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Obes Surg. 2017 Mar;27(3):560-568. doi: 10.1007/s11695-016-2366-y.

Enhanced Recovery after Bariatric Surgery in the Severely Obese, Morbidly Obese, Super-Morbidly Obese and Super-Super Morbidly Obese Using Evidence-Based Clinical Pathways: a Comparative Study.

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Max Super Speciality Hospital, East Wing, 2 Press Enclave Road, Saket, New Delhi, 110017, India.
Max Super Speciality Hospital, East Wing, 2 Press Enclave Road, Saket, New Delhi, 110017, India.



We discuss the anesthetic outcome in morbidly obese patients under the enhanced recovery after surgery (ERAS) protocol. Our evidence-based clinical pathways focused on prehabilitation and included interventions like aggressive preoperative optimization of medical comorbidities, familiarizing with perioperative protocols, thromboprophylaxis, opioid free multimodal analgesia, and early ambulation.


We did a retrospective analysis of prospectively collected data of 823 patients who underwent laparoscopic bariatric surgery. Our goal was to assess the effects of BMI on the recovery and anesthetic outcome parameters, under the categories of severely obese (SeO: BMI <39.9 kg/m2), morbidly obese (MO: BMI 40-49.9 kg/m2), super-morbidly obese (SMO: BMI 50-59.9 kg/m2), and super-super morbidly obese (SSMO: BMI >60 kg/m2). Time to ambulate (TA) was the primary variable.


Requirement for non-invasive ventilation (NIV) was the only significant predictor of TA and discharge readiness (DR); the DR was further affected by functional capacity and presence of chest pain. Our analysis indicated that each unit increase in BMI (kg/m2) contributes to increase in ambulation time by 1.24 min (95 % CI: 0.648 to 1.832 min; P < 0.001) and DR by 0.52 h (95 % CI: 0.435 to 0.606 h; P < 0.001). The odds ratio for requirement for NIV (per unit change in BMI) was 1.163 (CI: 1.127/1.197; P < 0.001).


Aggressive preoperative optimization can avert effects of BMI on anesthetic outcome. Practice of prehabilitation and preoperative optimization of comorbidities using evidence-based clinical pathways can complement the principles of ERAS in patients undergoing bariatric surgery to facilitate their discharge readiness.


Anesthetic; Bariatric; ERAS; Enhanced; Outcomes; Prehabilitation; Recovery; Super obesity; Super-super obesity

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