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Updates in Surgery
Diego Foschi
Giuseppe Navarra Editors
Emergency
Surgery in Obese
Patients
Updates in Surgery
The aim of this series is to provide informative updates on hot topics in the areas of
breast, endocrine, and abdominal surgery, surgical oncology, and coloproctology,
and on new surgical techniques such as robotic surgery, laparoscopy, and minimally
invasive surgery. Readers will find detailed guidance on patient selection,
performance of surgical procedures, and avoidance of complications. In addition, a
range of other important aspects are covered, from the role of new imaging tools to
the use of combined treatments and postoperative care.
The topics addressed by volumes in the series Updates in Surgery have been
selected for their broad significance in collaboration with the Italian Society of
Surgery. Each volume will assist surgical residents and fellows and practicing
surgeons in reaching appropriate treatment decisions and achieving optimal
outcomes. The series will also be highly relevant for surgical researchers.
More information about this series at http://www.springer.com/series/8147

Diego Foschi • Giuseppe Navarra
Editors
Emergency Surgery in
Obese Patients
Foreword by Paolo De Paolis
Editors
Diego Foschi Giuseppe Navarra
Department of Biomedical Sciences Department of Human Pathology of Adult
Luigi Sacco and Evolutive Age
University of Milan University of Messina
Milan Messina
Italy Italy
The publication and the distribution of this volume have been supported by the Italian Society
of Surgery
ISSN 2280-9848 ISSN 2281-0854 (electronic)

Updates in Surgery
ISBN 978-3-030-17304-3 ISBN 978-3-030-17305-0 (eBook)
https://doi.org/10.1007/978-3-030-17305-0
© Springer Nature Switzerland AG 2020

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recita-
tion, broadcasting, reproduction on microfilms or in any other physical way, and transmission or infor-
mation storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publica-
tion does not imply, even in the absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
Revision and editing: R. M. Martorelli, Scienzaperta (Novate Milanese, Italy)
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword
The incidence and prevalence of obesity have increased worldwide; in particular,

