Obesity Surgery

, Volume 29, Issue 4, pp 1268–1275 | Cite as

Does Lung Compliance Optimization Through PEEP Manipulations Reduce the Incidence of Postoperative Hypoxemia in Laparoscopic Bariatric Surgery? A Randomized Trial

  • Delphine Van HeckeEmail author
  • Javad S. Bidgoli
  • Philippe Van der Linden
Original Contributions



In obese patients (OP), the best intraoperative ventilation strategy remains to be defined. Dynamic lung compliance (Cdyn) and dead space fraction are indicators of efficient ventilation at an optimal positive end-expiratory pressure (PEEP). Herein, we investigated whether intraoperative dynamic lung compliance optimization through PEEP manipulations affects the incidence of postoperative hypoxemia (SpO2 < 90%) in OP undergoing laparoscopic bariatric surgery (LBS).


This was a single-center, prospective, randomized controlled study conducted from July 2013 to December 2015. After obtaining institutional review board approval and informed consent, 100 OP undergoing LBS under volume-controlled ventilation (tidal volume 8 mL/kg of ideal body weight) were randomized according to the PEEP level maintained during the surgery. In the control group, a PEEP of 10 cm H2O was maintained, while in the intervention group, the PEEP was adapted to achieve the best dynamic lung compliance. Anesthesia and analgesia were standardized. The patients received supplemental nasal oxygen on the first postoperative day and were monitored up to the second postoperative day with a portable pulse oximeter.


Demographics were similar between groups. There was no difference in the incidence of hypoxemia during the first 2 postoperative days (control: 1.3%; intervention: 2.1%; p = 0.264).


The incidence of postoperative hypoxemia was not reduced by an open-lung approach with protective ventilation strategy in obese patients undergoing LBS. A pragmatic application of a PEEP level of 10 cm H2O was comparable to individual PEEP titration in these patients.

Trial Registration identifier, NCT02579798;


Laparoscopic bariatric surgery Mechanical ventilation Anesthetic management Lung compliance Positive end-expiratory pressure Postoperative hypoxemia 



Assistance with the study: The authors would like to thank the following persons from the Department of Anaesthesiology, CHU Brugmann-HUDERF, Brussels, Belgium, who kindly performed the protocol study in the operating room: Ida Stany M.D., Robert Tircoveanu M.D., Yannick Ciccarella M.D., Jean-Louis Majcher M.D., Christiane Dzechi M.D., and Muj Mulaj M.D.

Funding Information

This work was supported only by CHU Brugmann-HUDERF departmental sources and the Brugmann foundation.

Compliance with Ethical Standards

Our study was a prospective, randomized controlled study, approved by the Institutional Ethics Committee. Written informed consent was obtained from all participating subjects. This manuscript adheres to the applicable Enhancing the Quality and Transparency of Health Research (EQUATOR) guidelines.

Conflicts of Interest

The authors declare that they have no conflict of interest.

Ethical and Consent Statement

Ethical and consent statement provided by the Institutional Ethics Committee. Written informed consent was obtained from all participating subjects.


