PONV, so these patients should be carefully evaluated for the feasibility of LSG before surgery.

Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update

Background

This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol.

Methods

A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations.

Results

The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries.

Conclusion

A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.

Prophylactic Administration of Diphenhydramine/Acetaminophen and Ondansetron Reduced Postoperative Nausea and Vomiting and Pain Following Laparoscopic Sleeve Gastrectomy: a Randomized Controlled Trial

PURPOSE

Postoperative nausea and vomiting (PONV) and pain following bariatric surgery are problematic and affect the outcome of patients. Intraoperative multimodal antiemetic prophylaxis is essential to improve postoperative outcomes. This study investigated the effect of adding diphenhydramine to acetaminophen and ondansetron in reducing postoperative nausea and vomiting and pain following laparoscopic sleeve gastrectomy (LSG).

MATERIALS AND METHODS

Eighty-two patients scheduled for LSG were assigned to receive a single preinduction dose of diphenhydramine 0.4 mg/kg VI (D group) in addition to acetaminophen 1g and ondansetron 4 mg IV at the end of surgery and just acetaminophen 1 g and ondansetron 4 mg IV (C group) in a randomized, double-blind trial. PONV was assessed in recovery and 24 hours after surgery in the ward. Postoperative pain, analgesic requirements, and patients' level of sedation were also assessed.

RESULTS

The PONV rates in the recovery of the D group and the C group were 30% and 56% (P = .001). It also had a more significant reduction in the D group than in the C group in the first 24 h after surgery (40% vs. 66%). The severity of pain score and level of sedation and analgesic requirements was significantly reduced in this period in the D group.

CONCLUSION

Prophylactic diphenhydramine 0.4 mg/kg at the induction of general anesthesia in combination with acetaminophen 1 g and ondansetron 4 mg at the end of surgery reduced the incidence of PONV and postoperative severity of pain in laparoscopic sleeve gastrectomy.

Perioperative hemodynamic optimization in laparoscopic sleeve gastrectomy using stroke volume variation to reduce postoperative nausea and vomiting

BACKGROUND

Risk of postoperative nausea and vomiting (PONV) is usually high among patients undergoing laparoscopic sleeve gastrectomy (LSG). Perioperative hemodynamic optimization using goal-directed fluid therapy (GDFT) based on stroke volume variation (SVV) has been suggested to reduce PONV.

OBJECTIVES

This study aimed to investigate the effectiveness of GDFT on reducing PONV.

SETTING

The operating rooms in China Medical University Hospital.

METHODS

This prospective cohort study included 75 patients undergoing LSG. Patients were randomized into 3 groups: controls (conventional fluid therapy), GDFT-hydroxyethyl starch (GH), and GDFT-lactated Ringer's (GL) groups. In both GDFT groups, optimization of fluid administration was achieved by continuous monitoring and adjusting of SVV. Severity of PONV was evaluated using a standardized questionnaire. Other clinically relevant events, including in-hospital surgical site infections and length of hospital stay were also investigated.

RESULTS

In the GH group, the total volume of fluid administered intraoperatively was significantly lower than that in the GL and control groups (P < .001). Assessment of PONV severity showed a significantly higher score at postoperative 24 hours in the GH group (P < .05), while no significant differences were found between the 3 groups at postoperative 48 hours. No significant differences were observed between the 3 groups in surgical site infections and length of hospital stay.

CONCLUSION

No significant benefit is found in reducing PONV by using GDFT in patients undergoing LSG, although GDFT effectively avoids excessive volume of fluid administration. PONV incidence appears to be higher with intraoperative colloid infusion for GDFT during LSG. Further investigation is warranted to elucidate the mechanism underlying PONV in postoperative LSG.