severe obesity is becoming an epidemic, affecting a considerable portion of the
population worldwide and leading to health, social, and economic problems. This
metabolic disease is associated with a shortened life expectancy, a decreased quality
of life, and increased health expenditure for the national health systems.
These considerations clearly demonstrate the necessity for a monograph that
takes into consideration all the problems related to emergency surgery in the obese
patient; we absolutely need to develop specific appropriate protocols and to strongly
promote teamwork strategies.
Therefore, with great satisfaction I introduce this important work by Diego
Foschi and Giuseppe Navarra; Diego and Giuseppe, top experts in the field, engaged
coworkers whose experience and scientific excellence have produced a high-quality
monograph.
This volume highlights all the important aspects of emergency surgery in obese
patients, providing updates on hot topics in this area and regarding new techniques,
not only related to surgery but also to the perioperative and intensive care manage-
ment. Considerable attention is also paid to the metabolic and surgical complica-
tions of bariatric surgery, without forgetting to discuss the subject of accreditation
in emergency bariatric surgery.
The high scientific level makes this volume valuable not only for the young sur-
geon who wants to understand the issues of bariatric surgery but also for the expe-
rienced surgeon who considers the sharing of knowledge and protocols a fundamental
aspect of the medical profession.
On behalf of the Italian Society of Surgery, I’d like to thank all the eminent
authors who collaborated in producing this very useful monograph.
Paolo
Turin, Italy De Paolis
September 2019 President
Italian Society of Surgery
v
Preface
We would like to start this preface by thanking the Board of the Italian Society of
Surgery for giving us the opportunity to present this volume on “Emergency Surgery
in Obese Patients.”
In Italy, 10% of the population is obese and this percentage is expected to increase
mainly in the younger age groups. Obesity carries a high risk of cardiovascular and
respiratory complications and is accompanied by several comorbidities which make
the obese a medically challenging patient population. This is especially true in the
emergency setting when optimal treatment of obese patients relies on a multidisci-
plinary approach with close cooperation between many specialists. If the best care
is provided, however, the prognosis of obese patients seems to be better than that of
normal-weight subjects for many pathologic conditions: this is the obesity paradox.
To obtain these results, a profound knowledge of the pathophysiology of morbid
obesity and its consequences on different body systems is essential. Resuscitation,
anesthesia, and intensive care management of the obese patient raise specific prob-
lems and need appropriate solutions. The first part of this volume examines this
topic extensively with an easily understandable approach.
The second part of this volume focuses on surgical emergencies in the obese
population. Prevention and treatment of the abdominal compartment syndrome,
trauma, and burns are also dealt with in this part. Symptoms may be atypical, signs
are poor, and the possibility of sudden deterioration of the general condition is very
frequent. Patients are often old and affected by several chronic conditions. A rapid
diagnosis and prompt treatment improve the results of surgery and lower the inci-
dence of complications in several clinical conditions.
Bariatric surgery has increased dramatically in our country: in the last 5 years, it
is estimated that more than 70,000 operations have taken place, 99% of which have
been performed laparoscopically, mainly by four procedures: sleeve gastrectomy,
Roux-en-Y gastric bypass, adjustable gastric banding, and one-anastomosis-gastric
bypass. Other operations are less frequent. Each operation is characterized by spe-
cific complications, which can occur early or late after surgery. Although they can
be classified as septic, hemorrhagic, and obstructive, the possibility of recognizing
their causes after surgery needs a profound knowledge of bariatric surgery. Although
some complications are common to all general surgery patients, others are unique to
the bariatric patient and a few may follow either general or bariatric surgery but may
differ in clinical presentation and management between the two patient populations.
vii
viii Preface
We thank all the contributors to this part of the volume for their effort to present the
very difficult aspects of the complications of bariatric surgery. These are very dis-
tinguished clinicians and researchers—fellows of the Italian Society of Surgery
(SIC), Italian Association of Hospital Surgeons (ACOI), and Italian Society of
Obesity Surgery and Metabolic Diseases (SICOb)—who have collaborated together
to provide the reader with the in-depth knowledge of emergency surgery in the
obese patients after bariatric surgery, under the auspices of the Società Italiana di
Chirurgia.
Finally, we would like to acknowledge the fundamental contributions of Juliette
Kleemann and Donatella Rizza at Springer and of Marco Martorelli at Scienzaperta
in realizing this excellent book.
In conclusion, we hope this volume will offer general and bariatric surgeons as
well as emergency medicine professionals a valid tool to help them in the decision-
making processes concerning obese patients in the emergency setting.
Milan, Italy Diego Foschi

Messina, Italy Giuseppe Navarra
September 2019
Contents
Part I Anesthesia and Resuscitation in Obese Patients

1 Frailty of the Obese Patient and the Obesity Paradox
After Surgical Stress�� 3
Diego Foschi, Marcello Lucchese, Giuliano Sarro, and Andrea Rizzi
2 Emergency Anesthesia and Resuscitation in the Obese Patient�� 11
Rita Cataldo, Ida Di Giacinto, Massimiliano Sorbello,
and Flavia Petrini
3 Perioperative and Intensive Care Management
of the Obese Surgical Patient�� 21
Giulia Bonatti, Chiara Robba, Lorenzo Ball, and Paolo Pelosi
4 Postoperative Complications in the Intensive Care Unit�� 31
Michele Carron
5 The ERAS Protocol�� 37
Luca Cabrini, Martina Baiardo Redaelli, Stefano Turi,
and Luigi Beretta
Part II Clinical Settings in Obese Patients

6 Trauma and Burns in Obese Patients�� 45
Osvaldo Chiara, Stefania Cimbanassi, Francesco Ciancio,
and Vincenzo Rapisarda
7 Perforations of the Upper Gastrointestinal Tract �� 53
Paolo Bernante, Matteo Rottoli, Stefano Cariani,
Francesca Balsamo, and Gilberto Poggioli
8 Acute Appendicitis in Obese Patients�� 59
Francesco Roscio, Federico Clerici, Luigi Armiraglio,
and Ildo Scandroglio
9 Pancreatic and Biliary Emergencies�� 65
Gennaro Nappo, Alessandro Zerbi, and Marco Montorsi
ix
x Contents
10 Bowel Obstruction in Obese Patients �� 73

