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13 Postoperative Care
155
13.14 Length ofStay
Length of stay after one-stage BPD-DS is slightly longer than for other bariatric
procedures. Upon discharge, patients’ pain should be adequately controlled by oral
analgesia, patients should be able to tolerate their liquid diet, and they should be
ambulating by themselves. These criteria can be reached by the majority of patients
by postoperative day 2, and even by postoperative day 1 for most second-stage
BPD-DS patients.
References
1. Marceau P, Biron S, Bourque RA, etal. Biliopancreatic diversion with a new type of gastrectomy. Obes Surg. 1993;3(1):29–35.
2. Prachand VN, Davee RT, Alverdy JC. Duodenal switch provides superior weight loss
in the super-obese (BMI > or 5 50 kg/m2) compared with gastric bypass. Ann Surg.
2006;244(4):611–9.
3. Goucham AB, Coblijn UK, Hart-Sweet HB, etal. Routine postoperative monitoring after bariatric surgery in morbidly obese patients with severe obstructive sleep apnea: ICU admission
is not necessary. Obes Surg. 2016;26:737–42.
4. Biertho L, Thériault C, Bouvet L, etal. Second-stage duodenal switch for sleeve gastrectomy
failure: A matched controlled trial. Surg Obes Relat Dis. 2018;14(10):1570–9.
5. Biertho L, Lebel S, Marceau S, etal. Perioperative complications in a consecutive series of
1000 duodenal switches. Surg Obes Relat Dis. 2013;9(1):63–8.
6. Helm MC, Simon K, Higgins R, etal. Perioperative complications increase the risk of venous
thromboembolism following bariatric surgery. Am J Surg. 2017;214:1135–40.
7. Mechanick JI, coll. Clinical practice guidelines for the perioperative nutrition, metabolic and nonsurgical support of patients undergoing bariatric procedures—2019 update.
SOARD. 2020;16:175–247.
8. Simoneau MD, Vachon A, Picard F.Effect of prophylactic dalteparin on anti-factor Xa levels
in morbidly obese patients after bariatric surgery. Obes Surg. 2010;20(4):487–91.
9. Dallal RM, Bailey L, Nahmias N. Back to basics—clinical diagnosis in bariatric surgery.
Routine drains and upper GI series are unnecessary. Surg End. 2007;21:2268–71.
10. Tammela T, Kontturi M, Lukkarinen O.Postoperative urinary retention: I. incidence and predisposing factors. Scand J Urol Nephrol. 2009;20(3):197–201.
11. Nelson R, Edwards S, Tse B.Prophylactic nasogastric decompression after abdominal surgery.
Cochrane Database Syst Rev. 2007;2007(3):CD004929. https://doi.org/10.1002/14651858.
CD004929.pub3.
12. Musella M, Cantoni V, Green R, etal. Efcacy of postoperative upper gastrointestinal series
(UGI) and computed tomography (CT) scan in bariatric surgery: a meta-analysis on 7516
patients. Obes Surg. 2018;28(8):2396–405.
13. Buchwald H, Avidor Y, Braunwald E, etal. Bariatric surgery: a systematic review and metaanalysis. JAMA. 2004;292:1724–37.
14. Owen JG, Yazdi F, Reisin E.Bariatric Surgery and Hypertension. Am J Hyper. 2018;31(1):11–7.
15. Marceau P, Biron S, Marceau S, etal. Long-term metabolic outcomes 5 to 20 years after biliopancreatic diversion. Obs Surg. 2015;25(9):1584–93.
16. Plourde CE, Grenier-Larouche T, etal. Biliopancreatic diversion with duodenal switch improves
insulin sensitivity and secretion through caloric restriction. Obesity. 2014;22(8):1838–46.
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L. Bouvet
17. Guidone C, Manco M, Valera-Mora E, etal. Mechanisms of recovery from type 2 diabetes
after malabsorptive bariatric surgery. Diabetes. 2006;55(7):2025–31.
18. Mari A, Manco M, Guidone C, etal. Restoration of normal glucose tolerance in severely
obese patients after bilio-pancreatic diversion: role of insulin sensitivity and beta cell function.
