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Anaesthesia Considerations in the Obese Patient for Bariatric Surgery

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Obesity, Bariatric and Metabolic Surgery

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Abstract

Bariatric surgery in the United Kingdom (UK) is an established specialty both in National Health Service and private sectors. Nationally, many well-established centers have significant expertise managing pre-, peri-, and postoperative anesthesia for morbidly obese patients undergoing bariatric surgery. Many centers also provide training and expertise for managing the growing cohort of morbidly obese patients undergoing non-bariatric surgery. In this chapter, we outline key considerations for safely managing this challenging patient group and highlight areas where care may differ from “standard” anesthetic practice. Particular consideration is given to the importance of the pre-assessment clinic, the specialist anesthetic involvement in the surgical weight management multidisciplinary team, and the value of a team-based approach and safety culture throughout the care pathway. We outline the importance of ensuring the availability of basic equipment such as appropriately sized chairs, patient gowns, high-weight theatre tables, and electric beds.

Effective preoperative assessment and investigations are outlined with discussion of determining appropriate levels of postoperative care. The importance of identifying and optimizing obstructive sleep apnea, heart failure, and metabolic disease is also discussed. Anesthetic techniques are discussed including correct positioning of patients prior to anesthesia, preoxygenation, and determining appropriate drug regimens aiming for short-acting agents with sparing opioid use. Postoperative management is also discussed.

Morbidly obese patients are at a higher risk of venous thromboembolism than the general population and suggestions are made for minimizing this risk.

Anesthesia for bariatric surgery in the UK is very safe and the margin for error is small. Patient safety is best assured by meticulous attention to detail, appropriate training, and care delivered by experienced staff.

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References

  1. Burns EM, Naseem H, Bottle A, Lazzarino AI, Aylin P, Darzi A, et al. Introduction of laparoscopic bariatric surgery in England: observational population cohort study. BMJ. 2010;341:c4296. https://doi.org/10.1136/bmj.c4296.

    Article  Google Scholar 

  2. National Bariatric Surgery Registry (NBSR) [Internet]. 2013. Available from: https://hscn.e-dendrite.com/csp/nbsrv2/frontpages/indehtml

  3. British Obesity and Metabolic Surgery Society. BOMSS standards for clinical services and commissioning guidelines [Internet]. 2012 [cited 2013 Dec 23].

    Google Scholar 

  4. NHS England. 2013/2014 NHS standard contract for severe and complex obesity (all ages). [Online] Accessed 7 July 2014.

    Google Scholar 

  5. National Confidential Enquiry into Patient Outcome and Death. Too lean a service? A review of the care of patients who underwent bariatric surgery [Internet]. 2012 [cited 07 July 2014]. Available from: https://www.ncepod.org.uk/2012report2/downloads/BS_fullreport.pdf

  6. Association of Anaesthetists of Great Britain and Ireland. Peri-operative management of the obese surgical patient 2015. Anaesthesia. 2015;70:859–76.

    Article  Google Scholar 

  7. Wren AM, Feher MD. Medical management of the patient considering bariatric surgery. Curr Anaesth Crit Care. 2010;21(1):3–8. https://doi.org/10.1016/j.cacc.2009.09.002.

    Article  Google Scholar 

  8. National Institute for Health and Care Excellence. Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. [Online] Available from: https://www.nice.org.uk/guidance/cg189. Accessed 07 July 2014

  9. Kenchaiah S, Evans JC, Levy D, Wilson PW, Benjamin EJ, Larson MG, et al. Obesity and the risk of heart failure. N Engl J Med. 2002;347(5):305–13. https://doi.org/10.1056/NEJMoa020245.

    Article  Google Scholar 

  10. Carbone S, Canada JM, Billingsley HE, Siddiqui MS, Elagizi A, Lavie CJ. Obesity paradox in cardiovascular disease: where do we stand? Vasc Health Risk Manag. 2019;15:89–100. https://doi.org/10.2147/VHRM.S168946.

    Article  CAS  Google Scholar 

  11. Pandey A, LaMonte M, Klein L, Ayers C, Psaty BM, Eaton CB, et al. Relationship between physical activity, body mass index, and risk of heart failure. J Am Coll Cardiol. 2017;69(9):1129–42. https://doi.org/10.1016/j.jacc.2016.11.081. Available from: https://pubmed.ncbi.nlm.nih.gov/28254175/

    Article  Google Scholar 

  12. Fursevich DM, LiMarzi GM, O’Dell MC, Hernandez MA, Sensakovic WF. Bariatric CT imaging: challenges and solutions. Radiographics. 2016;36(4):1076–86.