Vincenzo Pilone and Mafalda Romano
11 Large Bowel Obstruction in Obese Patients�� 81
Antonio Di Cataldo, Salvatore Perrotti, Carlos Rivera,
and Emanuele Lo Menzo
12 Abdominal Compartment Syndrome in Obese Patients�� 87
Jacopo Viganò, Angelo D’Ovidio, Gabriele Bocca,
and Paolo Dionigi
Part III Clinical Settings After Bariatric Surgery

13 A Brief History of Bariatric Surgery �� 97
Giuseppe Navarra, Gianfranco Silecchia, Luigi Piazza,
Iman Komaei, and Mauro Toppino
14 Bariatric Surgery Complications in the Emergency Department �� 109
Giuseppe Maria Marinari
15 Metabolic Complications After Bariatric Surgery: The False
Acute Abdomen�� 113
Luca Busetto
16 Complications of Intragastric Balloons �� 119
Alfredo Genco, Stefano Cariani, and Ilaria Ernesti
17 Complications of Restrictive Procedures �� 125
Mirto Foletto, Alice Albanese, and Luca Prevedello
18 Upper Gastrointestinal Bleeding After Bariatric Surgery �� 131
Luigi Angrisani, Antonella Santonicola, Giovanni Galasso,
Alessandra D’Alessandro, Antonio Vitiello, and Paola Iovino
19 Peptic Ulcer After Bariatric Surgery �� 139
Mario Musella and Antonio Vitiello
20 Bowel Obstruction After Bariatric Surgery�� 145
Alessandro Giovanelli and Antonio Zullino
21 Acute Peritonitis and Abscess After Bariatric Surgery�� 153
Stefano Olmi, Giovanni Cesana, and Alberto Oldani
22 Anastomotic Leak After Bariatric Surgery: Prevention
and Treatment�� 159
Maurizio De Luca, Giacomo Piatto, Cesare Lunardi, Alberto Sartori,
Nicola Clemente, and Natale Pellicanò
23 Gallstones and Related Complications, Cholecystitis and Cholangitis
After Bariatric Surgery �� 169
Marco Antonio Zappa and Elisa Galfrascoli
Contents xi
24 Emergencies After Bariatric Surgery: The Role of Flexible

Endoscopy and Interventional Radiology�� 175
Antonio Granata, Michele Amata, Valeria Provenzano,
and Mario Traina
25 Accreditation of the Surgeon in Emergency Bariatric Surgery�� 189
Valerio Ceriani, Ferdinando Pinna, and Marta Tagliabue
26 Litigation After Bariatric Surgery �� 193
Ludovico Docimo and Salvatore Tolone
Contributors
Alice Albanese Bariatric Unit and Week Surgery Unit, Padua University Hospital,
Padua, Italy
Michele Amata Endoscopy Service, ISMETT–Istituto Mediterraneo per i Trapianti
e Terapie ad Alta Specializzazione, Palermo, Italy
Luigi Angrisani General and Endoscopic Surgery Unit, S. Giovanni Bosco
Hospital, Naples, Italy
Luigi Armiraglio Division of General Surgery, ASST Valle Olona, Busto Arsizio
Hospital, Busto Arsizio, Varese, Italy
Martina Baiardo Redaelli Department of Anesthesia and Intensive Care, San
Raffaele Scientific Institute, Milan, Italy
Lorenzo Ball Anesthesia and Intensive Care Unit, San Martino Policlinico
Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
Department of Surgical Sciences and Integrated Diagnostics, University of Genoa,
Genoa, Italy
Francesca Balsamo Department of Medical and Surgical Sciences, University of
Bologna, S. Orsola-Malpighi University Hospital, Bologna, Italy
Luigi Beretta Department of Anesthesia and Intensive Care, San Raffaele
Scientific Institute, Milan, Italy
Paolo Bernante Department of Medical and Surgical Sciences, University of
Gabriele Bocca Division of General Surgery 1, Department of Surgery, Policlinico
San Matteo Hospital, and General Surgery Residency, University of Pavia, Pavia,
Italy
Giulia Bonatti Anesthesia and Intensive Care Unit, San Martino Policlinico
Genoa, Italy
xiii
xiv Contributors
Luca Busetto Department of Medicine, University of Padua, and Clinica Medica 3,

