Perioperative Care & Surgical Optimization

The five steps below are the pathway. Work through them in order — each step states its own thresholds, exclusions and exceptions.

Before: The §8.2 pathway existed in the monograph as prose; its stepwise table was not usable in v2.4.

Now: The five steps below are the pathway. Work through them in order — each step states its own thresholds, exclusions and exceptions.

Patients covered by the chapter's §8.2 prose (Pathways 8A–8E): bariatric candidates, patients on SGLT2 inhibitors or GLP-1 / dual GIP-GLP-1 agonists facing surgery, VTE prophylaxis decisions, and diabetic foot limb salvage.

Exclusions and exceptions live inside the steps themselves. Apply them exactly as written in each step; do not generalise a step beyond the population it names.

Regional adaptation is built into Step 5 of this pathway (see its text): the Saudi/GCC position is stated there, separately from the global recommendations.

1. 1

   Step 1: Pathway 8A — Bariatric Eligibility, Procedure Evidence & Lifelong Surveillance

   Apply the 2022 ASMBS/IFSO clinical thresholds: metabolic and bariatric surgery is recommended at BMI ≥35 kg/m² regardless of the presence, absence or severity of comorbidities, and should be considered at BMI 30.0–34.9 kg/m² with metabolic disease (such as type 2 diabetes) when non-surgical methods fail to achieve substantial or durable weight loss or comorbidity improvement (thresholds adjusted to ≥27.5 kg/m² in Asian populations). BMI is never a standalone rule — eligibility requires comprehensive multidisciplinary medical, nutritional, psychological and cardiopulmonary evaluation — and clinicians must separate society clinical eligibility from local administrative/insurance criteria (some Saudi payers still reference the 2016 Saudi MOH thresholds of BMI ≥40, or ≥35 with comorbidities). Keep the landmark trials separate, with their own remission definitions: STAMPEDE (uncontrolled T2DM) — HbA1c ≤6.0% at 5 years in 29% (RYGB), 23% (LSG) vs. 5% (medical therapy), medication-free remission 22.4% / 14.9% / 0%, weight change −23% / −19% / −5% (not powered as an RYGB-vs-LSG head-to-head, and OAGB untested); SLEEVEPASS at 10 years — %EWL 43.5% (LSG) vs. 51.9% (RYGB), strict equivalence not met, T2DM remission 26% vs. 33% (relapse occurs — remission is not permanent cure), more de novo oesophagitis after LSG (31% vs. 7%); SM-BOSS at 5 years — %EBMIL 61.1% vs. 68.3% (P = 0.22), GERD remission favouring RYGB (60.4% vs. 25.0%); YOMEGA — OAGB with a 200-cm biliopancreatic limb was non-inferior for weight loss but carried excess nutritional serious adverse events (21.4% of OAGB SAEs vs. 0), so OAGB requires limb lengths ≤150 cm, careful selection and long-term surveillance. Surveillance is lifelong and procedure-specific: CBC, ferritin, iron/TIBC, B12, folate, 25-OH vitamin D, intact PTH, calcium and albumin at baseline, 3, 6 and 12 months and at least annually thereafter (adding vitamins A, zinc, copper and selenium after RYGB/OAGB); plan pregnancy only after the rapid weight-loss phase (avoid the first 12–18 months) with preconception folate, iron, B12, vitamin A and D optimisation; and in any post-bariatric patient with persistent vomiting (>2 weeks), give parenteral thiamine before dextrose-containing fluids to prevent Wernicke encephalopathy.

