Final Master’s thesis:
Treatment of nausea and vomiting after bariatric surgery.
TABLE OF CONTENTS
Summary……….3 Acknowledgements……….5 Conflict of interest………....………...5 Abbreviations………..5 Terms………. ……….5 Introduction………...6 Aim………7 Objectives………...7 Methods……….. 9 Results………..……….11 Discussion……….16 Limitation……….17Clinical implications, practical and research recommendations………..17
Conclusions………..18
Summery
Atrin SalehFinal Master Thesis: Treatment of nausea and vomiting after bariatric surgery. Aim:
This study is aimed to perform a systematic review to identify methods of prevention and treatments of nausea and vomiting after bariatric surgery.
Objectives:
To describe recent methods of bariatric surgery.
To describe in short principles of enhanced recovery after bariatric surgery. To identify problems of postoperative nausea and vomiting after bariatric surgery.
To describe the physiology and current recommendations of prevention of postoperative nausea and vomiting after surgery.
To describe current studies on postoperative nausea and vomiting after bariatric surgery, identifying available treatment options of postoperative nausea and vomiting.
Methods:
This systematic review was initiated by online literature search, using key words ”nausea and vomiting after gastric surgery”, ” problems of recovery after gastric surgery” and ” recovery after gastric surgery” and ”
Enhanced Recovery After Surgery”, which result in a wide range of articles. In order to narrow the research, the key word ”nausea and vomiting after bariatric surgery” was used. Only articles with full text, related to our main objectives were included in this systematic review. Articles containing only abstract and those articles that were duplicated and not related to this study were excluded.
Results:
The online literature search resulted in finding of a total of 114 articles: n= 97 on PubMed, n=17 on JAMA network. In the following two screening processes 98 articles were excluded due to lack of, leaving 16 eligible articles that were used in this study. Among the eligible studies 6 of them [1] [2] [3] [4] [5] [7] addressed the effect of using a multiple prophylactic antiemetic drug regimen as treatment of PONV. There was a very small variation in the outcomes of the studies. All the studies supported that the use of multiple prophylactic
reducing the incidence of PONV. A very interesting study on Healing Touch [13] showed patients undergoing bariatric surgery can benefit from this techniq and it can be used as a complementory treatment of both
postsurgical pain och PONV. Conclusions:
Acknowledgements
I want to sincerely thank my supervisor Assoc. prof. Aurika Karbonskienė for leading me throughout this journey and for all the advices.
I would also like to thank my family and closest friend for all the support that made this journey possible for me.
Conflict of interest
I declare no conflict of interest related to this work.Abbreviations
PONV – Postoperative Nausea and VomitingBMI – Body Mass Index
ERAS – Enhanced Recovery After Surgery BBB – Blood Brain Barrier
CTZ – Chemoreceptor Trigger Zone
RYGB – ROUX-EN-Y GASTRIC BYPASS 5-HT3 – Serotonin receptor antagonist
Terms
Introduction
Obesity is an increasing health problem in many parts of the world, with a higher prevalence in the developed countries. According to a recent study performed in 2013, obesity rates 18 to 20 % in the developed countries, [1]. By definition obesity is accumulation of excessive body fat, which may have adverse health effect. Body weight is measured in Body Mass Index (BMI). BMI is a simple index that describes the relationship between weight and length and is often used to classify adult obesity, [2]. A BMI of 18-25 corresponds to normal
weight, 25-30 corresponds to over weight and a BMI of 30 is considered as obesity in adults. To describe it in a simple way a healthy body weight is maintained when there is balance between the amount of energy that the body is supplied with and the energy it consumes. Over time when the amount of energy supplied to the body outweighs the energy required it could lead to overweight or eventually obesity.
Obesity is caused by a number of factors including genetic factors, behavioral and cultural, as well as social factors and certain drugs. Due to this variety of underlying factors it is difficult to identify the exact underlying cause. Obesity is considered to be a chronic disorder which is associated with many other disorders including diabetes mellitus, atherosclerosis, metabolic syndrome, dyslipidemia, stroke, sleep apnea, infertility, back and joint problems, certain types of cancer and liver/bile disease, etc. [3].