University Hospital of Padua, Padua, Italy
Luca Cabrini Department of Anesthesia and Intensive Care, San Raffaele
Scientific Institute, Milan, Italy
Stefano Cariani Department of Medical and Surgical Sciences, University of
Michele Carron Department of Medicine–DIMED, Section of Anesthesiology
and Intensive Care, University Hospital of Padua, Padua, Italy
Rita Cataldo Unit of Anesthesia, Intensive Care and Pain Management, Department
of Medicine, Campus Bio-Medico University, Rome, Italy
Valerio Ceriani Department of General Surgery, MultiMedica Hospital, Sesto San
Giovanni, Milan, Italy
Giovanni Cesana Department of General and Oncological Surgery, Policlinico
San Marco Hospital, Zingonia, Bergamo, Italy
Osvaldo Chiara Department of Pathophysiology and Transplantation, University
of Milan and General Surgery and Trauma Team, Niguarda Hospital, Milan, Italy
Francesco Ciancio Department of Plastic and Reconstructive Surgery, University
of Bari, Bari, Italy
Stefania Cimbanassi General Surgery and Trauma Team, Niguarda Hospital,
Milan, Italy
Nicola Clemente Department of Surgery, Castelfranco and Montebelluna
Hospitals, Treviso, Italy
Federico Clerici Division of General Surgery, ASST Valle Olona, Busto Arsizio
Alessandra D’Alessandro Endoscopic Unit, Pineta Grande Hospital, Caserta,
Italy
Angelo D’Ovidio Division of General Surgery 1, Department of Surgery,
Policlinico San Matteo Hospital, and General Surgery Residency, University of
Pavia, Pavia, Italy
Maurizio De Luca Department of Surgery, Castelfranco and Montebelluna
Antonio Di Cataldo Chair of General Surgery, University of Catania, Catania, Italy
Oncological Surgery Unit, Department of General Surgery, Policlinico-Vittorio
Emanuele University Hospital, Catania, Italy
Ida Di Giacinto Anesthesiology, Polyvalent Intensive Care and Transplantation
Unit, Department of Organ Failure and Transplantation, S. Orsola-Malpighi
University Hospital, Bologna, Italy
Contributors xv
Paolo Dionigi Division of General Surgery 1, Department of Surgery, Policlinico

San Matteo Hospital, Pavia, Italy
Ludovico Docimo General, Mininvasive and Bariatric Surgery Unit, Department
of Medical, Surgical, Neurological, Metabolic and Ageing Sciences, University of
Campania Luigi Vanvitelli, Naples, Italy
Ilaria Ernesti Medical Pathophysiology, Food Science, and Endocrinology
Section, Department of Experimental Medicine, Sapienza University of Rome,
Rome, Italy
Mirto Foletto Bariatric Unit and Week Surgery Unit, Padua University Hospital,
Padua, Italy
Diego Foschi Department of Biomedical Sciences Luigi Sacco, University of
Milan, Milan, Italy
Giovanni Galasso Endoscopic Unit, Pineta Grande Hospital, Caserta, Italy
Elisa Galfrascoli Department of General Surgery, Fatebenefratelli Hospital,
Milan, Italy
Alfredo Genco Surgical Endoscopy Unit, Department of Surgical Sciences,
Sapienza University of Rome, Rome, Italy
Alessandro Giovanelli Bariatric and Metabolic Surgery Unit, Policlinico San
Donato Hospital, Milan, Italy
Antonio Granata Endoscopy Service, ISMETT–Istituto Mediterraneo per i
Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
Paola Iovino Department of Medicine, Surgery and Dentistry, Scuola Medica
Salernitana, University of Salerno, Salerno, Italy
Iman Komaei General Surgery Unit, Gaetano Martino University Hospital,
Messina, Italy
Emanuele Lo Menzo Bariatric and Metabolic Institute and Digestive Disease
Institute, Cleveland Clinic Florida, Weston, FL, USA
Marcello Lucchese General, Metabolic and Emergency Unit, Department of
Surgery, Santa Maria Nuova Hospital, Florence, Italy
Cesare Lunardi Department of Surgery, Castelfranco and Montebelluna Hospitals,
Treviso, Italy
Giuseppe Maria Marinari Bariatric Surgery Unit, Humanitas Research Hospital,
Rozzano, Milan, Italy
Marco Montorsi Department of Surgery, Humanitas Research Hospital, Rozzano,
Milan, Italy
Mario Musella Department of Advanced Biomedical Sciences, Federico II
University, Naples, Italy
xvi Contributors
Gennaro Nappo Pancreatic Surgery Unit, Humanitas Research Hospital, Rozzano,