  1. 1.
    Coussa M, Proietti S, Schnyder P, et al. Prevention of atelectasis formation during the induction of general anesthesia in morbidly obese patients. Anesth Analg. 2004;98(5):1491–5.CrossRefPubMedGoogle Scholar
  2. 2.
    Magnusson L, Spahn DR. New concepts of atelectasis during general anaesthesia. Br J Anaesth. 2003;91(1):61–72.CrossRefPubMedGoogle Scholar
  3. 3.
    Duggan M, Kavanagh BP. Pulmonary atelectasis: a pathogenic perioperative entity. Anesthesiology. 2005;102(4):838–54.CrossRefPubMedGoogle Scholar
  4. 4.
    Pelosi P, Croci M, Ravagnan I, et al. The effects of body mass on lung volumes, respiratory mechanics, and gas exchange during general anesthesia. Anesth Analg. 1998;87(3):654–60.PubMedGoogle Scholar
  5. 5.
    Eichenberger A, Proietti S, Wicky S, et al. Morbid obesity and postoperative pulmonary atelectasis: an underestimated problem. Anesth Analg. 2002;95(6):1788–92. table of contentsCrossRefPubMedGoogle Scholar
  6. 6.
    Imberger G, McIlroy D, Pace NL, et al. Positive end-expiratory pressure (PEEP) during anaesthesia for the prevention of mortality and postoperative pulmonary complications. Cochrane Database Syst Rev. 2010;9:56–67. Scholar
  7. 7.
    Fernandez-Bustamante A, Hashimoto S, Serpa Neto A, et al. Perioperative lung protective ventilation in obese patients. BMC Anesthesiol. 2015;15(1):56.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Shander A, Fleisher LA, Barie PS, et al. Clinical and economic burden of postoperative pulmonary complications: patient safety summit on definition, risk-reducing interventions, and preventive strategies. Crit Care Med. 2011;39(9):2163–72.CrossRefPubMedGoogle Scholar
  9. 9.
    Futier E, Constantin J-M, Pelosi P, et al. Intraoperative recruitment maneuver reverses detrimental pneumoperitoneum-induced respiratory effects in healthy weight and obese patients undergoing laparoscopy. Anesthesiology. 2010;113(6):1310–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Whalen FX, Gajic O, Thompson GB, et al. The effects of the alveolar recruitment maneuver and positive end-expiratory pressure on arterial oxygenation during laparoscopic bariatric surgery. Anesth Analg. 2006;102(1):298–305.CrossRefPubMedGoogle Scholar
  11. 11.
    Talab HF, Zabani IA, Abdelrahman HS, et al. Intraoperative ventilatory strategies for prevention of pulmonary atelectasis in obese patients undergoing laparoscopic bariatric surgery. Anesth Analg. 2009;109(5):1511–6.CrossRefPubMedGoogle Scholar
  12. 12.
    Almarakbi WA, Fawzi HM, Alhashemi JA. Effects of four intraoperative ventilatory strategies on respiratory compliance and gas exchange during laparoscopic gastric banding in obese patients. Br J Anaesth. 2009;102(6):862–8.CrossRefPubMedGoogle Scholar
  13. 13.
    Reinius H, Jonsson L, Gustafsson S, et al. Prevention of atelectasis in morbidly obese patients during general anesthesia and paralysis: a computerized tomography study. Anesthesiology. 2009;111(5):979–87.CrossRefPubMedGoogle Scholar
  14. 14.
    Pelosi P, Ravagnan I, Giurati G, et al. Positive end-expiratory pressure improves respiratory function in obese but not in normal subjects during anesthesia and paralysis. Anesthesiology. 1999;91(5):1221–31.CrossRefPubMedGoogle Scholar
  15. 15.
    Hemmes SN, Gama de Abreu M, Pelosi P, et al. High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial. Lancet. 2014;384(9942):495–503.CrossRefPubMedGoogle Scholar
  16. 16.
    Tusman G, Böhm SH, Suarez-Sipmann F, et al. Alveolar recruitment improves ventilatory efficiency of the lungs during anesthesia. Can J Anesth. 2004;51(7):723–7.CrossRefPubMedGoogle Scholar
  17. 17.
    Maracajá-Neto LF, Verçosa N, Roncally AC, et al. Beneficial effects of high positive end-expiratory pressure in lung respiratory mechanics during laparoscopic surgery. Acta Anaesthesiol Scand. 2009;53(2):210–7.CrossRefPubMedGoogle Scholar
  18. 18.
    Meininger D, Byhahn C, Mierdl S, et al. Positive end-expiratory pressure improves arterial oxygenation during prolonged pneumoperitoneum. Acta Anaesthesiol Scand. 2005;49(6):778–83.CrossRefPubMedGoogle Scholar
  19. 19.
    Futier E, Constantin JM, Paugam-Burtz C, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med. 2013;369(5):428–37.CrossRefPubMedGoogle Scholar
  20. 20.
    Aldenkortt M, Lysakowski C, Elia N, et al. Ventilation strategies in obese patients undergoing surgery: a quantitative systematic review and meta-analysis. Br J Anaesth. 2012;109(4):493–502.CrossRefPubMedGoogle Scholar
  21. 21.
    Gattinoni L, Carlesso E, Caironi P. Stress and strain within the lung. Curr Opin Crit Care. 2012;18(1):42–7.CrossRefPubMedGoogle Scholar
  22. 22.
    Suter PM, Fairley B, Isenberg MD. Optimum end-expiratory airway pressure in patients with acute pulmonary failure. N Engl J Med. 1975;292(6):284–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Maisch S, Reissmann H, Fuellekrug B, et al. Compliance and dead space fraction indicate an optimal level of positive end-expiratory pressure after recruitment in anesthetized patients. Anesth Analg. 2008;106(1):175–81.CrossRefPubMedGoogle Scholar
  24. 24.
    Blankman P, Hasan D, Groot Jebbink E, et al. Detection of “best” positive end-expiratory pressure derived from electrical impedance tomography parameters during a decremental positive end-expiratory pressure trial. Crit Care. 2014;18(3):R95.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Carvalho ARS, Jandre FC, Pino AV, et al. Effects of descending positive end-expiratory pressure on lung mechanics and aeration in healthy anaesthetized piglets. Crit Care. 2006;10(4):R122.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Terragni PP, Rosboch G, Tealdi A, et al. Tidal hyperinflation during low tidal volume ventilation in acute respiratory distress syndrome. Am J Respir Crit Care Med. 2007;175(2):160–6.CrossRefPubMedGoogle Scholar
  27. 27.
    Defresne AA, Hans GA, Goffin PJ, et al. Recruitment of lung volume during surgery neither affects the postoperative spirometry nor the risk of hypoxaemia after laparoscopic gastric bypass in morbidly obese patients: a randomized controlled study. Br J Anaesth. 2014;113(3):501–7.CrossRefPubMedGoogle Scholar
  28. 28.
    Severgnini P, Selmo G, Lanza C, et al. Protective mechanical ventilation during general anesthesia for open abdominal surgery improves postoperative pulmonary function. Anesthesiology. 2013;118(6):1307–21.CrossRefPubMedGoogle Scholar
  29. 29.
    Pelosi P, Gama de Abreu M, Rocco PR. New and conventional strategies for lung recruitment in acute respiratory distress syndrome. Crit Care. 2010;14(2):210.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial I, Cavalcanti AB, Suzumura ÉA, et al. Effect of lung recruitment and titrated positive end-expiratory pressure (PEEP) vs low PEEP on mortality in patients with acute respiratory distress syndrome: a randomized clinical trial. JAMA. 2017;318(14):1335–45.CrossRefGoogle Scholar
  31. 31.
    Jo YY, Kwak HJ. What is the proper ventilation strategy during laparoscopic surgery? Korean J Anesthesiol. 2017;70(6):596–600.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Bluth T, Teichmann R, Kiss T, et al. Protective intraoperative ventilation with higher versus lower levels of positive end-expiratory pressure in obese patients (PROBESE): study protocol for a randomized controlled trial. Trials. 2017;18(1):202.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Anaesthesiology, CUB ErasmeUniversité Libre de BruxellesBrusselsBelgium
  2. 2.Department of Anaesthesiology, CHU Brugmann-HUDERFUniversité Libre de BruxellesBrusselsBelgium
  3. 3.Department of Anaesthesiology, CHU Brugmann-HUDERFUniversité Libre de BruxellesBrusselsBelgium

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