Conference Coverage

Think beyond BMI to optimize bariatric patients presurgery



– A structured, four-pronged approach to get patients as fit and healthy as possible prior to bariatric surgery holds the potential to improve postoperative outcomes. In general, bariatric surgery patients are in a better position than most surgery candidates because of a longer preoperative period. During this time, surgeons can work with a multidisciplinary team to optimize any medical, nutritional, exercise-related, and mental health concerns.

Dr. Teresa LaMasters of West Des Moines, Iowa
Dr. Teresa LaMasters
“We have a unique window of opportunity. There is some emergent bariatric surgery, but the bulk is going to be scheduled, elective surgery. We typically have a longer lead time in many cases, and that has to do with insurance requirements and hoops we have to jump through,” said Teresa L. LaMasters, MD, FACS, medical director of bariatric surgery at UnityPoint Clinic Weight Loss in West Des Moines, Iowa.

“People focus on the size of our patients and the weight of our patients, but [body mass index] is only one factor. They can have many other comorbidities that are significant,” Dr. LaMasters said. Patients can present with cardiac and pulmonary issues, hypertension, sleep apnea, diabetes, asthma, reflux and “a very high incidence of anxiety and depression.”

“So we have a lot of challenges,” she added. “We take care of complex, high-risk patients, and our goal is to improve outcomes. Using presurgery optimization can be a key to that.”

Maximizing medical readiness

Multiple providers drive the medical intervention, Dr. LaMasters said, including surgeons and primary care doctors, as well as advanced practice providers, medical weight loss providers, and other specialists. “We do try to get patients to lose weight before surgery, but that’s not an absolute requirement. More important is adjustment of other risk factors like pulmonary risk factors, control of hypertension, treatment of sleep apnea, and control of hyperglycemia. We’d like to have their A1c [test results to be] under 8%. We want to start [proton pump inhibitors] early because there is a very high prevalence of reflux and gastritis in this population.”

Bariatric surgery patients “are uniquely positioned to have a substantial benefit from that ‘prehabilitation,’ but this only works if you have a multidisciplinary team,” Dr. LaMasters said at the American College of Surgeons Quality and Safety Conference. “Think of this as down-staging disease, like in a cancer model.”

“The message from this is there is an opportunity if we build it into the prehab phase of care. It’s a new way of thinking in surgery. You can change your results,” said session moderator David B. Hoyt, MD, FACS, Executive Director of the American College of Surgeons.

Nutritional know-how

Dietitians determine the second component – how to optimize nutrition before surgery. They focus on education, evaluation, setting goals, “and very importantly, supporting patients to attain those goals,” Dr. LaMasters said. Goals include increasing protein intake prior to surgery to a recommended 1.5 g/kg/day and starting nutritional supplements ahead of time.

Even though they typically consume an excess amount of calories, “many of our patients have baseline malnutrition,” Dr. LaMasters said. Establishing mindful behavior for meal planning, preparation, and eating is a potential solution, as is addressing any socioeconomic factors that can present challenges to healthy eating.

Emphasizing exercise

“The exercise piece is really key for our patients,” Dr. LaMasters said. Many candidates for bariatric surgery have mobility issues. “The first thing many say is ‘I can’t exercise.’ We instruct them that they can exercise. Our job is to find out what they can do – there are many different exercise modalities.”

A good baseline assessment is a 6-minute walk test to assess their distance limits, oxygen level, and any resulting symptoms.

“Our goal is to get them to walking – even those who can barely walk with a walker – for 5-10 minutes, six times a day,” Dr. LaMasters said. “We feel that is a minimum threshold to prevent blood clots after surgery.” Another recommendation is to get surgical candidates to do some activity 30 minutes a day, four times a week, at a minimum. “Eventually, after surgery and when they’ve lost weight and are healthier, the goal is going to be 1 hour, five days a week.”

Start the exercise program at least 4-8 weeks prior to surgery. Most studies show significant benefit if you start at least 4 weeks prior to surgery, Dr. LaMasters suggested. “In our own practice, we’ve seen if you can start a daily walking program even just 2 weeks prior to surgery, we see a significant benefit.”

Addressing anxiety or depression

The mental health piece is very important and should be guided by mental health providers on the multidisciplinary team, Dr. LaMasters said.

“Our patients have a high degree of stress in their lives, especially related to socioeconomic factors. A patient who does not have their anxiety or depression under control will not do as well after surgery.”

Optimization in other specialties

The benefits of a prehabilitation exercise program have been demonstrated across many other specialties, especially in colorectal surgery, cardiovascular surgery, and orthopedic surgery, Dr. LaMasters said. In randomized, controlled studies, this optimization is associated with decreased complications, mortality, and length of hospital stay.

“There is actually way less data from bariatric studies. I suggest to you that our bariatric surgery patients have similar comorbidities when compared with those other specialties – specialties that refer their patients to us for treatment,” Dr. LaMasters said.

In a study of cardiorespiratory fitness before bariatric surgery, other researchers found that the most serious postoperative complications occurred more often among patients who were less fit preoperatively (Chest. 2006 Aug;130[2]:517-25). These investigators measured peak oxygen consumption (VO2) preoperatively in 109 patients. “Each unit increase in peak VO2 rate was associated with 61% decrease in overall complications,” Dr. LaMasters said. “So a small increase in fitness led to a big decrease in complications.”

Other researchers compared optimization of exercise, nutrition, and psychological factors before and after surgery in 185 patients with colorectal cancer (Acta Oncol. 2017 Feb;56[2]:295-300). A control group received the interventions postoperatively. “They found a statistically significant difference in the prehabilitation group in increased functional capacity, with more than a 30-meter improvement in 6-minute walk test before surgery,” Dr. LaMasters said. Although the 6-minute walk test results decreased 4 weeks after surgery, as might be expected, by 8 weeks the prehabilitation patients performed better than controls – and even better than their own baseline, she added. “This model of optimization can be very well applied in bariatric surgery.”

“The goal is safe surgery with outstanding long-term outcomes,” Dr. LaMasters said. “It is really not enough in this era to ‘get a patient through surgery.’ We really need to optimize the risk factors we can and identify any areas where they will have additional needs after surgery,” she added. “This will allow us to have excellent outcomes in this complex patient population.”

Dr. LaMasters and Dr. Hoyt had no relevant financial disclosures.

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