Diabetologia. 2006;49:2136–43.
19. Batterham RL, Cummings DE. Mechanisms of diabetes improvement following bariatric/
metabolic surgery. Diabetes Care. 2016;39:893–901.
20. Plourde CÉ, Grenier-Larouche T, Caron-Dorval D, etal. Biliopancreatic diversion with duodenal switch improves insulin sensitivity and secretion through caloric restriction. Obesity.
2014;22(8):1838–46.
21. Kapeluto J, Tchernof A, Masckauchan D, etal. Ten-year remission rates in insulin-treated
type 2 diabetes after biliopancreatic diversion with duodenal switch. Surg Obes Relat Dis.
2020;16(11):1701–12.
Chapter 14
Preoperative Testing andCounseling
VirginiaTan andAbrahamFridman
14.1 Introduction
Bariatric surgery is an effective modality used today to help maintain weight loss
and decrease obesity-associated comorbid conditions such as diabetes, heart disease, hypertension, sleep apnea, and different orthopedic disabilities. Common bariatric surgeries done today are sleeve gastrectomy, Roux-en-Y gastric bypass, and
the biliopancreatic diversion with duodenal switch (BPD/DS). The biliopancreatic
diversion was rst described by Scorpinaro in 1979 and still remains one of the most
effective procedures for treatment of morbidly obsess patients, especially those who
have a body mass index of over 50kg/m2. Modications by Hess and Marceau,
sleeve gastrectomy and duodenal switch (BPD/DS), have signicantly diminished
the more severe complications of BPD such as dumping syndrome, hypoproteinemia, and hypocalcemia [1]. A thorough preoperative work-up is recommended in
all patients undergoing this procedure in order to help ensure long-term success.
This chapter will describe the preoperative workup needed in patients who will
undergo the duodenal switch procedure with biliopancreatic diversion (BPD/DS).
(Table14.1).
V. Tan
Frank H.Netter School of Medicine at Quinnipiac University, North Haven, CT, USA
e-mail: Virginia.tan@quinnipiac.edu
A. Fridman (*)
Grifn Hospital, Derby, CT, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
A. Teixeira et al. (eds.), Duodenal Switch and Its Derivatives in Bariatric and
Metabolic Surgery, https://doi.org/10.1007/978-3-031-25828-2_14
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Table 14.1
comprehensive work-up
Preoperative
Preoperative
comprehensive work-up
History Medications
Physical exam Medical
Psychosocial evaluation Psychopathology
Laboratory CBC
GI evaluation esophagogastroduodenoscopy
Medical subspecialty
evaluation
Informed consent Education
Medical and surgical history
Weight loss history
Smoking history
VTE history
Surgical
Eating disorders/habits
Chemistry
Coagulation prole
Renal function
Urine analysis
Liver function tests
Lipid panel
Fasting blood glucose
Vitamins (B1, B12, D, folic acid,
iron, fat soluble vitamins)
Zinc and copper
(EGD)
upper gastrointestinal (UGI)
H. pylori screening
Abdominal ultrasound
Pulmonary
Cardiology
Endocrinology
Communication
Expectations
14.2 History
All patients considering a BPD/DS should undergo preoperative evaluation for different causes of obesity and obesity-associated comorbid conditions. Preoperative
evaluation should include a comprehensive medical history, a psychosocial history,
and a physical examination.
A complete preoperative history and physical should be obtained on every patient
during evaluation for bariatric surgery. Comorbid conditions should be identied at
this time; some examples would include diabetes, cardiac disease, gastroesophageal
reux disease (GERD), obstructive sleep apnea (OSA), and hypertension. In addition, weight loss history, commitment to bariatric procedure, and other potential risk
factors should be obtained at this time. A physical exam should be performed with
focus on any potential medical/surgical contraindications to the planned procedure.
A complete medical history and medication list should be elicited and reviewed.
Immobility can signicantly increase the risk of morbidity and mortality; therefore,
patients should be evaluated for any mobility limitations [2].