2. 2

   Step 2: Pathway 8B — SGLT2 Inhibitors: Label Holds, Risk Stratification, euDKA & Restart Criteria

   Distinguish U.S. FDA product labels from consensus: the labels direct withholding empagliflozin and dapagliflozin for at least 3 days before major surgery or procedures with prolonged fasting, canagliflozin for at least 3 days before scheduled surgery, and ertugliflozin for at least 4 days — these are U.S. label instructions, not universal Saudi instructions, so check local SFDA product information. The 2026 SPAQI multidisciplinary consensus proposes a risk-stratified approach only for selected ambulatory/minor procedures with minimal fasting and low metabolic risk; for major surgery, inpatient procedures, prolonged fasting, bariatric/GI resections or high metabolic risk, the label-based 3–4-day hold remains the conservative default unless a specialist-led institutional pathway specifies otherwise. If urgent or emergency surgery intervenes before the hold is complete, never delay necessary source control to finish it — instead assign explicit team responsibility (anaesthesiology, surgery, endocrinology/ICU, clinical pharmacy) to watch for euglycaemic DKA, which can present with normal blood glucose: with nausea, vomiting, abdominal pain, tachypnoea or malaise, or a reduced bicarbonate/elevated anion gap, measure blood beta-hydroxybutyrate (or urine ketones if unavailable) and blood gas pH, and start insulin-plus-dextrose infusion and hydration per the institutional DKA protocol. Do not restart on a fixed postoperative day; resumption requires all of: (1) haemodynamic and clinical stability without active sepsis or ongoing surgical complications; (2) full resumption of adequate oral hydration and nutrition; (3) stable renal function at or near baseline without acute kidney injury; (4) documented absence of ketosis (normal beta-hydroxybutyrate) and metabolic acidosis (normal bicarbonate and anion gap); and (5) review of the prescribing indication (type 2 diabetes vs. heart failure vs. chronic kidney disease) with agreement of the managing team (synchronised with Appendix A).

3. 3

   Step 3: Pathway 8C — GLP-1 / Dual GIP-GLP-1 Agonists: Risk-Stratify, Don't Blanket-Hold

   Follow the evolved guidance, not the superseded rule: the June 2023 ASA consensus (hold daily agents on the day of surgery, weekly agents for 1 week) was replaced by the October 2024 U.S. Multi-Society guidance (ASA/AGA/ASMBS/ISPCOP/SAGES) and the 2024/2025 UK CPOC/RCoA consensus, which moved away from a blanket mandatory hold — stopping therapy risks perioperative hyperglycaemia in type 2 diabetes, and a 1-week hold of long-acting agents (half-life ~5–7 days) does not guarantee normal gastric emptying. Separate aspiration risk from mere medication presence and assess patient-specific factors: dose-escalation phase (first 4–8 weeks) or recent dose increase; higher maintenance doses and weekly vs. daily formulations; active GI symptoms (nausea, vomiting, retching, bloating, early satiety, upper abdominal pain); coexisting diabetic gastroparesis, Parkinson disease, or opioid/anticholinergic dysmotility; the indication (glycaemic control vs. weight management) and surgical urgency. In elective patients without elevated risk factors, therapy may be continued when the anaesthesiology, prescribing and surgical teams agree. With elevated risk, the joint team chooses mitigation under local protocol: a 24-hour preoperative clear-liquid diet; point-of-care gastric ultrasound where trained operators and equipment exist (solid content or >1.5 mL/kg clear fluid on the Perlas nomogram signals elevated risk — an operator-dependent adjunct, not a standalone guarantee of safety); anaesthesia-plan modification (regional anaesthesia where suitable, or rapid-sequence induction with full-stomach precautions); elective postponement during acute GI symptoms or dose escalation; or a shared-decision medication hold balanced against glycaemic risk.

4. 4

   Step 4: Pathway 8D — VTE Prevention: Separate Inpatient Prophylaxis from Extended Prophylaxis

   Keep the two decisions apart. Inpatient prophylaxis = early ambulation, intermittent pneumatic compression, and pharmacological LMWH or UFH. Extended 28-day post-discharge pharmacological prophylaxis is not a blanket recommendation for all general surgery or all bariatric patients: it is supported by randomised evidence (ENOXACAN II) and ACCP/ASCO/ESMO guidelines specifically for high-risk patients undergoing major open or laparoscopic abdominal or pelvic cancer surgery who do not have a high bleeding risk. Whenever pharmacological prophylaxis is prescribed, dose for the patient in front of you — body weight, renal function, bleeding risk, platelet count and neuraxial anaesthesia timing: standard enoxaparin 40 mg SC once daily is reduced to 30 mg once daily, or substituted with UFH, when creatinine clearance is <30 mL/min, while higher weight-adjusted dosing is often used in severe obesity per local bariatric protocol (the chapter and Appendix A apply identical modifier rules).