Milan, Italy
Giuseppe Navarra Department of Human Pathology of Adult and Evolutive Age,
Gaetano Martino University Hospital, University of Messina, Messina, Italy
Alberto Oldani Department of General and Oncological Surgery, Policlinico San
Marco Hospital, Zingonia, Bergamo, Italy
Stefano Olmi Department of General and Oncological Surgery, Policlinico San
Marco Hospital, Zingonia, Bergamo, Italy
Natale Pellicanò Department of Surgery, Castelfranco and Montebelluna
Paolo Pelosi Anesthesia and Intensive Care Unit, San Martino Policlinico Hospital,
IRCCS for Oncology and Neurosciences, Genoa, Italy
Genoa, Italy
Salvatore Perrotti Department of General Surgery, Policlinico-Vittorio Emanuele
University Hospital, Catania, Italy
Flavia Petrini Department of Perioperative Medicine, Pain Therapy, Rapid
Response Systems and Intensive Care, University of Chieti-Pescara, and ASL2
Abruzzo, Chieti, Italy
Giacomo Piatto Department of Surgery, Castelfranco and Montebelluna Hospitals,
Treviso, Italy
Luigi Piazza General Surgery Unit, ARNAS Garibaldi Hospital, Catania, Italy
Vincenzo Pilone Department of Medicine, Surgery, and Dentistry, Scuola Medica
Salernitana, University of Salerno, Salerno, Italy
Ferdinando Pinna Department of General Surgery, MultiMedica Hospital, Sesto
San Giovanni, Milan, Italy
Gilberto Poggioli Department of Medical and Surgical Sciences, University of
Luca Prevedello Bariatric Unit and Week Surgery Unit, Padua University Hospital,
Padua, Italy
Valeria Provenzano Endoscopy Service, ISMETT–Istituto Mediterraneo per i
Trapianti e Terapie ad Alta Specializzazione, Palermo, Italy
Vincenzo Rapisarda Department of Plastic Reconstructive Surgery and Burn
Unit, Niguarda Hospital, Milan, Italy
Carlos Rivera Bariatric and Metabolic Institute and Digestive Disease Institute,
Cleveland Clinic Florida, Weston, FL, USA
Contributors xvii
Andrea Rizzi Unit of General Surgery, Hospital of Tradate, Varese, Italy

