Evaluation of Spirometric Testing as a Routine Preoperative Assessment in Patients Undergoing Bariatric Surgery Diana Clavellina-Gaytán, David Velázquez-Fernández, Eduardo DelVillar, Guillermo Domínguez-Cherit, Hugo Sánchez, et al. Obesity Surgery The Journal of Metabolic Surgery and Allied Care ISSN 0960-8923 Volume 25 Number 3 OBES SURG (2015) 25:530-536 DOI 10.1007/s11695-014-1420-x
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Author's personal copy OBES SURG (2015) 25:530–536 DOI 10.1007/s11695-014-1420-x
ORIGINAL CONTRIBUTIONS
Evaluation of Spirometric Testing as a Routine Preoperative Assessment in Patients Undergoing Bariatric Surgery Diana Clavellina-Gaytán & David Velázquez-Fernández & Eduardo Del-Villar & Guillermo Domínguez-Cherit & Hugo Sánchez & Maureen Mosti & Miguel F. Herrera
Published online: 22 September 2014 # Springer Science+Business Media New York 2014
Abstract Background The value of spirometry as a routine preoperative test for bariatric surgery is debatable. The aim of this study was to assess the relationship between spirometry results and the frequency of postoperative pulmonary complications in 602 obese patients. Methods Clinical files of patients undergoing bariatric surgery between 2004 and 2013 were reviewed. Demography, risk factors, respiratory symptoms, and spirometry results (forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), FEV1/FVC) were recorded, and their relationship with postoperative pulmonary complications was evaluated. Results There were 256 males and 346 females with a mean age of 40.2±11.6 years and a mean BMI of 42.1±6.4 kg/m2. History of smoking was found in 408 patients (68 %). Preoperative respiratory symptoms were present in 328 (54.5 %). Most frequent symptoms were snoring (288), dyspnea (119), bronchospasm [6], and chronic productive cough [6]. In 153 patients, history of respiratory disease was documented. The obstructive sleep apnea syndrome (OSAS) was present in 124, 20 requiring continuous positive airway pressure (CPAP). Asthma was present in 27 and chronic obstructive pulmonary disease (COPD) in 2. Variables associated to a higher risk of pulmonary complications were OSAS (OR 2.3), an abnormal spirometry (OR 2.6), male gender (OR 1.9), and preoperative respiratory symptoms (OR 1.9). Using multivariate logistic regression, an abnormal spirometry was a significant predictor of postoperative pulmonary complications in patients with respiratory symptoms and/or OSAS. D. Clavellina-Gaytán : D. Velázquez-Fernández : E. Del-Villar : G. Domínguez-Cherit : H. Sánchez : M. Mosti : M. F. Herrera (*) Center for Nutrition, Obesity and Metabolic Disorders, The American British Cowdray Medical Center, Sur 136 # 126 Col Las Américas México, Mexico, DF, Mexico e-mail:
[email protected]
However, it lost prognostic significance when both conditions were subtracted. Conclusions In obese patients undergoing bariatric surgery, abnormal preoperative spirometry predicts postoperative respiratory complications only in patients with OSAS. Keywords Spirometry . Bariatric surgery . Respiratory complications . Preoperative . COPD . OSAS
Background Morbidly obese patients undergoing bariatric surgery are at high risk for postoperative pulmonary complications such as atelectasis, pneumonia, laryngospasm, respiratory distress, impaired gas exchange, and the need of re-intubation [1]. Physiological changes involved in the high risk include reduced lung volumes, impaired ventilation/perfusion ratio, and hypoxemia [2]. It has been suggested that the increased risk of pulmonary complications is associated with a forced expiratory volume in the first second (FEV1) and a forced vital capacity (FVC) less than 70 % of the predicted values, and to a FEV1/FVC ratio less than 70 % [3]. Postoperative pulmonary complications prolong hospital stay and may be catastrophic [4, 5]. There are known pulmonary diseases that may increase the risk for pulmonary complications. However, the screening of asymptomatic obese patients by spirometry before bariatric surgery has not been fully supported. According to the 2013 guidelines of the American Society for Metabolic and Bariatric Surgery (ASMBS), spirometry as a preoperative test is indicated only in the presence of risk factors previously identified by other tests [6]. In contrast, a recent publication by Van Huisstede et al. [7] based on the analysis of 485 patients undergoing laparoscopic bariatric surgery recommends spirometry in the preoperative evaluation of all obese patients.
Author's personal copy OBES SURG (2015) 25:530–536
The aim of this study was to assess the relationship between risk factors for respiratory diseases, preoperative respiratory symptoms and spirometry, and the frequency of postoperative pulmonary complications in 602 obese patients undergoing bariatric surgery.
Patients and Methods All consecutive obese patients who underwent bariatric surgery at our center between 2004 and 2013 were included in the study. Clinical files were retrospectively reviewed looking for demographic characteristics such as age, BMI, and gender;
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history of smoking; respiratory symptoms; spirometry results (FEV1, FVC and FEV1/FVC); and postoperative complications. Symptoms were collected at the time of the preoperative visit in all patients. The interview included specific questions about the presence or absence of shortness of breath or air hunger for dyspnea, cough with wheezing for bronchospasm, cough with mucus expectoration for productive cough, and hoarse breathing while sleeping identified by either patients or their relatives for snoring. Spirometry was performed in the Department of Pulmonary Physiology using a CPL Collins spirometer (Ferreraris-Respiratory). Results were interpreted based on the Global Initiative for COPD (GOLD) and the American Thoracic Society criteria [8, 9] as follows: COPD
Table 1 Independent variables included in the multivariate analysis listed by name, measure, and code Variable name
Measure
Code
1 2 3 5 6 7 8 9 10 11 12 13
Gender Age at surgery Initial weight BMI Obesity grade Predicted forced vital capacity (FVC) Measured forced vital capacity (FVC) Forced vital capacity (FVC) 2, congestive heart failure, COPD, and functional dependency [16]. Guimaraes et al. conducted a study on 36 morbidly obese patients without any known pulmonary disease [17]. A complete pulmonary function testing with spirometry, lung volumes, carbon monoxide diffusing capacity, maximum respiratory pressures, and arterial blood gases analysis was performed. The authors found that only two patients had normal functional and arterial blood gas studies, emphasizing the impact that morbid obesity has on the respiratory function. The impact of obesity on the rate of postoperative complications is debatable. Brooks-Brunn in a study published in 1977 [18] found, similarly to our study, that obesity is a risk factor for the development of pulmonary complications after abdominal surgery. In contrast, Smetana, basing on the analysis of ten series of obese patients undergoing gastric bypass, concluded that obesity is not a significant risk factor for postoperative pulmonary complications after bariatric surgery [19]. For patients with known risk factors for respiratory postoperative complications, a complete pulmonary evaluation has been recommended. However, for the general population, the role of spirometry in the preoperative evaluation for abdominal surgery is debatable. In the era of open bariatric surgery, it was demonstrated that pulmonary function tests were predictive for postoperative complications [20]. A study combining open and laparoscopic RYGB showed that a FEV1