Antiemetic Prophylaxis and Anesthetic Approaches to Reduce Postoperative Nausea and Vomiting in Bariatric Surgery Patients: a Systematic Review

While guidelines exist for the management of postoperative nausea and vomiting (PONV) in the general surgical setting, there are no established guidelines for the prevention or treatment of PONV in bariatric patients, in whom PONV contributes significantly to perioperative morbidity and hospital resource utilization. This systematic review found that the multimodal pharmacological approach to PONV prevention recommended in current guidelines for high-risk surgical patients is appropriate for the bariatric subset. This includes multi-agent antiemetic prophylaxis with dexamethasone and one or more agents from other classes, and opioid-free total intravenous anesthesia, though the advantages of the latter need further evaluation. There remains a need for a standardized validated instrument to assess PONV in the bariatric setting.

Preventing Nausea and Vomiting After Bariatric Surgery: Is the Apfel Risk Prediction Score Enough to Guide Prophylaxis?

Postoperative nausea and vomiting (PONV) is a frequent side effect in patients undergoing bariatric procedures. The simplified Apfel score is an attractive and frequently used tool to assess PONV risk in the general surgical population. Despite applying the recommendations based on the Apfel risk prediction score, several studies show that up to 82% of patients undergoing metabolic and bariatric surgery suffer from PONV in the PACU. A combination of multiple antiemetic drugs of different pharmacologic classes targeting a variety of receptors in addition to an intraoperative opioid-free TIVA technique should be considered in high-risk patients.

Disordered eating following bariatric surgery: a review of measurement and conceptual considerations

Eating disorders are associated with significant medical morbidity and mortality and serious psychological impairment. Individuals seeking bariatric surgery represent a high-risk group for evidencing disordered eating and eating disorders, with some patients experiencing the persistence or onset of disordered eating postsurgery. This review synthesizes the available literature on problematic or disordered eating in the bariatric field, followed by a review of measurement and conceptual considerations related to the use of eating disorder assessment tools within the bariatric population.

Comparison of Interview to Questionnaire for Assessment of Eating Disorders after Bariatric Surgery

The Eating Disorder Examination Interview Bariatric Surgery Version (EDE-BSV) assesses eating pathology after bariatric surgery but requires significant training and time to administer. Consequently, we developed a questionnaire format called the Eating Disorders After Bariatric Surgery Questionnaire (EDABS-Q). This study evaluates the consistency of responsiveness between the two formats. After surgery, 30 patients completed the EDE-BSV and EDABS-Q in a restricted randomized design. Patient reported behavior for each item which was converted to a score following the Eating Disorder Examination-Questionnaire (EDE-Q) scoring scheme. Responses fell into three distributions: (1) dichotomous, (2) ordinal, or (3) unimodal. Distributions of items were not different between the two formats and order did not influence response. Tests of agreement (normal approximation of the binomial test) and association (χ² analyses on binary data and spearman rank order correlations on ordinal items) were performed. Percent concordance was high across items (63-100%). Agreement was significant in 31 of 41 items (Bonferroni-P < 0.001). Association was significant in 10 of 21 in χ²-appropriate items (Bonferroni-P < 0.002), and the ordinal items had highly significant correlations between formats (Bonferroni-P < 0.0125). The EDABS-Q is an adequate substitute for the EDE-BSV and may be useful for research and clinical evaluation of eating pathology after bariatric surgery.

Transcutaneous Electrical Acupoint Stimulation Combined with Dexamethasone and Tropisetron Prevents Postoperative Nausea and Vomiting in Female Patients Undergoing Laparoscopic Sleeve Gastrectomy: a Prospective, Randomized Controlled Trial

BACKGROUND

Despite the administration of prophylactic antiemetics, some patients who undergo laparoscopic sleeve gastrectomy (LSG) remain at high risk for postoperative nausea and vomiting (PONV). Although many trials have been conducted, the effectiveness of transcutaneous electrical acupoint stimulation (TEAS) on the prevention of PONV remains unknown.

METHODS

Sixty-two female patients undergoing elective LSG were randomly assigned to the TEAS combined with dexamethasone and tropisetron (TEAS group, n = 31) or dexamethasone and tropisetron (control group, n = 31) groups. The incidence and severity of PONV, as well as the need for rescue antiemetics, were collected within 48 h after surgery.