Chiara Robba Anesthesia and Intensive Care Unit, San Martino Policlinico
Mafalda Romano General, Bariatric, and Emergency Surgery Unit, Gaetano
Fucito Hospital, Mercato San Severino, Salerno, Italy
Francesco Roscio Division of General Surgery, ASST Valle Olona, Busto Arsizio
Matteo Rottoli Department of Medical and Surgical Sciences, University of
Antonella Santonicola Department of Medicine, Surgery and Dentistry, Scuola
Medica Salernitana, University of Salerno, Salerno, Italy
Giuliano Sarro General Surgery Unit, Hospital of Magenta, Magenta, Milan, Italy
Alberto Sartori Department of Surgery, Castelfranco and Montebelluna Hospitals,
Treviso, Italy
Ildo Scandroglio Division of General Surgery, ASST Valle Olona, Busto Arsizio
Gianfranco Silecchia Department of Medical-Surgical Sciences and
Biotechnologies, Sapienza University of Rome, ICOT—Polo Pontino, Latina, Italy
Massimiliano Sorbello Anesthesia and Intensive Care Unit, Policlinico-Vittorio
Emanuele University Hospital, Catania, Italy
Marta Tagliabue Department of General Surgery, MultiMedica Hospital, Sesto
San Giovanni, Milan, Italy
Salvatore Tolone General, Mininvasive and Bariatric Surgery Unit, Department of
Medical, Surgical, Neurological, Metabolic and Ageing Sciences, University of
Campania Luigi Vanvitelli, Naples, Italy
Mauro Toppino Department of Surgical Sciences, University of Turin, Turin, Italy
Mario Traina Endoscopy Service, ISMETT–Istituto Mediterraneo per i Trapianti
e Terapie ad Alta Specializzazione, Palermo, Italy
Stefano Turi Department of Anesthesia and Intensive Care, San Raffaele Scientific
Institute, Milan, Italy
Jacopo Viganò Division of General Surgery 1, Department of Surgery, Policlinico
San Matteo Hospital, Pavia, Italy
Antonio Vitiello Department of Advanced Biomedical Sciences, Federico II
University, Naples, Italy
Marco Antonio Zappa Department of General Surgery, Fatebenefratelli Hospital,
Milan, Italy
xviii Contributors
Alessandro Zerbi Pancreatic Surgery Unit, Humanitas Research Hospital,

Rozzano, Milan, Italy
Antonio Zullino Bariatric and Metabolic Surgery Unit, Policlinico San Donato
Hospital, Milan, Italy
Part I
Anesthesia and Resuscitation
in Obese Patients
Frailty of the Obese Patient
and the Obesity Paradox After 1
Surgical Stress
Diego Foschi, Marcello Lucchese, Giuliano Sarro,

and Andrea Rizzi
1.1 Introduction
Obesity is a metabolic disease characterized by abnormal or excessive adipose tis-

sue accumulation and body weight increase. It is recognized on the basis of a num-
ber of anthropometric characteristics and can be classified according to the body
mass index (BMI = weight [kg]/height [m2]) into three different classes [1]:
• class I: BMI 30–34.9

• class II: BMI 35–39.9
• class III: BMI ≥40
Obesity reduces life expectancy, especially when BMI > 35 [2, 3], since it is
generally related to concomitant chronic metabolic complications (hypertension,
insulin resistance, cholesterol and glucose increase), which are prognostic factors
for cancer [4], cardiovascular diseases (CVD) and stroke [2, 5].
D. Foschi (*)
Department of Biomedical Sciences Luigi Sacco, University of Milan, Milan, Italy
e-mail: diego.foschi@unimi.it
M. Lucchese
General, Metabolic and Emergency Unit, Department of Surgery, Santa Maria Nuova
Hospital, Florence, Italy
e-mail: mlucch@iol.it
G. Sarro
General Surgery Unit, Hospital of Magenta, Magenta, Milan, Italy
e-mail: giuliano.sarro@asst-ovestmilanese.it
A. Rizzi
Unit of General Surgery, Hospital of Tradate, Varese, Italy
e-mail: andrea.rizzi@asst-settelaghi.it
© Springer Nature Switzerland AG 2020 3