Obesity is a serious pathological condition and it requires treatment like any other disorder. Obesity is treated in a stepwise fashion starting with life style changes including changes in diet and increased physical exercise as the first step. In addition to life style changes pharmacological medications can also be used in order to maximize weight loss. In those with a BMI higher than 30kg/m2 or in those with comorbidities, medication options include orlistat, benzphetamine, phentermine etc [28]. A meta-analysis study performed earlier shows that all these medication are equally effective [4]. In cases when these above mentioned methods do not result in desirable effect, surgical methods may be considered. Candidates for bariatric surgery include adults over 18 years old with BMI more than 35 kg/m2 or lower when in combination with serious comorbidities. With the increased prevalence of obesity worldwide there is also an increase in the number of bariatric surgeries
performed. The number of bariatric surgeries worldwide in 2014 was estimated to be 579,517 [6], compared to surgeries in 2011 estimating 340,768 surgeries [6].In Canada, the number of bariatric surgeries performed in 2016 was estimated to be 8583 compared to 6525 surgeries performed in the years 2013 and 2014 [6]. Today the surgical options for bariatric surgeries include Rouxen-Y-Gastric bypass procedure, adjustable gastric banding and vertical sleeve gastrectomy, the latter is the most popular procedure and represents approximately 46 percent of all performed operations [6].
The prevalence of bariatric surgery is increasing worldwide for this reason; complication such as PONV must be paid more attention to. Because PONV itself can have various side effects such as rupture of the newly formed incision, water and electrolyte misbalance etc. it is extra important to indentify the risk factors and minimize them so that the recovery after such surgery is as pleasant as possible. There are four main risk factors that are associated with increased incidence of PONV, including the female gender, history of
PONV/motion sickness, smoking status, and use of postoperative opioids. Beside these risk factors other risk factors have been identified to have an effect on PONV, these factors can be divided into three categories: patient risk factors, including genetic predisposition, smoking status, history of PONV/motion sickness and female gender, anesthetic technique, including use of opioid, and lastly surgical procedure including longer duration of surgery and different types of surgeries, for instance, the risk of PONV is higher after gastric banding compared to RYGB [7].
with a incidence of 1-5.6%, anastomotic stricture with a incidence of 3-11%, and internal hernias which can result in intestinal obstruction or ischemia or both. The most common complications related to adjustable gastric banding are dysphagia, severe reflux like symptoms and band erosion. Postoperative pulmonary embolism, cholelithiasis, gastrointestinal bleeding and wound problems such as cellulitis and sepsis, are complications that can result in all types of surgeries. Postoperative pulmonary embolism is a major cause of death in patients undergoing bariatric surgery with an incidence of 1-2%. Cholelithiasis is a common
complication after bariatric surgery with incidence of up to 30% and may be precipitated by rapid weight loss. Wound problems such as cellulitis and sepsis are most frequently caused by staphylococcus aureus,
Enterococcus spp. and α-haemolytic Streptococcus spp. [29] In addition to these complications, there are other
short term complications associated with bariatric surgery, including postoperative pain, nausea and vomiting. In this study the main focus will be on post-operative nausea and vomiting and the prophylaxis and treatment of these complications. Nausea and vomiting associated with bariatric surgery are very common and expected complications with an incidence of 8.69–9.04% [8] [9].
Prophylaxis and early treatment of PONV is crucial because not only can these complications cause dehydration and electrolyte imbalance but also they can lead to rupture of the newly performed incision. Currently different medication and methods are used for prophylaxis of post-operative nausea and vomiting, in this study the main focus is to identify effective methods of prophylaxis and treatment of nausea and vomiting after gastric resection. Serotonin type 3-receptor (5-HT3) antagonists such as ondansetron are commonly used for prophylactic purposes to control PONV, other medications that may be used are promethazine suppository or scopolamine patch in cases when the patient is intolerant to 5-HT3 antagonist and cannot tolerate oral medications. Medications reviewed in this study are dexamethasone, haloperidol, granisetron alone or in combination with dexamethasone/droperidol, prochlorperazine, promethazine/dexametasone and
metoclopramide/dexametasone [9].