RESULTS

The patients in both groups had similar clinical characteristics and underwent the same surgical procedure. In the TEAS group, 13 patients (41.9%) had PONV within 48 h after LSG compared to 24 patients (77.4%) in the control group (P = 0.004, relative risk: 0.39 [0.19, 0.80]). The severity of PONV differed significantly between groups, with five patients (16.1%) in the TEAS group and 15 patients (48%) in the control group experiencing clinically important PONV (P = 0.007, relative risk: 0.62 [0.42, 0.90]). Moreover, fewer patients required antiemetic rescue medication in the TEAS group compared with the control group (29.0% vs. 58.1%, P = 0.021).

CONCLUSION

Multimodal antiemetic prophylaxis consisting of TEAS and antiemetics was effective in reducing PONV incidence and intensity in high-risk patients undergoing LSG.

Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. The routine use of opioid analgesics for perioperative pain management is a major contributing factor to both PONV and PDNV after surgery. PONV and PDNV can delay discharge from the hospital or surgicenter, delay the return to normal activities of daily living after discharge home, and increase medical costs. The high incidence of PONV and PDNV has persisted despite the introduction of many new antiemetic drugs (and more aggressive use of antiemetic prophylaxis) over the last two decades as a result of growth in minimally invasive ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major surgical procedures (e.g. enhanced recovery protocols). Pharmacologic management of PONV should be tailored to the patient’s risk level using the validated PONV and PDNV risk-scoring systems to encourage cost-effective practices and minimize the potential for adverse side effects due to drug interactions in the perioperative period. A combination of prophylactic antiemetic drugs with different mechanisms of action should be administered to patients with moderate to high risk of developing PONV. In addition to utilizing prophylactic antiemetic drugs, the management of perioperative pain using opioid-sparing multimodal analgesic techniques is critically important for achieving an enhanced recovery after surgery. In conclusion, the utilization of strategies to reduce the baseline risk of PONV (e.g. adequate hydration and the use of nonpharmacologic antiemetic and opioid-sparing analgesic techniques) and implementing multimodal antiemetic and analgesic regimens will reduce the likelihood of patients developing PONV and PDNV after surgery.

A Role for GLP-1 in Treating Hyperphagia and Obesity

Obesity is a chronic recurring disease whose prevalence has almost tripled over the past 40 years. In individuals with obesity, there is significant increased risk of morbidity and mortality, along with decreased quality of life. Increased obesity prevalence results, at least partly, from the increased global food supply that provides ubiquitous access to tasty, energy-dense foods. These hedonic foods and the nonfood cues that through association become reward predictive cues activate brain appetitive control circuits that drive hyperphagia and weight gain by enhancing food-seeking, motivation, and reward. Behavioral therapy (diet and lifestyle modifications) is the recommended initial treatment for obesity, yet it often fails to achieve meaningful weight loss. Furthermore, those who lose weight regain it over time through biological regulation. The need to effectively treat the pathophysiology of obesity thus centers on biologically based approaches such as bariatric surgery and more recently developed drug therapies. This review highlights neurobiological aspects relevant to obesity causation and treatment by emphasizing the common aspects of the feeding-inhibitory effects of multiple signals. We focus on glucagon like peptide-1 receptor (GLP-1R) signaling as a promising obesity treatment target by discussing the activation of intestinal- and brain-derived GLP-1 and GLP-1R expressing central nervous system circuits resulting from normal eating, bariatric surgery, and GLP-1R agonist drug therapy. Given the increased availability of energy-dense foods and frequent encounters with cues that drive hyperphagia, this review also describes how bariatric surgery and GLP-1R agonist therapies influence food reward and the motivational drive to overeat.