D. Foschi, G. Navarra (eds.), Emergency Surgery in Obese Patients,
Updates in Surgery, https://doi.org/10.1007/978-3-030-17305-0_1
4 D. Foschi et al.
1.2 The Obesity Paradox
The obesity paradox has been observed in many cases in the literature; clinically
healthy obese patients have an increased overall survival in cases of heart failure,
even though their condition reduces life expectancy. Furthermore, under acute
stress, such as surgical stress, obesity “protects” against mortality [6–27]. This
evidence-based conclusion is supported by the literature, even though a few cita-
tions do not confirm these findings [18–22].
In 2003, Dindo et al. [7] studied postoperative complications in 6336 patients
undergoing elective general surgery. Patients were classified according to BMI: non-
obese (BMI < 30), mildly obese (BMI 30–35) and severely obese (BMI > 35). The
incidence of complications was the same in all three groups (16.3% vs. 16% vs.
15.1%) and an additional multivariate regression analysis showed that obesity was not
a risk factor. Mortality was not investigated. In a prospective, multi-centric clinical
study, Mullen et al. [8] found that in 118,707 patients undergoing non-bariatric sur-
gery, the mortality risk related to BMI showed a reverse J-shaped relationship; highest
rates were found in underweight and morbidly obese patients. Overweight and mod-
erately obese patients had the lowest risk of mortality. A prospective analysis of a
single center clinical study investigating postoperative complications [9] studied 4293
patients, of whom 743 were obese. Obese patients more frequently reported diabetes
(18.1% vs. 4.7%), hypertension (30.3% vs. 14.2%), cardiac (21.3% vs. 16.7%) or
pulmonary (18.6% vs. 14.4%) diseases. They used medications more frequently than
normal-weight patients, yet they were less frequently smokers (26.9% vs. 35.4%).
Obesity resulted in a significantly longer intervention time, higher intraoperative
blood loss and rate of surgical site infections (SSI) but not mortality, considered at
30 days. Furthermore, mildly obese or overweight patients had longer overall sur-
vival. The above observations were confirmed by several studies. Vargo et al. [10]
studied 6,240,995 patients who underwent cardiovascular surgery, of whom about
10% were obese. These patients had lower in-hospital mortality (2% vs. 4.2%,
p < 0.0001), postoperative stroke (1.3% vs. 2.3%) and incidence of pneumonia (3.6%
vs. 5.1%), the most common complication, but a higher incidence of acute renal fail-
ure (8.7% vs. 8.2%) and need for blood transfusions (20.9% vs. 19.3%). The risk of
wound infection was also higher (1.1% vs. 0.8%). In the vascular surgery setting [11,
12], obese patients had lower cardiac and respiratory morbidity as well as lower mor-
tality in comparison to normal-weight patients. However, a higher rate of wound com-
plications was observed. Obese patients who underwent esophageal [13], gastric [14]
and colon surgery [15–17] had prolonged intraoperative intervention time and
increased complication rate and SSI but had no difference in perioperative mortality
and reoperation rate. Similar results were observed in patients who underwent surgery
for Crohn’s disease [18]; BMI did not influence cardiac, pulmonary and renal compli-
cations or mortality but patients with a BMI > 40 had a higher prevalence of SSI.
In addition, obese patients affected by various organ cancers experienced less
serious morbidity and lower risk-adjusted odds of mortality, despite a higher fre-
quency of deep venous thrombosis, renal complications and ventilator dependency
(considered as >48 h) [19]. Benjamin et al. [20] retrospectively reviewed the ACS-
NSQJP database and extrapolated 101,078 patients who underwent emergency
1 Frailty of the Obese Patient and the Obesity Paradox After Surgical Stress 5
abdominal surgery between 2005 and 2010; approximately 30% were obese, 32%
overweight, 3.5% underweight and the remaining normal weight. A history of dia-
betes and hypertension was more frequent in the obese group; a higher complication
rate was evident in the underweight and morbidly obese patients. Crude mortality
was increased in the underweight group alone.
Different results were obtained in obese patients admitted to the intensive care
unit (ICU) for blunt trauma [21]. Obese patients had fewer head injuries but more
chest and lower-extremity traumas. Nevertheless, they had more complications, lon-
ger time of mechanical ventilation and ICU stay. In the above study, obesity was an
independent risk factor for mortality. In a prospective study on 1167 patients admit-
ted to the ICU after trauma, Bochicchio et al. [22] examined the outcome of 62
obese (BMI > 30) patients (5.3% of the total). More than a two-fold increase in risk
of infection was observed and seven-times higher likelihood of in-hospital death.
Ditillo et al. [23] accessed the USA National Trauma Data Base and identified
32,780 morbidly obese patients who had blunt trauma injury. These patients had
higher in-hospital complication rate, longer ICU- and in-hospital stay and higher
mortality in morbidly obese patients compared with the non-obese population.
Furthermore, Diaz et al. [24, 62] measured fasting glucose plasma levels in 1334
blunt trauma patients and found that mortality was related more to hyperglycemia
than to morbid obesity (BMI > 40). Observations on adult patients in ICUs, includ-
ing medical patients, produced contradictory results [25, 26]. Overall an inversely
proportional relationship between overweight-mild obesity and mortality was
observed, but these patients had an increased risk of infection, multiple organ failure
with longer overall stay in the ICU. Most of the studies were heterogeneous and the
interpretation of the results should be considered with caution since obesity was
defined only on the basis of BMI, an imperfect measure.
1.3 The Obesity Paradox Revised
Several factors must be considered, since it is quite difficult to explain why after
surgical stress, overweight and mildly obese patients seem to show a better progno-
sis in comparison to the normal-weight patients.
BMI The definition of obesity using the BMI alone is misleading and incomplete
•
[1]. It does not distinguish if the increase of the fat is peripheral or central, visceral
or subcutaneous. We know that adipose tissue is not only an energetic reserve use-
ful during periods of food deprivation, but it forms the diffuse endocrine system.
Visceral and subcutaneous adipose tissue possesses different patterns of hormone
secretion and regulates specific metabolic pathways. The increase of visceral fat
has a higher pathogenic potential than the subcutaneous adipose tissue. Prognosis
of obese patients with heart failure had a good linear relationship with overall sur-
vival and waist circumference (considered an index of central adiposity) but not
BMI [27, 28]. The same observation was true for surgical patients [29].
• Inflammatory pattern of obesity Obesity is not only a metabolic but also an atten-
uated inflammatory disease [30]. Adipose tissue secretes TNFα and other
6 D. Foschi et al.
cytokines, which mediate inflammatory cell activation causing endothelial cell