In modern surgery including in bariatric surgeries the concept of ERAS, short for enhanced recovery after surgery is implemented to reduce surgical stress, reduce complications and shorten hospitalization. ERAS is a multimodal perioperative care pathway, that have been developed based of medical science to achieve early recovery for patients undergoing major surgery. ERAS, when implemented, is associated with improved quality of care, reduced number of complications and shorten period of hospital stay. [11]
Studies have shown that using a combination of different antiemetic medication is more effective than using them individually [1]. This can be explained by the pathophysiological pathway of PONV. Vomiting center in the brain controlls vomiting, which becomes activated when receiving afferent input from different sites of body, including vagal input from stomach, and also afferent input from the chemoreceptor trigger zone (CTZ). CTZ is located outside blood brain barrier (BBB) and it contains several different type of receptor through which antimetic drugs stimulate the vomiting center. Because there are several types of receptors involved, using several different types of anti-emetic medication yeild a better effect on the treatment of PONV [10]. Aim:
This study is aimed to perform a systematic review to identify methods of prevention and treatments of nausea and vomiting after bariatric surgery.
Objectives:
To describe recent methods of bariatric surgery. (1)
To describe in short principles of enhanced recovery after bariatric surgery. (2)
To describe the physiology and current recommendations of prevention of postoperative nausea and vomiting after surgery. (4)
Methods
All the articles of interest included in this research were published between May 2005 and May 2018. These articles are addressing the issue of ”nausea and vomiting after gastric surgery” and ” enhanced recovery methods after bariatric surgery”, which were obtained from PubMed and JAMA network, by using the key word ”nausea and vomiting after gastric surgery”, other key words used, to expand the research, included ” problems of recovery after gastric surgery” and ” recovery after gastric surgery” but the articles found by using these specific key words were unrelated to this study. In this study only electronic database literature were used. Inclusion criteria: During the research only articles with full text, that analyzed treatment of post-operation nausea and vomiting, were included in this study. Inclusion of articles was done in 2 steps, during the first step the title and the abstract of each article was analyzed and during the second step the full text of the articles were read and only those related to the topic of this study were included. This includes the articles that analyzed the most suitable type treatment and prophylaxis of nausea and vomiting after gastric resection.
Exclusion criteria: Articles that contained only abstract without full text and those articles that were duplicated and not related to this study were excluded. For exclusion all the articles were screened and those addressing issues such as ”long term treatment” and ”long term outcome of gastric resection”, which are not in the interested for this study, were excluded. In this study only the articles addressing short-term outcome after a gastric surgery were included.
PubMed (n = 118) JAMA network (n = 17) Oxford academic (n = 2) Total (n = 139)
Full-text articles for 2nd stage evaluation
(n = 41)
Eligibale articles (n = 32)
Wiley Online Libery (n = 2)
Irrelevant articles n=71 Unaccessible full text n=27 n=98 excluded
Results
Systemic review covering the topic of ”treatment of nausea and vomiting after gastric resection” was conducted on the autumn of 2018. For the purpose of this study a total number of 139 articles were identified. Among these articles 118 were published on PubMed, 17 on JAMA network, 2 on Oxford academic and 2 on Wiley Online Library. In order to choose the most eligible articles for this study, two screening processes were
performed, during which the articles where reviewed. In the first screening process a total number of 98 articles where removed due to inadequate information on this specific topic, lack of complete study and due to
irrelevance. The remaining 41 articles were then screened for the second time; amongst these articles those most relevant were selected. The relevance was based on whether the study answered the main question of interest. After the second screening process a total number of 29 eligible articles were selected.