14 Preoperative Testing andCounseling
Patients who are active smokers should be advised to quit at least 6weeks prior
to a BPD/DS procedure [3]. There is not sufcient data to support the exact timeline
of smoking cessation prior to surgery. However, smoking cessation should be
encouraged in all patients, as studies have shown that smoking is a modiable risk
factor for signicant increases in the incidence of postoperative morbidity in bariatric surgery. Smoking cessation could minimize the risk of adverse outcomes in
patients [4]. Tobacco cessation should also be encouraged post operatively due to
increased risk of poor wound healing and ulcer formation.
Patients interested in bariatric surgery should be consulted to avoid pregnancy
preoperatively and for 12–18 months postoperatively. Patients who do become
pregnant following bariatric surgery should have routine nutritional surveillance
and laboratory screening for deciencies every trimester, including iron, folate and
B12, calcium, and other fat-soluble vitamins. Estrogen therapy should be discontinued before bariatric surgery to reduce the risk of postoperative thromboembolic
events (1cycle of oral contraceptives in premenopausal women and 3weeks of
hormone replacement therapy in postmenopausal women) [5].
159
14.3 Laboratory Testing
All patients undergoing a BPD/DS should undergo routine laboratory screening.
This would include a complete blood count, chemistry, coagulation prole, kidney
function, urine analysis, liver function tests, lipid panel, and fasting blood glucose.
Lipid prole and preoperative triglyceride levels correlate with nonalcoholic steatohepatitis and high-density lipoprotein levels negatively correlate with nonalcoholic fatty liver disease. All of this supports the utility of preoperative lipid panels.
Because BPD/DS is a malabsorptive procedure, it will require a more extensive
nutritional evaluation, including micronutrient measurements prior to any bariatric
surgery procedures [6]. In addition, micronutrient deciencies persist or could
worsen postoperatively, therefore routine nutritional screening, recommendation
for appropriate supplements, and monitoring adherence are important [7].
Preoperative nutrition panel for a BPD/DS would include thiamine, vitamin B12,
folic acid, iron, vitamin D and calcium, fat soluble vitamins, zinc, and copper [8].
14.4 Psychosocial Evaluation
Psychosocial factors can affect the outcome of bariatric surgeries. Therefore, a thorough psychological evaluation is required before a patient is approved for surgery,
usually by a bariatric behavioral health clinician with specialized knowledge and
experience with the bariatric surgery population. The role of the psychosocial evaluation is to identify factors that can pose challenges, that can hinder optimal surgical
outcomes, and recommendations to the patient and the care team on how to properly
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address these issues [9]. Because of the importance of the preoperative psychosocial
evaluation, most bariatric practices universally include a clinical interview as part of
the preoperative workup [10].
A comprehensive history of the patient’s weight trajectory over time, including
past weight loss attempts, is an important part of the evaluation. This is important
because it can reveal important contributors that have affected the patient’s weight.
In addition, it is important at this time to carefully assess past and current eating
disorder symptoms. Disorders such as binge eating disorder, night eating disorder,
bulimia, and anorexia nervosa should be all screened for. Eating habits should also
be elicited in order to ensure optimal surgery outcomes. This would include eating
habits such as “grazing” or “emotional eating.” [11].
Patients with severe obesity also tend to exhibit more psychopathology than
healthy weight individuals or those with less-severe obesity [12]. Patients who seek
bariatric surgery can also have more psychopathology than individuals with obesity
in the community [13]. Therefore, screening patients for disorders such as depression, bipolar disorder, anxiety, and schizophrenia should all be identied preoperatively and treated prior to receiving surgery. Patients should be well informed,
motivated, and willing to engage in the necessary postoperative dietary and behavioral changes needed for bariatric surgery.
14.5 GI Evaluation
The role of a routine upper gastrointestinal (GI) endoscopy before a bariatric surgery is a controversial topic. While the European Association for Endoscopic
Surgery recommends it in all patients, Society of American Gastrointestinal and
Endoscopic Surgeons (SAGES) recommends endoscopies only in patients where
gastric pathology is suspected [14]. A systematic review by Bennett etal. showed
that endoscopic ndings resulted in a change in surgical management in 0.4–7.8%
of patients, depending on the interpretation and application of the surgeon.