5. 5

   Step 5: Pathway 8E — Diabetic Foot Limb Salvage (WIfI) & the Saudi/GCC Frame

   Stage with the SVS WIfI classification — Wound, Ischaemia and foot Infection, each graded 0–3 — to estimate 1-year amputation risk and the likely benefit of revascularisation; measure ischaemia objectively with ankle/toe pressures or TcPO2, because medial arterial calcification in diabetes falsely elevates ABI (>1.3). WIfI is a risk-stratification aid, not a treatment formula, and staging must never delay urgent drainage or debridement of a severe or necrotising infection. Follow the clinical sequence: (1) immediate resuscitation, broad-spectrum empiric antimicrobials and urgent surgical source control (<24 hours) for deep abscess, wet gangrene, compartment syndrome or necrotising soft-tissue infection; (2) objective pedal vascular assessment and prompt endovascular or open bypass revascularisation when toe pressure is <30 mmHg or ankle pressure <50 mmHg; (3) deep tissue or bone biopsy for culture and histopathology to guide targeted antimicrobial therapy (2–6 weeks for residual infected bone); (4) non-removable knee-high off-loading for plantar neuropathic ulcers; and (5) coordinated glycaemic, renal and podiatric care — while distinguishing limb salvage (avoidance of major above-ankle amputation) from complete wound healing, functional ambulation and amputation-free survival. Saudi/GCC adaptation: diabetic foot infection ranks #7 among surgical emergencies in the SCFHS curriculum and is detailed in the Saudi MOH Pocket Manual (Ch. 5, with its DVT prophylaxis table), and the 2026 GCC multidisciplinary Delphi consensus adapts WIfI staging, toe-pressure triage and bone-biopsy-guided antimicrobials regionally, with patient education to prevent barefoot thermal plantar burns on sun-heated outdoor surfaces in summer and to avoid traditional thermal cautery ("Kaiy") on neuropathic/ischaemic limbs. Overarching local rule for the whole chapter: U.S. FDA labels and U.S. society consensus statements do not automatically establish Saudi policy — confirm SFDA-approved prescribing information, local hospital anaesthesia/pharmacy protocols, drug availability, bariatric service capacity and insurance/MOH administrative eligibility locally; the 2016 Saudi National GRADE Obesity Guideline remains the Saudi framework alongside contemporary SASMBS practice applying the 2022 ASMBS/IFSO thresholds.

• ASMBS/IFSO 2022 indications (PMID 36280539)
• STAMPEDE (PMID 28199805)
• SLEEVEPASS (PMID 35731535)
• SM-BOSS (PMID 29340679)
• YOMEGA (PMID 30851879)
• 2026 SPAQI SGLT2 Consensus (Ref. 70 in §8.2) — as cited in §8.2
• U.S. FDA SGLT2 product labels (Refs. 72–75 in §8.2) — as cited in §8.2
• Oct 2024 U.S. Multi-Society GLP-1 Guidance (PMID 39480373)
• UK CPOC/RCoA GLP-1 Consensus (PMCID PMC11951578)
• ENOXACAN II (PMID 11919306)
• IWGDF/IDSA 2023 diabetic foot guideline (PMID 37779323)
• 2026 GCC Diabetic Foot Consensus (PMID 42208663)
• Saudi National GRADE Obesity Guideline 2016 (PMID 27652370)
• Saudi MOH Pocket Manual — as cited in §8.2
• SCFHS Curriculum — as cited in §8.2