The eligible articles included in this study were published between the years 2005 and 2018. The target population in each study were obese adults, with a body mass index over 35 kg/cm2. The size of patients’ population as well as the gender varied depending on the study. All of the investigations were carried out in a hospital setting. The main purpose of this study was to investigate the best prophylactic and treatment options for nausea and vomiting after vertical gastric surgery. Postsurgical nausea and vomiting is a major cause of patient dissatisfaction. Beside it being very uncomfortable, the consequences of vomiting can be very serious. During such surgery the size of the stomach is decreased, making the stomach more fragile for vomiting and the increase pressure caused during vomiting process. This can eventually lead to rupture of the newly incised wounds [12].
With the global increase in the numbers of bariatric surgery, PONV have become an important issue to deal with. Researches have taken different measures in order to prevent or if not possible to reduce the incidence of PONV. In this research we will review the most common and effective measures used. In the table below, the incidence of PONV is reviewed.
Table 1. The incidence of nausea and vomiting in various studies. First author, year Patient
population
Type of surgery Incidence of nausea an vomiting
Mendes MN, 2009 77 Video-laparoscopic bariatric surgery
78.94 % Moussa AA, 2007 120 Laparoscopic bariatric surgery 30 % Bamgbade OA, 2018 400 Laparoscopic bariatric surgery 19.5 % Therneau IW, 2018 338 Laparoscopic bariatric surgery 17 % Sinha AC, 2014 125 Laparoscopic bariatric surgery 15 Talebpour M, 2017 80 Laparoscopic gastric plication 97.5 Ziemann-Gimmel P,
2014
119 Gastric banding 37.3 %
Among the chosen eligible studies (N=29), 7 of them were conducted to investigate the effect of using multiple antiemetic drugs for treatment of PONV. Each one of these studies supports that the use of multiple antiemetic drug therapy in bariatric surgery is very effective.
One study was performed to investigate the effect of combining haloperidol, dexamethasone and ondansetron on PONV after laparoscopic bariatric surgery. The target population in this study was 90 patients with BMI over 35 kg/cm2. These patients were divided into 3 groups. First group received ondansetron 8 mg (Group O); the second group recived ondansetron 8 mg and dexamethasone 8 mg (Group OD); and the third group
ondansetron 8 mg, dexamethasone 8 mg, and haloperidol 2 mg (Group HDO). Afterwards the intensity of nausea and pain was evaluated using the verbal numeric scale, cumulative number of vomiting episodes, and morphine consumption in the period of 0-2, 2-12, 12-24, and 24-36 hours postoperatively. Nausea intensity was lower in Group HDO compared to Group O (p = 0.001), pain intensity was lower in Group HDO compared to Group O (p = 0.046), and morphine consumption was lower in Group HDO compared to Group O (p = 0.037). There was no difference between groups regarding the number of vomiting episodes (p = 0.052). [13].
Another similar study was performed using ondansetron and dexamethasone as prophylaxis [2], this study was conducted with the purpose to compare different prophylaxis methods for postoperative nausea and vomiting after a video-laparoscopic bariatric surgery. In this study 77 patients were included, these patients were then divided into 4 groups. Cont group, control (n = 19) where antiemetics were not administered; Dexa group (n = 16) receiving dexamethasone; Onda group (n = 20) receiving ondansetron; and Dexa+Onda group (n = 22) receiving a combination of dexamethasone and ondansetron. The incidence of nausea and/or vomiting in the different groups was: Cont group - 78.94%; Dexa group - 62.25%; Onda group - 50%; and Dexa+Onda group - 18.8% (p = 0.0002). This study showed that the incidence of postoperative nausea and vomiting after video-laparoscopic bariatric surgeries was more effectively reduced when combining ondansetron and dexamethasone compared to using these drugs individually. [14].