Intra-operative methadone effect on quality of recovery compared with morphine following laparoscopic gastroplasty: a randomised controlled trial

The effect of intra-operative intravenous methadone on quality of postoperative recovery was compared with morphine after laparoscopic gastroplasty. We included 137 adult patients with a body mass index > 35 kg.m^-2 who underwent bariatric surgery. Patients were allocated at random to receive either intra-operative methadone (n = 69) or morphine (n = 68). All patients received the same postoperative care and analgesia. The primary outcome of postoperative quality of recovery was assessed using the Quality of Recovery-40 questionnaire total score 24 h after surgery. Secondary outcomes were assessed in the post-anaesthesia care unit the night of the day of surgery (T1), in the morning after surgery (T2); and at night on the day following surgery (T3). The median (IQR [range]) total Quality of Recovery-40 questionnaire score of 194 (190-197 [165-200]) was higher (p < 0.0001) in the methadone group compared with the score of 181 (174-185.5 [121-200]) in the morphine group. In the post-anaesthesia care unit, the pain burden; incidence of nausea and vomiting; rescue morphine dose; and time to discharge, were significantly lower in the methadone group. On the ward, the methadone group had a lower: incidence of rescue morphine requests at T1 (5.8 vs. 54.4%, p < 0.0001) and T2 (0 vs. 20.1%, p < 0.0001); and incidence of nausea (21.7 vs. 41.2%, p = 0.014), compared with the morphine group. We conclude that intra-operative intravenous methadone improved quality of recovery in patients who underwent laparoscopic gastroplasty, compared with intra-operative morphine. Methadone also reduced postoperative pain, postoperative opioid consumption and the incidence of opioid-related adverse events.

Assessment of postoperative nausea and vomiting after bariatric surgery using a validated questionnaire

BACKGROUND

Postoperative nausea and vomiting (PONV) is known to occur after bariatric surgery, with over two thirds of patients affected. However, variability exists in how to objectively measure PONV.

OBJECTIVES

The goals of the present study were to use a validated, patient-centered scoring tool, the Rhodes Index of Nausea, Vomiting, and Retching to measure the severity of PONV after bariatric surgery, to directly compare PONV between patients who underwent laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB), and to identify risk factors for the development of PONV after bariatric surgery.

SETTING

Barnes-Jewish Hospital/Washington University School of Medicine, St. Louis, Missouri, United States of America.

METHODS

The Washington University Weight Loss Surgery team prospectively surveyed patients from January 1, 2017 to December 1, 2018 at the following 6 different timepoints: postoperative day (POD) 0, POD 1, POD 2, POD 3 to 4, the first postoperative outpatient visit (POV 1: POD 5-25), and the second postoperative visit (POV 2: POD 25-50). At each timepoint, a cumulative Rhodes score was calculated from the sum of 8 questions. The American Society for Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was used to collect patient demographic characteristics and perioperative clinical data.

RESULTS

A total of 274 patients met study criteria and completed 605 Rhodes questionnaires. Two hundred fifty Rhodes questionnaires were completed by patients after SG and 355 were completed by patients after LRYGB. Total Rhodes scores are statistically higher in LSG patients compared with patients who underwent LRYGB (LSG = 5.45 ± 6.27; LRYGB = 3.08 ± 4.19, P = .0002). Additionally, at the earlier timepoints, scores were higher among patients who underwent LSG than those who had undergone LRYGB as follows: POD 0 (LSG = 6.96 ± 6.50; LRYGB = 2.89 ± 2.90, P = .0115), POD 1 (LSG = 8.20 ± 6.76; LRYGB = 2.88 ± 3.44, P < .0001), and POD 2 (LSG = 4.05 ± 4.88; LRYGB = 2.06 ± 3.43, P = .05). On subset analysis, examining patients who either underwent an LSG or LRYGB, both procedures had a statistically significant PONV peak emerge on POV 2. Last, overall Rhodes scores were statistically higher in female patients compared with male patients (female: 4.43 ± 5.46; male: 2.35 ± 3.90, P = .021). Although the magnitude of the difference varied somewhat across POD time intervals, the difference was most pronounced at POV 2.

