Enchanced preoperative rehabilitation as part of the complex perioperative rehabilitation of patients with super-obesity and obstructive sleep apnea syndrome (clinical outlook)

Obesity is a global social and economic problem. The bariatric surgery is a most effective treatment for obesity. The presented clinical case demonstrates the usage of principles of enchanced perioperative rehabilitation for the preoperative preparation of a patient with super obesity and with severe obstructive sleep apnea and alveolar hypoventilation syndrome.

A 54-year-old patient was hospitalized with complaints of obesity, impossibility of persistent weight loss conservatively, severe daytime sleepiness, frequent nocturnal awakenings (up to 8 times per night). The patient’s weight was 230 kg with a height of 157 cm (BMI 93.5 kg / m²). The examination revealed a syndrome of sleep apnea of mixed genesis of extremely severe degree, chronic night hypoxemia of an extremely severe degree. Preoperative preparation was performed in accordance with the program of enchanced perioperative rehabilitation. The duration of preoperative preparation was 19 days; weight loss — 40 kg (%WL -17,4), compensation of comorbidities was achieved as well. After that the patient underwent a laparoscopic sleeve gastrectomy. There were no complications in the postoperative period. Length of postoperative hospital stay was 6 days. At follow-up examination one year after surgery, body weight dropped from 230 to 153 kg (% WL-33.5), a significant improvement of the quality of life was achieved.

The enchanced perioperative rehabilitation program can be successfully used as an effective method for preoperartive preparation of the patients with morbid obesity in combination with severe obstructive sleep apnea syndrome.and obesity hypoventilation. It can be a reasonable alternative to the standard program with preoperative intragastric balloon treatment. The use of this technique allows to increase the effectiveness of treatment of these high-risk patients, as well as to reduce the risk of perioperative complications.

1. Dietz WH, Baur LA, Hall K, et al. Management of obesity: improvement of health-care training and systems for prevention and care. Lancet. 2015;385:2521-2533. doi: https://doi.org/10.1016/S0140-6736(14)61748-7

2. Kelly T, Yang W, Chen CS, et al. Global burden of obesity in 2005 and projections to 2030. Int J Obes (Lond). 2008;32:1431-1437. doi: https://doi.org/10.1038/ijo.2008.102

3. Hakim NS, Favretti F, Segato G, Dillemans B. Bariatric surgery. UK; 2011.

4. SAGES guideline for clinical application of laparoscopic bariatric surgery. Surg Obes Relat Dis. 2009;5(3):387-405. doi: https://doi.org/10.1016/j.soard.2009.01.010

5. Lemanu DP, Singh PP, Berridge K, et al. Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy. Br J Surg. 2013;100:482-489. doi: https://doi.org/10.1002/bjs.9026

6. Joliat GR, Labgaa I, Petermann D, et al. Cost-benefit analysis of an enhanced recovery protocol for pancreaticoduodenectomy. Br J Surg. 2015;102:1676-1683. doi: https://doi.org/10.1002/bjs.9957

7. King PM, Blazeby JM, Ewings P, et al. The influence of an enhanced recovery programme on clinical outcomes, costs and quality of life after surgery for colorectal cancer. Colorectal Dis. 2006;8:506-513. doi: https://doi.org/10.1111/j.1463-1318.2006.00963.x

8. Thorell A, MacCormick AD, Awad S, et al. Guidelines for perioperative care in bariatric surgery: enhanced recovery after surgery (ERAS) society recommendations. World J Surg. 2016;40:2065-2083. doi: https://doi.org/10.1007/s00268-016-3492-3

9. Vasu TS, Grewal R, Doghramji K. Obstructive sleep apnea syndrome and perioperative complications: a systematic review of the literature. J Clin Sleep Med. 2012;8:199-207. doi: https://doi.org/10.5664/jcsm.1784

10. Kushida CA, Littner MR, Hirshkowitz M, et al. Practice Parameters for the Use of Continuous and Bilevel Positive Airway Pressure Devices to Treat Adult Patients With Sleep-Related Breathing Disorders. Sleep. 2006;29(3):375-380. doi: https://doi.org/10.1093/sleep/29.3.375

11. Lemanu DP, Srinivasa S, Singh PP, et al. Optimizing perioperative care in bariatric surgery patients. Obes Surg. 2012;22:979-990. doi: https://doi.org/10.1007/s11695-012-0648-6