Another medication that has shown to be safe and effective in reducing the incidence of PONV is granisetron. A study was done in 2007 comparing the effect of granisetron alone vs granisetron combined with
dexamethasone/droperidol on postoperative nausea and vomiting in patients undergoing laparoscopic bariatric surgery. The incidence of PONV was 30% with granisetron alone, 30% with granisetron plus droperidol, 20%, with granisetron plus dexamethanone, and 67% with placebo. (P < 0.05; overall Fisher's exact probability test). This study showed that combination granisetron and dexamethasone is effective and safe in reducing the incidence of PONV. [15]
There is also a study done on the outcome of antiemetic multi-drug therapy after a longer period of time, 6 years in particular. This study shows that the use of antiemetic multi-drug therapy composed of
prochlorperazine, dexamethasone, ondansetron, or cyclizine is associated with significantly less PONV, shorter post-anesthesia care unit stay, earlier postoperative drinking, and shorter hospital stay (p = 0.001). Comparing the drugs, dexamethasone + cyclizine + prochlorperazine provided the best prophylaxis and outcome,
p = 0.002. This study shows that the use of more than one antiemetic drug is very effective in both a short-term period and also over a longer period of time. [16]
patients with and without aprepitant therapy. Patients were obeserved also 1 h as well as 48 hours after PACU discharge. After 1 h fewer patients in the aprepitant group had PONV (19 vs 31%; odds ratio [OR] [95% CI], 0.5 [0.30-0.80]; P = .007). During the first 48 postoperative hours, PONV rates were similar between the groups (68 and 66%; P = .73), but fewer emesis episodes occurred in the aprepitant group (6 vs 13%; OR [95% CI], 0.45 [0.21-0.95]; P = .04). This study showes that adding aprepitant to triple antiemetic prophylaxis is associated with lower incidence of PONV during early recovery but a forth antiemetic medication may not have a very significant effect on vomiting during later period. [17]
The effect of antiemetic aprepitant (neurokinin-1 inhibitor) was evaluated in another study. This study was a double-blind placebo-controlled trial, in which 125 patients undergoing laparoscopic bariatric surgery were divided into two groups. Patients in group A, were given aprepitant (80 mg), patientes in group P received a similar-appearing placebo an hour prior to surgery. All patients received intravenous ondansetron (4 mg). After surgery the patients were evaluated for nausea and vomiting by a blinded evaluator at 30 min, 1, 2, 6, 24, 48, and 72 h. In group A the incidence of vomiting 72 h after surgery was lower (3 %) compared to group P (15%; p = 0.021). Beside that, the occurrence of first vomiting was delayed in group A (p = 0.019), also a higher number of patients showed complete absence of nausea or vomiting in group A compared to group P (42.18 vs. 36.67%). From this study we can conclude that adding aprepitant to ondansetron can lead to delay vomiting episodes as well as lower the incidence of vomiting after this type of surgery. [18]
Another study showed that using a combination of some medications such as promethazine/dexametasone is more effective than using a combination of other medications such as metoclopramide/dexametasone. The goal of this research was to compare the effect of promethazine/dexamethasone versus metoclopramide/
dexamethasone on the prevention of nausea and vomiting after laparoscopic gastric plication (LGP). For this study the patients were divided into 2 groups. During the recovery period the patients in group metoclopramide received metoclopramide 10 mg and dexamethasone 4 mg/8 hours intravenous for 48 hours, patients in group promethazine receiced promethazine 50 mg/12 hours, intramuscular for the first 24 hours followed by
promethazine 25 mg/12 hours for the next 24 hours plus dexamethasone 4 mg/8 hours intravenous for 48 hours. During this period of time the frequency of nausea and vomiting was recorded. This study showed that patients in group Promethazine had a lower 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], this in turn means that obese patient undergoing laparoscopic gastric plication will benefit more from promethazine/dexametasone than
metoclopramide/dexametasone, due to a more significant effect of promethazine/dexametasone in preventing and reducing the incidence of nausea and vomiting. [19]