CONCLUSIONS

This is the largest study using a validated nausea and vomiting questionnaire to objectively measure PONV after bariatric surgery. The factors found to be most associated with increased PONV were LSG and female sex. Ultimately, these data can help bariatric surgery programs, including Washington University Weight Loss Surgery, identify patients who may require more intensive treatment of PONV, particularly POD 0 to 2, and help to identify patients that continue to struggle with PONV in the later surgical recovery phase.

A Comprehensive Approach for the Prevention of Nausea and Vomiting Following Sleeve Gastrectomy: a Randomized Controlled Trial

BACKGROUND

Postoperative nausea and vomiting (PONV) following sleeve gastrectomy (SG) is a common occurrence. The effect of specific interventions in PONV prevention within enhanced recovery pathways remains unclear. The aim of this study was to evaluate the impact of a comprehensive approach for the prevention of PONV on patient outcomes and hospital resource utilization.

METHODS

A prospective randomized trial was conducted for patients undergoing SG. The intervention group received aprepitant and transdermal scopolamine preoperatively followed by ondansetron and dexamethasone intraoperatively, with total intravenous anesthesia. The control group received inhalational anesthetic and two intraoperative antiemetics without preoperative prophylaxis. The primary endpoint was a PONV-related delay in hospital discharge.

RESULTS

Eighty-three patients completed the study (41 in the intervention and 42 in the control group). Eighty-nine percent of patients were discharged home on the first postoperative day. Four patients in the control group and none in the intervention group experienced a PONV-related delay in discharge (9.5% vs 0, p = 0.119). Intervention patients reported significantly lower PONV scores at all in-hospital time points examined (p = 0.0392 for verbal scores and p < 0.0001 for Rhodes Index) and significantly higher self-rated quality of recovery at 24 h (Quality of Recovery-15 instrument, p < 0.05).

CONCLUSIONS

A multilevel approach to PONV leads to significantly lower severity of PONV and improved self-reported quality of recovery, compared with control. PONV-related readmissions, ED visits, and discharge delays were uncommon within the overall enhanced recovery cohort.

Eating Pathology After Bariatric Surgery: an Updated Review of the Recent Literature

PURPOSE OF REVIEW

The goal of this paper was to extend the prior literature on eating pathology following bariatric surgery by highlighting themes in data published over the past 3 years and identifying limitations and future directions for research.

RECENT FINDINGS

Changes in eating pathology after bariatric surgery remain consistent with previous research. Specifically, diagnostic prevalence rates and incidence of related behaviors generally decrease following surgery. However, some research supports that these factors increase and/or remit over time following surgery, and that they subsequently have a negative impact on weight loss outcomes. While recent findings have extended knowledge on eating pathology following bariatric surgery, the overall body of literature is still relatively limited. Additional research is needed, including work focusing on the standardization of eating pathology definitions, development/validation of standardized eating pathology instruments for bariatric surgery patients, and predictors of risk for continued or new onset eating pathology following surgery.

Mechanical factors in the prediction of integrity of the gastrojejunal anastomosis in ex-vivo RYGB models

BACKGROUND

Surgical staplers represent one of the important instruments in modern surgery. Laparoscopic Roux-en-Y gastric bypass is one of the most commonly performed bariatric procedures. Various techniques have been described for performing gastrojejunal (GJ) anastomosis, including linear stapled anastomosis (LSA), circular stapled anastomosis (CSA) and hand-sewn anastomosis (HSA).

OBJECTIVES

An ex-vivo porcine-based experiment was designed to compare the mechanical integrity of the GJ anastomosis among the 3 different techniques by measuring burst pressure (BP).

SETTING

Laboratory-based study conducted at the clinical skills laboratory at Birmingham Heartlands Hospitals, Birmingham, United Kingdom.

