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Kanika Bowen-Jallow, MD and Faisal Qureshi, MD - 2024 Pediatric Bariatric Surgery Update Course
With Dr. Kanika Bowen-Jallow & Dr. Faisal Qureshi
Part of
Diabetes 3 items
Chapter 1 of 5 · Fundamentals
Preop ERAS
Introduction and Preoperative ERAS Protocol
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What the experts said
Aprepitant is given 1-2 hours prior to surgery in pre-op and has become standard in patients with high risk for post-operative nausea
Pills given in pre-op area have never been observed in the stomach during intraoperative scoping in sleeve gastrectomy cases
Minimizing narcotics helps prevent postoperative nausea, achieved by running medications like propofol at low baseline during anesthesia
Aprepitant is given in preoperative holding before surgery, while Zofran is used in the OR prior to extubation, to achieve synergistic anti-emetic effect
The number one concern after sleeve gastrectomy is nausea, retching, and vomiting
Haldol is not used for anti-emetic purposes due to sedative effects that interfere with waking patients in the PACU
80% of pediatric bariatric patients spend one night in the hospital
Expected postoperative pain level is 3 out of 5
TAP blocks have improved pain control and reduced nausea compared to non-exparel or exparel local anesthetic at port sites, with most patients going home the next day
Pure exparel diluted with normal saline is used for TAP blocks, performed immediately after camera insertion and epigastric port placement, adding only 3-5 minutes to case time
Ice chips are started within 4-6 hours postoperatively
Hematocrit is checked approximately 6 hours postoperatively
Sequential compression devices and Lovenox are used for DVT prophylaxis
Clear liquids are started on postoperative day one, with patients circling 1 ounce of liquids every 15 minutes for 3-4 hours; if no nausea or significant pain, patients are discharged home without narcotics
TAP block provides pain control for 2-3 days postoperatively
Patients are instructed to shower the next day and pat themselves dry, with no swimming or baths in hot tubs for 4 weeks
The primary reason for avoiding straws is to prevent patients from drinking too quickly rather than concerns about air ingestion
Patients return to school within 5 days to 1 week postoperatively
Week one diet consists of 1 ounce of fluid every 15 minutes with targets of at least 40 ounces of liquids and 40 grams of protein
Week two diet advances to blended soups consistency with no lumps, bumps, or chunks, targeting 60 grams of protein and 60 ounces of fluids
Weeks 3-6 diet consists of soft foods (applesauce, mashed potatoes consistency) with targets of 60 grams protein, 64 ounces water, 600-800 calories, and beginning exercise
Week 4 onwards maintains 60 grams protein, 64 ounces water, 600-800 calories, and 60 minutes of exercise daily
After week 6, patients advance to regular diet with small portions, moist cooking methods, and 1/4 to 1/2 cup portion sizes
Levsin (hyoscyamine) is effective as a smooth muscle relaxant for patients struggling with fluid intake in the first few days after surgery
Levsin is used as needed for patients having difficulty swallowing or getting down fluids, either in hospital or at home
Adult bariatric surgeons use Air Seal technology to maintain stable insufflation pressure second-to-second, allowing procedures at 10 mmHg pressure compared to typical 15 mmHg or higher
Stryker or Storz insufflators can be set to pediatric mode to check pressure more frequently, similar to Air Seal technology
Higher laparoscopic pressures may be necessary in adolescents due to different abdominal wall physical properties, particularly in women compared to men
Sleeve gastrectomy comprises 90% of pediatric bariatric procedures performed
ERAS recommendations for bariatric surgery include carbohydrate drink the night before surgery and clear liquids up to 2 hours prior to surgery
Sugar-free carbohydrate drinks should be used for diabetic patients
DVT prophylaxis with Lovenox or subcutaneous heparin is administered at the start of the case, but there is no standard recommendation and practices vary greatly among surgeons
ASMBS recommends using DVT prophylaxis intraoperatively and postoperatively before discharge, but most patients do not go home on DVT prophylaxis unless there is a specific indication such as family history
New literature demonstrates laparoscopic TAP block is not superior to local infiltration of incisions for pain control
Total daily acetaminophen dose should not exceed 4000 mg whether given IV or orally, requiring careful tracking of pre-op and post-op doses
Pure oxycodone immediate-release without acetaminophen is the ERAS-recommended narcotic option if needed, though typically not required or prescribed at discharge
Operating at lower insufflation pressures results in less TNF-alpha production and decreased postoperative pain