A comparative study was done to evaluate the effect of using Opioid-sparing analgesia (dexmedetomidine) versus conventional analgesic regimens on postsurgical complications after bariatric surgeries. Various factors affected by analgesics including morphine consumed, pain, nausea and vomiting and heart rate were studied to evaluate the effect of opioid-sparring analgesia. Different scores such as PACU pain scores, postoperative nausea and vomiting pain scores were used. The most relevatnt for our study is postoperative nausea and
vomiting scores. This study showed that the patients in dexmedetomidine group had lower postoperative nausea and vomiting incidence (odds ratio =±0.26, I2 = 0%). [20]
PONV is a well‐known side effect of general anesthesia. As any other surgical procedure PONV related to bariatric surgery is also influenced by the use of anesthesia during the surgical procedure. But in this case anesthesia is not the only factor that can cause PONV, beside anesthesia, bariatric surgery itself is a major cause of PONV due to the anatomical changes performed during such procedure, as well as other complication such as gastrojejunostomy anastomotic stricture or gastro-gastric fistula can cause PONV in patients
anesthesia versus volatile anesthetics with opioids has an effect of PONV. Patients in this study were divided into 2 groups, classic group (n=59) receiving general anesthesia with volatile anesthetics and opioids, and total i.v. anesthesia (TIVA) group (n=60), who received opioid-free TIVA with propofol, ketamine, and
dexmedetomidine. In the Classic group, 22 patients (37.3%) reported PONV compared with 12 patients (20.0%) in the TIVA group [P=0.04; risk 1.27 (1.01-1.61)]. This study shows that the use of opioid-free anesthesia is associated with reduction in occurrence of PONV in patients undergoing bariatric surgery, and should preferably be used in case of bariatric surgery. [21][22][23]
A studies was performed to evaluate whether the level of IAP have a effect on postoperative nausea and pain. The size of patient population in this study was fifty female patients undergoing gastric bypass. These females were randomized to intraabdominal pressure of 12 (IAP12) or 18 (IAP18) mm Hg during the surgery. After the surgery was successfully performed the level of nausea and pain was assessed using visual analogue scales. The study showed that there as no difference between the two groups regarding pain IAP18 and IAP12 (p = 0.7408), there was also no difference between the groups regarding postoperative nausea, according to this study higher IAP used during laparoscopic Roux-en-Y gastric bypass have no negative effect on pain or nausea.
[24]
There were also studies investigating ERAS (N=2). The concept of ERAS is designed to address the issue of postsurgical complications such as PONV, pain and inability to digest food, this concept is a framework for optimal perioperative care meaning that health care professionals employ ERAS to optimize fluid and nutritional supply, pain relief and postsurgical care in order to achieve the goal of minimizing postsurgical complications. This evidence‐based comprehensive framework for optimal perioperative care has been gathered by an international working group within ERAS society for patients undergoing gastrectomy, the data used in this study are taken from standard databases and personal archives. In the process of development of ERAS, the available evidence has been summarized and recommendations are given for 25 items, eight of which contain procedure‐specific evidence, and 17 containing non-procedure specific items, the latter is most relevant for our study, in which the issue of PONV has been investigated. This evindence based study shows that using different pharmacological agents, depending on the patient's history of PONV, type of surgery and type of anaesthesia, is effective in reducing PONV. [25]
Another study was done, during which the Enhanced recovery after surgery (ERAS) was implemented in order to address the issue of PONV. In this study the main objective was to determine whether the implication of ERAS will lead to discharge on postoperative day 1 [q], decrease use of opioids and antiemetic. In this research the patients who were undergoing bariatric surgery were divided into 2 groups, comparison group (N = 366) and ERAS group (N = 715). The results of this study showed that ERAS did not have an effect on discharge on the first postoperative day (79.8% non-ERAS versus 83.1% ERAS, P = 0.52), however the consumption of opioids was lowered (41.0 versus 16.2 morphine equivalents, P<0.001), and there was a significant reduction in PONV and antiemetic consumption (68.8% versus 46.2%, P<.001). [26]
