Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA
Department of Anesthesiology, Weill Cornell Medical College, New York, New York, USA.
Reg Anesth Pain Med. 2021 Nov;46(11):941-945. doi: 10.1136/rapm-2021-102967. Epub 2021 Aug 30.
Patients with morbid obesity may require both bariatric surgery and total knee/hip arthroplasty (TKA/THA). How to sequence these two procedures with better outcomes remains largely unstudied.
This cohort study extracted claims data on patients with an obesity diagnosis that received both bariatric surgery and TKA/THA surgery within 5 years of each other (Premier Healthcare database 2006-2019). Overall, 1894 patients received bariatric surgery before TKA or THA, while 1000 patients underwent TKA or THA before bariatric surgery. Main outcomes and measures include major complications (acute renal failure, acute myocardial infarction, other cardiovascular complications, sepsis/septic shock, pulmonary complications, pulmonary embolism, pneumonia, and central nervous system-related adverse events), postoperative intensive care unit utilization, ventilator utilization, 30-day readmission, 90-day readmission, 180-day readmission and total hospital length of stay after the second surgery. Regression models measured the association between the complications and sequence of TKA/THA and bariatric surgery.
Undergoing TKA/THA before bariatric surgery (compared with the reverse) was associated with higher odds of major complications (7.0% vs 1.9%; adjusted OR 4.8, 95% CI 3.1, 7.6, p<0.001). Similar patterns were also observed for intensive care unit admission, ventilator use postoperatively, 30-day, and 90-day readmissions. Patients who received a second surgery within 6 months of their first surgery exhibited worse outcomes, especially among the TKA/THA first patient cohort. Major complication incidences occurred at 20.5%, 12.5%, 5.1%, 5.0%, 5.8% and 8.5% with time between TKA/THA and bariatric surgery at <6 months, 6 months-1 year, 1-2, 2-3, 3-4 and 4-5 years, respectively.
Patients who require both bariatric surgery and TKA/THA should consider bariatric surgery before TKA/THA as it is associated with improved outcomes. Procedures should be staged beyond 6 months.
病态肥胖患者可能需要同时接受减重手术和全膝关节/髋关节置换术（TKA/THA）。如何更好地安排这两种手术的顺序，目前仍缺乏研究。
本队列研究从 Premier Healthcare 数据库（2006-2019 年）中提取了在 5 年内同时接受减重手术和 TKA/THA 手术的肥胖症诊断患者的索赔数据。共有 1894 例患者在 TKA 或 THA 之前接受了减重手术，而 1000 例患者在减重手术之前接受了 TKA 或 THA。主要结局和指标包括主要并发症（急性肾衰竭、急性心肌梗死、其他心血管并发症、脓毒症/感染性休克、肺部并发症、肺栓塞、肺炎和中枢神经系统相关不良事件）、术后重症监护病房利用、呼吸机利用、术后 30 天再入院、术后 90 天再入院、术后 180 天再入院和第二次手术后的总住院时间。回归模型衡量了 TKA/THA 和减重手术的顺序与并发症之间的关联。
与相反的顺序相比，先接受 TKA/THA（而非减重手术）与更高的主要并发症风险相关（7.0%比 1.9%；调整后的 OR 4.8，95%CI 3.1，7.6，p<0.001）。类似的模式也出现在重症监护病房入院、术后使用呼吸机、术后 30 天和 90 天再入院的情况中。在第一次手术后 6 个月内接受第二次手术的患者预后更差，尤其是在 TKA/THA 首先接受手术的患者队列中。主要并发症发生率分别为 20.5%、12.5%、5.1%、5.0%、5.8%和 8.5%，时间间隔分别为 TKA/THA 和减重手术<6 个月、6 个月-1 年、1-2 年、2-3 年、3-4 年和 4-5 年。
需要同时接受减重手术和 TKA/THA 的患者应考虑先进行减重手术，因为这与改善结局相关。手术应间隔 6 个月以上进行分期。
