Perioperative Management of GLP-1 Receptor Agonists in Patients with Gastric Sleeve Surgery

Introduction to Perioperative Considerations

Gastric sleeve surgery is not a contraindication for GLP-1 receptor agonists, but special perioperative management is required due to the increased risk of aspiration from delayed gastric emptying 1, 2

GLP-1 receptor agonists significantly delay gastric emptying, increasing the risk of regurgitation and pulmonary aspiration during procedures requiring sedation or anesthesia 1, 3
Previous gastro-oesophageal surgery, including gastric sleeve, is specifically listed as a risk factor that should be documented when assessing patients on GLP-1 agonists 1, 4
Multiple case reports document regurgitation and pulmonary aspiration in patients on GLP-1 agonists despite appropriate fasting periods, highlighting the need for caution in all surgical patients 5

Hold GLP-1 receptor agonists for at least three half-lives before any elective procedure to clear approximately 88% of the drug 1, 6
For patients taking GLP-1 receptor agonists for weight loss after gastric sleeve surgery, holding for three half-lives is strongly recommended 7, 8
For patients with diabetes taking GLP-1 receptor agonists, consult with an endocrinologist regarding the risks and benefits of holding the medication for three half-lives 1

Consider prokinetic drugs such as metoclopramide or erythromycin pre-operatively for patients who cannot hold GLP-1 receptor agonists for three half-lives or who have recently started/increased their dose 1, 2
Use point-of-care gastric ultrasound to assess residual gastric contents for high-risk patients 1, 6
Consider rapid sequence intubation to reduce aspiration risk for high-risk patients 1, 4

Document indication and dose of GLP-1 receptor agonist, date drug commenced, dose variations, last dose taken, symptoms of nausea, vomiting or abdominal distention, and details of gastric sleeve surgery 1, 4
Determine appropriate holding period based on specific GLP-1 agent, such as weekly semaglutide (21 days), weekly dulaglutide (14 days), or daily liraglutide (39 hours) 2
Risk stratification should consider factors such as inability to hold medication for three half-lives, recent start of medication, and GI symptoms 1

For high-risk patients, consider postponing elective procedures, implement aspiration risk reduction strategies, and use gastric ultrasonography to guide decision-making 1, 2, 6
The American Society of Anesthesiologists recommends individualized approaches for patients on GLP-1 agonists undergoing surgery, considering the increased risk of aspiration 2