Therefore, they concluded that it would be reasonable to not have a routine preoperative endoscopy in the absence of suspicion for gastric pathology [15].
In operations that exclude anatomy, like the BPD/DS, a preoperative endoscopy
can be performed because many abnormal endoscopic ndings are asymptomatic.
In this case, an endoscopy would be preferred as it can visualize and biopsy lesions
if needed [16].
Evaluation can also include H. pylori testing as a possible contributor to persistent gastrointestinal symptoms after bariatric surgery [5]. H. pylori prevalence can
vary from 8.7 to 85.5% in different populations [17, 18]. Evidence overall does not
support routine screening, but in high prevalence areas routine screening is
recommended.
14 Preoperative Testing andCounseling
161
14.6 VTE/Deep Venou Thrombosis (DVT)
History of venous thromboembolic events (VTE) or pulmonary embolism (PE) should
be obtained in all patients. The overall risk of VTE after surgery was 0.42% via the
BOLD Database. Most VTE events occurred after discharge (73%). VTE was more
frequent when the procedure was performed open as opposed to a laparoscopic
approach [19]. An extended course of thromboprophylaxis after bariatric surgery is a
safe and effective strategy for VTE prevention [20]. A longer duration of chemoprophylaxis is recommended for patients who are at a higher risk of postoperative
VTE.Inferior venous cava (IVC) lter placement before surgery is not shown to prevent pulmonary embolisms and might lead to increased complications [21].
14.7 Cholelithiasis/Abdominal US
Surgically induced weight loss is associated with an increased risk, up to 32–42%,
for developing cholelithiasis [22]. Routine administration of ursodeoxycholic acid,
simultaneous cholecystectomy during a bariatric procedure, and performance of a
cholecystectomy following a bariatric surgery are the mainstays of treatment for
these patients [23]. The risk factors for gallstone formation in the postoperative
bariatric surgery patient include diminished bile acid and phospholipid secretion,
high biliary cholesterol secretion, and gallbladder stasis [24].
Timing of cholecystectomy and bariatric surgery is complicated. Bariatric surgery increased risk for gallbladder pathologies due to massive weight reduction,
which is associated with altered gastrointestinal anatomy, which can make the cholecystectomy more challenging. However, simultaneous cholecystectomy and BPD/
DS is associated with increased morbidity in patients with obesity [24].
Warschkow etal. published a meta-analysis that showed concomitant cholecystectomy during bariatric surgery would not be recommended. This is based on the
fact that the rate of subsequent cholecystectomy after laparoscopic roux-n-y gastric
bypass (LRYGB) is low (6.8%) and that the main cause for subsequent cholecystectomy was uncomplicated biliary disease. They also found that around 95% of the
subsequent cholecystectomies were performed and had little complications (0.1%)
[25]. A case can be made that since the access to the biliary tree after a BPD/DS is
more difcult, a preoperative or concomitant cholecystectomy should be performed
to minimize the risk for a more complicated procedure in the future.
Nevertheless, patients who are symptomatic and have signs that indicate gallbladder pathology should undergo a transabdominal ultrasound. Ultrasound is still
the conventionally utilized technique in order to assess gallstone formation though
US might have limited sensitivity in the obese patient [26]. Though there is controversy surrounding preoperative gallbladder evaluation prior to bariatric surgery, data
supports evaluation in symptomatic patients and subsequent cholecystectomy [27].
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14.8 Medical Subspecialty Evaluation
14.8.1 Pulmonary
Included in the preoperative evaluation, chest radiograph and standardized screening for obstructive sleep apnea with conrmatory polysomnography if screening
tests are positive [5]. OSA is an important aspect of the preoperative workup for
patients considering bariatric surgery because OSA is associated with increased
postoperative complications [28]. OSA is also very prevalent in patients prior to
bariatric surgery with up to 38% of patients having undiagnosed OSA [29]. Standard
preoperative management of OSA with continuous positive airway pressure (CPAP)
is recommended.