Other than a pharmacological approach of preventing or reducing post operative nausea and vomiting, non-pharmacological methods have been implemented that seem to be beneficial in making the recovery period for patients undergoing bariatric surgeries easier, such method include Healing Touch. Healing Touch is a
effective for patients undergoing bariatric surgery, and can be used as a complementary method to conventional pharmacological therapy to make the recovery period easier and more pleasant. [27]
(https://www-ncbi-nlm-nih-gov.ezproxy.dbazes.lsmuni.lt/pubmed/25797686)
Table 2. Types of PONV prophylaxis and outcome
First author, year
Patient populatio n
Type of PONV prophylaxis Outcomes
Lowering the incicence of PONV Benevides ML, 2013 30 Ondansetron + dexamethasone + haloperidol (HDO) vs Ondansetron (O) Nausea P = 0.001 Vomiting P = 0.052 Mendes MN 2009
77 Count group (no medication) vs
Dexamethasone vs
ondansetron vs
Dexamethasone and ondansetron
Cont group - 78.94%; vs Dexa group - 62.25%; vs Onda group - 50%; vs Dexa+Onda group - 18.8%, p = 0.0002 Bamgbade OA, 2018 400 dexamethasone + cyclizine + prochlorperazine P = 0.002 Therneau IW, 2018
338 dexamethasone, droperidol, and ondansetron + aprepitant vs dexamethasone, droperidol, ondansetron 19 vs 31%, P = .007 Sinha AC, 2014 125 Aprepitant vs Placebo 3% vs 15%, p = 0.021 Talebpour M, 2017 80 Promethazine/dexamethasone vs Metoclopramide/ dexamethasone 41% vs. 97.5% p = 0.042 Singh PM, 2017 312 Ziemann-Gimmel P, 2014 119 Opioid-free anastetics vs
Anaesthetics and opioids
Discussion
Among patients undergoing surgery, PONV is a very common complication after the use of general anesthesia, with an incidence up to 30%. Studies have shown patients undergoing bariatric surgery can experience PONV for up to 48 hours [30]. PONV is a common complication of general anesthesia that occurs in any surgical procedure during which general anesthesia is used, but in case of bariatric surgery, the anatomical changes performed during such procedure is an additional risk factor causing PONV. PONV becomes extra problematic for patients undergoing bariatric because the process of vomiting causes increase pressure inside the newly created small stomach sac, which can eventually lead to its rupture releasing the content into the abdomen. Despite the risk factors being present for obese patients undergoing bariatric surgery and the global increase of bariatric surgery there are very limited reports in the literature regarding PONV after bariatric surgery. All studies included here show that using prophylactic antiemetic drug, as mono-therapy is not sufficient for prophylaxis. According to the same studies a multi-drug therapy can benefit the patients in reducing the incidence of PONV. This can be explained by the fact that there are multiple receptors in the brain stem responsible for triggering vomiting, when using multi-drug therapy a higher number of receptors will be blocked resulting in lower incidence of vomiting [31].
The studies conducted on the effect of multi-drug therapy on PONV, can be divided into three categories, multi-drug therapy with triple drugs (13), (16), those with two drugs (14), (15), (18), (19) and one study with 4 drugs (17). The results of the studies did not differ very significantly and showed a similar outcome p < 0.05, indicating that a multi drug therapy has a significant effect on PONV, which was the most important finding in this study. While a combination of multiple drugs reported to have a significant lowering effect on PONV, there is no evidence supporting that use of triple drug therapy is more effective than using of a multi-drug therapy consisting of two medications. With the current data available, we cannot say that a specific number of antiemetic drugs are superior to the other. So as a conclusion, based of the currently available data the use of two medication as multi-drug therapy is as effective as using triple drug therapy for the prophylaxis of PONV. Further more, higher number of patients showed almost complete absence of nausea or vomiting when
receiving ondansetron in combination to aprepitant (P = 0.019), which is the best outcome among all the studies, however addition of aprepitant to a triple drug therapy did not show a noteworthy effect on PONV during the first 48 hours (68 and 66%; P = .73), this once again indicates that the use of more medication does not necessary equal to a better outcome.