METHODS

Porcine stomachs and small bowels were used to create a GJ model. Four GJ anastomosis models each were created using circular stapler (CSA group) and hand-sewn techniques (HSA group). Stomach and small bowel thickness were recorded. BP was measured by sequential injections of methylene-blue diluted saline until a leak was detected. Total volume until leak is recorded. Compliance (C) was calculated using the formula C = ΔP/ΔV.

RESULTS

Results from our previous experiment for the LSA group are included. One model was excluded from the CSA and the HSA groups due to technical errors. Results were presented as mean ± standard deviation. Total volume in LSA, CSA, and HSA groups was 60 ± 4.08 mL, 73.67 ± 3.22 mL, and 51.67 ± 20.21 mL, respectively. BP in LSA, CSA, and HSA groups was 18 ± 4.69 mm Hg, 20.33 ± 5.77 mm Hg, and 9.67 ± 3.79 mm Hg, respectively. There was a statistically significant difference in BP among the 3 groups (P = .033; Kruskal-Wallis test). C in LSA, CSA, and HSA were 3.50 ± .88 mm Hg/mL, 3.78 ± .85 mm Hg/mL, and 5.39 ± 1.34 mm Hg/mL, respectively (P = .064).

CONCLUSION

BP was higher in CSA and LSA groups compared with the HSA group, suggesting a mechanically stronger anastomosis. Despite the lack of statistical significance, higher BP recorded in the CSA group than in the LSA group suggests better anastomotic integrity.

Nutrition Knowledge and Satisfaction Levels of Postbariatric Surgery Adults in the United Arab Emirates: A Pilot Study

Research assessing the nutrition knowledge of postbariatric surgery patients is limited, although this category of patients is predisposed to malnutrition. In this pilot study, we explored postbariatric nutrition knowledge, satisfaction levels with dietitian nutrition counseling, and decision to undergo bariatric surgery of 83 patients who attended a postbariatric outpatient nutrition clinic in Dubai, United Arab Emirates (UAE). A cross-sectional design involving gender-stratified random sampling method was used to recruit 83 postbariatric surgery participants. A self-administered questionnaire was employed to collect information about nutrition knowledge related to dietary recommendations after bariatric surgery as well as participant views on dietitian nutrition counseling, their decision to undergo bariatric surgery, and nutrition-related complications experienced after the surgery. The mean (SD) knowledge score of postbariatric diet was 9.7 (2.05) out of a maximum possible score of 14. The majority of the participants (78.3%) correctly identified which foods are recommended during the first stage of the postbariatric surgery diet, and more than 90% knew about the importance of high-protein supplements after bariatric surgery. Female participants had significantly higher mean knowledge score compared to males (p=0.02). Although nearly 80% of the participants reported regular follow-up with their dietitian, only 10.8% reported high adherence to the dietitian's instructions. Moreover, more than two-thirds of the participants (71.1%) rated dietary advice provided by dietitians as vague. The most common complication experienced by the participants after bariatric surgery was nausea (61.4%). Furthermore, the majority of the participants (83.4%) found their daily and leisure activities to be more enjoyable after bariatric surgery. Ways of improving the quality of information delivery by dietitians should be explored to enhance patient comprehension and adherence to postbariatric surgery diet recommendations. Future research involving a larger and more representative sample to extend our findings are needed.

Transdiagnostic Approach to Food Avoidance After Bariatric Surgery: A Case Study

This study describes treatment of an adult woman, referred to as “Carla,” who was referred for psychological intervention following bariatric surgery due to recurrent nausea and vomiting along with food avoidance. Carla evinced symptoms including dietary range restriction, failure to progress to recommended caloric intake, fear of vomiting, and body dissatisfaction. She was diagnosed with generalized anxiety disorder, along with comorbidities including dysthymia, body dysmorphia, and subsyndromal specific phobia of vomiting (SPOV). Treatment included 20 weekly sessions utilizing a transdiagnostic approach to treatment, which has been shown to be efficacious in management of multiple comorbidities. The limited body of research and results of this case suggest expansion of the criteria for avoidant restrictive food intake disorder (ARFID) to allow for inclusion of this constellation of symptoms within bariatric patients.