    Article  Google Scholar 

  13. The NHS Information Centre, Lifestyles Statistics. Statistics on obesity, physical activity and diet: England. 2012. [Online] Available from: https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-obesity-physical-activity-and-diet/statistics-on-obesity-physical-activity-and-diet-england-2012

  14. Warnakulasuriya SR, Yates DR, Wilson JT, Stone M, Redman J, Davies S, et al. Cardiopulmonary exercise testing has no additive incremental value to standard scoring systems when risk stratifying for bariatric surgery. Obes Surg. 2017 Jan;27(1):187–93. https://doi.org/10.1007/s11695-016-2351-5.

    Article  Google Scholar 

  15. Subramani Y, Naggapa M, Wong J, Patra J, Chung F. Death or near-death in patients with obstructive sleep apnoea: a compendium of case reports of critical complications. Br J Anaesth. 2017;119(5):885–99. https://doi.org/10.1093/bja/aex341.

    Article  CAS  Google Scholar 

  16. Chung F, Subramanyam R, Liao P, Sasaki E, Shapiro C, Sun Y. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth. 2012;108(5):768–75. https://doi.org/10.1093/bja/aes022.

    Article  CAS  Google Scholar 

  17. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14(6):540–5. https://doi.org/10.1093/sleep/14.6.540.

    Article  CAS  Google Scholar 

  18. Shearer ES. Obesity anesthesia: the dangers of being an apple. Br J Anaesth. 2013;110(2):172–4. https://doi.org/10.1093/bja/aes471.

    Article  CAS  Google Scholar 

  19. Cook TM, Woodall N, Frerk C, Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anesthetists and the Difficult Airway Society. Part 1: anesthesia. Br J Anaesth. 2011;106(5):617–31. https://doi.org/10.1093/bja/aer058. https://pubmed.ncbi.nlm.nih.gov/21447488/

  20. Zhang W, Mason EE, Renquist KE, Zimmerman MB. IBSR contributors. factors influencing survival following surgical treatment of obesity. Obes Surg. 2005 Jan;15(1):43–50. https://doi.org/10.1381/0960892052993422.

    Article  CAS  Google Scholar 

  21. Association of Anaesthetists of Great Britain and Ireland. Peri-operative management of the surgical patient with diabetes 2015. Anaesthesia. 2015;70:1427–40.

    Article  Google Scholar 

  22. Hart A, Goffredo P, Carroll R, Lehmann R, Nau P, Smith J, … Hassan I (2020) Optimizing Bariatric Surgery outcomes: the impact of preoperative elevated hemoglobin A1c levels on composite perioperative outcome measures. Surg Endosc. https://doi.org/10.1007/s00464-020-07887-9.

  23. Schauer PR, Kashyap SR, Wolski K, Brethauer SA, Kirwan JP, Pothier CE, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012;366(17):1567–76. https://doi.org/10.1056/NEJMoa1200225.

    Article  CAS  Google Scholar 

  24. Singh M, Liao P, Kobah S, Wijeysundera DN, Shapiro C, Chung F. Proportion of surgical patients with undiagnosed obstructive sleep apnea. Br J Anaesth. 2013;110(4):629–36. https://doi.org/10.1093/bja/aes465.

    Article  CAS  Google Scholar 

  25. Rubino F, Cohen RV, Mingrone G, le Roux CW, Mechanick JI, Arterburn DE, et al. Bariatric and metabolic surgery during and after the COVID-19 pandemic: DSS recommendations for the management of surgical candidates and postoperative patients and prioritisation of access to surgery. Lancet Diabetes Endocrinol. 2020;8(7):640–8. https://doi.org/10.1016/S2213-8587(20)30157-1.

    Article  CAS  Google Scholar 

  26. Collins JS, Lemmens HJ, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: a comparison of the “sniff” and “ramped” positions. Obes Surg. 2004;14(9):1171–5. https://doi.org/10.1381/0960892042386869.

    Article  Google Scholar 

  27. Dixon BJ, Dixon JB, Carden JR, Burn AJ, Schachter LM, Playfair JM, et al. Preoxygenation is more effective in the 25 degrees head-up position than in the supine position in severely obese patients: a randomized controlled study. Anesthesiology. 2005;102(6):1110–5. https://doi.org/10.1097/00000542-200506000-00009.

    Article  Google Scholar 

  28. Lagandre S, Arnalsteen L, Vallet B, Robin E, Jany T, Onraed B, et al. Predictive factors for rhabdomyolysis after bariatric surgery. Obes Surg. 2006;16(10):1365–70. https://doi.org/10.1381/096089206778663643.

    Article  CAS  Google Scholar 

  29. Chakravartty S, Sarma DR, Patel AG. Rhabdomyolysis in bariatric surgery: a systematic review. Obes Surg. 2013;23(8):1333–40. https://doi.org/10.1007/s11695-013-0913-3.

