The perioperative care of the patient with obesity continues to attract significant scientific interest. Modern obesity management medications are emerging as valuable tools for addressing obesity and complementing metabolic bariatric surgery, highlighting the need for a tailored, multimodal approach to optimise perioperative outcomes.1,2 A recent consensus panel has provided recommendations for integrating obesity management medications into perioperative care.2 Nonetheless, metabolic bariatric surgery currently remains the most effective long-term treatment for clinical obesity and its complications, highlighting the need for optimal perioperative care.1,2
Since its publication, the 2020 review "Perioperative Care of the Obese Patient" in BJS has garnered significant and enduring interest from the scientific community, remaining a seminal reference in the field five years later.3 The review emphasised the importance of comprehensive preoperative evaluation for patients with obesity, including encouraging preoperative weight loss to prevent or address obesity-related co-morbidities and improve surgical conditions.3 It also highlighted the need for experienced teamwork, appropriate equipment and monitoring, meticulous anaesthetic and analgesic management, and an effective perioperative ventilation strategy3 to enhance postoperative outcomes.3,4 A multidisciplinary approach remains crucial for achieving optimal patient outcomes.3,4
While several studies have been published since, the original review's insights remain largely valid, with some gaps now addressed.3 Regarding anaesthetic choices, conflicting data on propofol versus desflurane3 was clarified by a meta-analysis showing desflurane promotes faster emergence but increases postoperative nausea.5 Multimodal prophylaxis for nausea and vomiting remains essential for patients with obesity undergoing general anaesthesia.3 For neuromuscular block management, sugammadex has proven superior to neostigmine in patients with obesity, providing faster, more predictable reversal of rocuronium-induced neuromuscular block3, while reducing early postoperative pulmonary complications,3,6 as confirmed by a subsequent meta-analysis.6 Multimodal analgesia strategies remain essential for reducing opioid use and related complications in patients with obesity.3 A network meta-analysis demonstrated that intravenous non-opioid analgesics significantly reduce opioid consumption, postoperative nausea, and respiratory complications.7 Another network meta-analysis confirmed the superiority of the transversus abdominis plane block over other regional anaesthesia techniques in reducing pain and nausea, further supporting the findings of the original review.8
Obesity care is propelled by continuous innovation, demanding regular updates to clinical practices. From an anaesthetic perspective, the 2020 review remains a benchmark in this field, offering comprehensive guidance on optimising perioperative management. We recommend adhering to its principles, now enriched with these updated insights, to further enhance surgical outcomes and address the evolving challenges of perioperative care under general anaesthesia.
References
1. Cohen RV, Park JY, Prager G, Bueter M, le Roux CW, Parmar C, et al. Role of obesity-management medications before and after metabolic bariatric surgery: a systematic review. BJS 2024; 111, doi: https://doi.org/10.1093/bjs/znae284.
2. Cohen RV, Busetto L, Levinson R, Le Roux CW, Salminen P, Prager G; International Consensus on the Role of Obesity Management Medications in the Context of Metabolic Bariatric Surgery. International consensus position statement on the role of obesity management medications in the context of metabolic bariatric surgery: expert guideline by the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO). BJS 2024; 111, doi: https://doi.org/10.1093/bjs/znae283.
3. Carron M, Safaee Fakhr B, Ieppariello G, Foletto M. Perioperative care of the obese patient. BJS 2020; 107, doi: https://doi.org/10.1002/bjs.11447.
4. Carron M, Ieppariello G, Safaee Fakhr B, Foletto M. Perioperative care of the obese patient: a successful approach. BJS 2020; 107, doi: https://doi.org/10.1002/bjs.11447.
5. Carron M, Tessari I, Linassi F, Navalesi P. Desflurane versus propofol for general anesthesia maintenance in obese patients: A pilot meta-analysis. J Clin Anesth 2021; 68: 110103.
6. Carron M, Tamburini E, Ieppariello G, Linassi F. Reversal of neuromuscular block with sugammadex compared with neostigmine and postoperative pulmonary complications in obese patients: meta-analysis and trial sequential analysis. Br J Anaesth. 2023; 130: e461-e463.
7. Carron M, Tamburini E, Linassi F, Pettenuzzo T, Boscolo A, Navalesi P. Efficacy of nonopioid analgesics and adjuvants in multimodal analgesia for reducing postoperative opioid consumption and complications in obesity: a systematic review and network meta-analysis. Br J Anaesth 2024; 133: 1234-1249.
8. De Cassai A, Paganini G, Pettenuzzo T, Zarantonello F, Boscolo A, Tulgar S, et al. Single-Shot Regional Anesthesia for Bariatric Surgery: a Systematic Review and Network Meta-Analysis. Obes Surg 2023; 33: 2687-2694.
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