Opioid analgesia such as morphine is a medication used for treatment of pain in bariatric surgeries as well as other in surgeries and for chronic pain. PONV in general is a common side effect of opioid analgesia. A study that was performed to identify the mechanism by which opioid causes nausea and vomiting reported that opioid act on both central and peripheral sites, including hypothalamus, cerebral cortex vestibular apparatus and the GI tract [32] Study [20] that was performed on using opioid-sparing analgesia (dexmedetomidine) rather than conventional analgesic regimens in bariatric surgery, reported that patients receiving dexmedetomidine had a lower incidence of PONV, this result shows use of intraoperative opioid-sparing analgesia provides a further reduction of PONV, and it should be used more frequently in these types of surgeries. Furthermore another study was performed on the effect of using opioid-free total intravenous anesthesia instead of volatile
anesthetics and opioid [21], as expected this study reported opioid-free anesthesia is also effective in reducing PONV. These studies shows that using an opioid free medication is an alternative way to further reduce PONV. Studies have shown (11), (12) employing ERAS instead of traditional care is associated with enhanced
The level intraoperative pressure used during bariatric surgery has no significant effect on PONV. One study was specifically performed concerning this issue, showed that there as no difference on the outcome when using a higher IAP (18 mmHg) or a lower IAP (12 mmHg), according to this study higher IAP used during laparoscopic Roux-en-Y gastric bypass have no negative effect on pain or nausea.
Healing touch is another technic that had a effective effect on PONV, according to one study (13), healing touch is a effective method for patients undergoing bariatric surgery, and can be use as a complementary to conventional pharmacological therapy to make the experience for patient more pleasant, however only a limited number of studies have been conducted on this matter and the available data bases is not sufficient to make a absolute conclusion.
Multimodal approach can be divided into preoperative period, intraoperative period and up until the patient is discharged.
In every period the potential cause of PONV should be identified. During preoperative periods anxiety can be a potential cause of PONV, thus reducing anxiety can eventually lead to decreased PONV. Anxiety can be reduced by informing the patient about the procedure and making the patient feel secure, other methods that may have a potential effect of PONV is using anxiolytics. I addition, during preoperative periods, preoperative antiemetic medication therapy significantly reduces the incidence of PONV, preferrely used as multi-drug therapy with minimum two anti-emetic drugs.
During the intraoperative period the choice of anesthesia is important, the use of opioid-free anasthesia is preferred.
When administering analgesics during the postoperative period, choosing opioid sparing analgetics such as dexmedetomidine is also a contributing factor to decrease PONV, and to further optimize recovery other non-pharmacological methods such as Healing Touch can be used during the postoperative period as a
complementary therapy.
Limitations:
Small sample size of eligible studies.
Small variation of studies performed of this topic.
Duplication of studies, same study found on various different electronic databases. Limited access to electronic bases
Limited reports in the literature regarding PONV after bariatric surgery.
Clinical implications, practical and research recommendations
Expand studies perfomed on this specific topic Expand variations of studies on this topic
Conclusions
To describe recent methods of bariatric surgery. (1)
The incidence of obesity is increasing worldwide, which has resulted in an increase of bariatric surgeries performed every year. Recently, the most commonly used methods of bariatric surgeries are roux-en-y gastric bypass procedure, adjustable gastric banding and vertical sleeve gastrectomy, with the latter being the most popular procedure [4].
To describe in short principles of enhanced recovery after bariatric surgery. (2)
ERAS is evidence based perioperative care, that was introduced to modern surgery in order to achieve a more rapid recovery for patients undergoing surgeries including bariatric surgeries.
To identify problems of postoperative nausea and vomiting after bariatric surgery. (3)
Continues nausea and vomiting after bariatric surgery have various side effects including electrolyte imbalance, dehydration and can cause rupture of the newly made incision, and these can delay the recovery period.
To describe the physiology and current recommendations of prevention of postoperative nausea and vomiting after surgery. (4)
The vomiting center in the brain that controls vomiting receives afferent input from varies sites including vagal input from stomach, and also afferent input from the chemoreceptor trigger zone (CTZ), because the
stimulations is coming from various sides of the body and varies different receptors are stimulated it is more effective to use a combination of different antiemetic medication to yield maximum antiemetic effect. Effect of bariatric surgery on GIT.
To describe current studies on postoperative nausea and vomiting after bariatric surgery, identifying available treatment options of postoperative nausea and vomiting. (5)
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