    Article  Google Scholar 

  30. Taha SK, El-Khatib MF, Baraka AS, Haidar YA, Abdallah FW, Zbeidy RA, et al. Effect of suxamethonium vs rocuronium on onset of oxygen desaturation during apnea following rapid sequence induction. Anesthesia. 2010;65(4):358–61. https://doi.org/10.1111/j.1365-2044.2010.06243.

    Article  CAS  Google Scholar 

  31. Woijcikiewicz T, Cousins J, Margarson M. The Bariatric Airway. Br J Hosp Med (Lond). 2018;79(11):612–9. https://doi.org/10.12968/hmed.2018.79.11.612.

    Article  Google Scholar 

  32. Ziemann-Gimmel P, Goldfarb AA, Koppman J, Marema RT. Opioid-free total intravenous anesthesia reduces postoperative nausea and vomiting in bariatric surgery beyond triple prophylaxis. Br J Anaesth. 2014;112(5):906–11. https://doi.org/10.1093/bja/aet551.

    Article  CAS  Google Scholar 

  33. Therneau IW, Martin EE, Sprung J, Kellogg TA, Schroeder DR, Weingarten TN. The role of Aprepitant in prevention of postoperative nausea and vomiting after bariatric surgery. Obes Surg. 2018;28(1):37–43. https://doi.org/10.1007/s11695-017-2797-0.

    Article  Google Scholar 

  34. Naeem Z, Chen IL, Pryor AD, Docimo S, Gan TJ, Spaniolas K. Antiemetic prophylaxis and anesthetic approaches to reduce postoperative nausea and vomiting in bariatric surgery patients: a systematic review. Obes Surg. 2020;30(8):3188–200. https://doi.org/10.1007/s11695-020-04683-1.

    Article  Google Scholar 

  35. Bamgbade OA, Oluwole O, Khaw RR. Perioperative antiemetic therapy for fast-track laparoscopic bariatric surgery. Obes Surg. 2018;28(5):1296–301. https://doi.org/10.1007/s11695-017-3009-7.

    Article  Google Scholar 

  36. Hayden P, Cowman S. Anesthesia for laparoscopic surgery. Br J Anaesth. 2011;11(5):177–80. https://doi.org/10.1093/bjaceaccp/mkr027.

    Article  Google Scholar 

  37. Department of Health. Comprehensive critical care: a review of adult critical care services [Internet]. [cited 07 July 2014]. Available from: http://webarchive.nationalarchives.gov.uk/20130107105354/ http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4082872.pdf

  38. DeMaria EJ, Murr M, Byrne TK, Blackstone R, Grant JP, Budak A, et al. Validation of the obesity surgery mortality risk score in a multicenter study proves it stratifies mortality risk in patients undergoing gastric bypass for morbid obesity. Ann Surg. 2007;246(4):578–84. https://doi.org/10.1097/SLA.0b013e318157206e.

    Article  Google Scholar 

  39. Sweetland S, Parkin L, Balkwill A, Green J, Reeves G, Beral V, et al. Smoking, surgery, and venous thromboembolism risk in women: United Kingdom cohort study. Circulation. 2013;127(12):1276–82. https://doi.org/10.1161/CIRCULATIONAHA.113.001428.

    Article  Google Scholar 

  40. Magee CJ, Barry J, Javed S, Macadam R, Kerrigan D. Extended thromboprophylaxis reduces incidence of postoperative venous thromboembolism in laparoscopic bariatric surgery. Surg Obes Relat Dis. 2010;6(3):322–5. https://doi.org/10.1016/j.soard.2010.02.046.

    Article  Google Scholar 

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Acknowledgments

The authors are grateful to Abigail A. Hine for their work in producing this chapter in the first edition of the book.

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Authors and Affiliations

  1. Department of Anesthesia, Taunton and Somerset NHS Trust, Taunton, UK

    Nicholas J. Kennedy & Alice R. Hodges

Authors
  1. Nicholas J. Kennedy
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  2. Alice R. Hodges
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Corresponding author

Correspondence to Nicholas J. Kennedy .

Editor information

Editors and Affiliations

  1. Homerton University Hospital, London, UK

    Sanjay Agrawal

Section Editor information

  1. Department of General Surgery, University Hospital Lewisham, London, UK

    Cynthia-Michelle Borg MD (Malta), MD (London), FRCS

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Kennedy, N.J., Hodges, A.R. (2023). Anaesthesia Considerations in the Obese Patient for Bariatric Surgery. In: Agrawal, S. (eds) Obesity, Bariatric and Metabolic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-60596-4_13

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  • DOI: https://doi.org/10.1007/978-3-030-60596-4_13

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-60595-7

  • Online ISBN: 978-3-030-60596-4

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