Comparison Effect of Promethazine/Dexamethasone and Metoclopramide /Dexamethasone on Postoperative Nausea and Vomiting after Laparascopic Gastric Placation: A Randomized Clinical Trial

Background

Laparoscopic gastric plication (LGP) is a technique in the restrictive category of bariatric procedures that reduces the gastric volume and increases intragastric pressure. Nausea and vomiting are the most common complications after this procedure. The goal of this research is to compare the combined effect of promethazine/dexamethasone versus Metoclopramide/ dexamethasone on the prevention of nausea and vomiting after LGP.

Methods

In recovery, the patients were divided into two groups, the Metoclopramide group which was given Metoclopramide 10 mg plus dexamethasone 4 mg/8 hours intravenous for 48 hours, and the promethazine group which was given promethazine 50 mg /12 hours, intramuscular for the first 24 hours and then promethazine 25 mg/12 hours for the next 24 hours plus dexamethasone 4 mg/8 hours intravenous for 48 hours. The frequency of nausea and vomiting, number of reflux episodes, frequency of epigastric fullness, and the duration of walking around q12 hours were recorded in the first 48 hours post-operation.

Results

Eighty patients were enrolled into the study. Promethazine group were found to significantly reduce the incidence of PONV in the first 24 hours compared with the other group (41% vs. 97.5%), relative risk = 0.042 [95% CI = 0.006, 0.299]. The mean numbers of epigastric fullness and severity of epigastria pain were lower in the promethazine group (P = 0.01) and the total opioid requirement was also reduced in promethazine group (32.1 ± 2.6 VS .68.5 ± 4.6 mg). However, the patients in the promethazine group were more sedated, which caused the duration of walking q12 hours in this group to decrease.

Conclusions

In morbidly obese patients undergoing laparoscopic gastric plication, promethazine/dexametasone was more effective than Metoclopramide/dexametasone in preventing and reducing the incidence of nausea, epigastric fullness, and reflux. That combination was also more effective than Metoclopramide in reducing the severity of epigastric pain.

Comparison of efficacy of palonosetron-dexamethasone combination with palonosetron or dexamethasone alone for prophylaxis against post-operative nausea and vomiting in patients undergoing laparoscopic cholecystectomy

Background and Aims:

Post-operative nausea and vomiting (PONV) is highly distressing and unpleasant symptom. Dexamethasone and palonosetron are effective antiemetics with minimal side effect profile. This study compares the efficacy of palonosetron or dexamethasone alone and their combination (palonosetron plus dexamethasone) for prevention of PONV after laparoscopic cholecystectomy.

Methods:

This prospective, randomised, double-blind trial was done on 187 adults, American Society of Anesthesiologists Grade I and II patients, aged 18–75 years undergoing laparoscopic cholecystectomy. They were allocated to three groups which were to receive either of the three treatment regimens: dexamethasone 8 mg (Group D, n = 57), palonosetron 0.075 mg (Group P, n = 66) or dexamethasone 8 mg plus palonosetron 0.075 mg (Group PD, n = 64). The primary outcome was incidence of PONV in 24 h and the secondary outcome was a number of rescue antiemetic required. One-way ANOVA test was used to compare the means amongst three groups. To compare the proportions in the groups, Chi-square test/Fisher's exact test/Two proportions Z-test was applied as appropriate.

Results:

Overall incidences of PONV in the study 24 h postoperatively were 23.4% in PD, 27.2% in P group and 56.14% in D group (P < 0.001). Requirement of rescue antiemetic was more in dexamethasone group than other two groups (PD = 1 time, P = 1.38 times and D = 1.5 times).

Conclusion:

Palonosetron alone and palonosetron-dexamethasone combination were equally effective in the prevention of PONV. Dexamethasone alone was least effective amongst the three groups. There is no difference between palonosetron and palonosetron-dexamethasone for PONV prevention.