Included in the preoperative evaluation should also be pulmonary evaluation for
other pulmonary pathology such as asthma, dyspnea, chronic obstructive pulmonary disease (COPD), and obesity hypoventilation syndrome (OHS). OHS is an
independent risk factor for more severe desaturations and is also associated with
OSA [28]. If severe disease is conrmed, patients should have preoperative arterial
blood gas measurements and pulmonary function tests [5].
14.8.2 Cardiology
Patients undergoing bariatric surgery have a high prevalence of known and unknown
cardiopulmonary diseases [30]. Therefore, it is recommended to do some cardiac
testing preoperatively. Patients with a known heart disease may require formal cardiology consultation before surgery. Noninvasive cardiac testing beyond an electrocardiogram is determined by the patient’s risk factors and history/physical exam. If
a patient is at risk for heart disease, evaluation for use of B-blocker should be done.
A paper by Thompson etal. shows that B-blocker continuation on the day of and
after surgery was associated with fewer cardiac events and lower 90-day mortality [31].
14.8.3 Endocrinology
Type 2 diabetes mellitus (T2D) is one of the risk factors contributing to postoperative complications in patients undergoing BPD/DS.Preoperative glycemic control
should be optimized using a diabetes comprehensive plan using diet, exercise, and
pharmacotherapy. Targets for perioperative glycemic control include having a
14 Preoperative Testing andCounseling
163
hemoglobin A1c value of 6.5–7.0% or less, a fasting blood glucose level of <110mg/
dL, and a 2-h postprandial blood pressure glucose concentration of <140mg/dL [5].
Studies have also found that a shorter duration and better control of diabetes prior
to surgery corresponds to a higher rate of remission [32].
14.9 Informed Consent
Informed consent of bariatric surgery is a dynamic process of education and comprehension in addition to the disclosure of risks and benets [33]. Prior to surgery,
the patient must be made aware of the full implications of bariatric surgery, since the
surgery will have lasting impacts on their life moving forward [34]. Educational
objectives, active teaching and learning processes, and assessments are recommended and should be communicated at a sixth to eighth grade reading level [34,
35]. Multimedia tools for informed consent and patient education show promise for
improving comprehension. However, the mainstay of informed consent will still be
personal counseling that allows for the patient to ask questions and express concerns [36]. Informational seminars can be useful at the beginning of the preoperative workup for a patient but education should be continued throughout the whole
preoperative period. Studies have shown that candidates for bariatric surgery understand its benets but still can have unrealistic expectations of weight loss. Therefore,
setting realistic expectations prior to surgery is an important aspect of the preoperative evaluation and education process [37]. Thorough discussion of the need for
long-term follow-up, vitamin supplementation, and long-term lifestyle change is
required in order to achieve post-operative success. Consent should also include
experience of the surgeon within the specic procedure offered, and whether the
hospital is an accredited institution should be mentioned.
The basic elements of informed consent should include the nature of the illness
and the natural consequences of no treatment, the nature of the proposed operation,
including the estimated risks of mortality and morbidity, the more common known
complications, and any alternative forms of treatment, including nonoperative techniques. The patient should understand the risks as well as the benets of the proposed operation [35]. Patients can sometimes forget signicant elements of their
preoperative teaching and education, including risks of serious complications.
Therefore, discussion about the risk of serious complications should happen again
immediately prior to the proposed operation.
Ultimately, the privilege of consent lies with the patient alone. Therefore, it is
prudent and safer to have a well-educated and informed patient prior to the
procedure.
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14.10 Conclusion
Preoperative work-up for BPD/DS is essential in the subsequent success and happiness of the patient and operation. It is important to have practice standards so that
patients can be approached in a standardized fashion with evidence-based guidelines preoperatively to optimize care. Having a standardized preoperative protocol
will limit errors of omissions and ensure that patients all received high quality care
while also maintaining efciency and avoiding unnecessary testing.
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