dysfunction. The inflammatory pathways elicited by obesity are the same as
induced by surgical stress and it may be possible that obese patients have an adap-
tive immune-protection exerted by an attenuated inflammation against an acute
stress. Mullen et al. [8] considered that the nutritional reserve and more efficient
metabolic state of obese patients would be able to elicit a more appropriate inflam-
matory (and immune) response to surgical stress.
Patient selection The main results reported in observational studies in the literature
•
[8, 10, 11, 13, 20] showed that obese patients (especially morbidly obese) were
younger than the control population. We suspect that obese patients were selected
for intervention only when they were young and at low risk of mortality.
Heterogeneity of the obese population Obese patients are a heterogeneous popula-
•
tion and up to 30% are metabolically healthy (MHO) with normal insulin sensitiv-
ity, low visceral fat storage and absence of significant angiopathy [31]. Intra- and
postoperative risks are similar to those of normal-weight patients. MHO patients
have normal mean arterial blood pressure, C-reactive protein, HDL cholesterol, tri-
glycerides and plasma glucose. The risk of developing type 2 diabetes mellitus
(T2DM) and CVD is 1.24 times higher than in the normal-weight population [32],
since these patients easily progress to metabolically unhealthy obesity (MUO), in
particular metabolic syndrome; gender (female), low HDL-cholesterol levels,
greater insulin resistance and more visceral (and abdominal) fat are the prognostic
predictors [33]. It is noteworthy that 30-day morbidity following colon resection in
colorectal cancer patients can be predicted by visceral fat not BMI [29]. Furthermore,
the presence of the metabolic syndrome, including central obesity, entails a higher
risk of respiratory events (OR 2.6) and SSI (OR 3.47) following surgery [34]. In the
above mentioned study, mortality was not analyzed, and conclusions cannot be
made on the influence of central adiposity on the obesity paradox.
• Presence of comorbidities Table 1.1 illustrates potential risk factors for complica-
tions and death after surgery and trauma in obese patients.
Obesity leads to an increase in body mass by augmenting adipose tissue and

ectopic fat accumulation in the liver, muscles and other organs. This modification
causes morphological, metabolic and functional changes in a unique pattern for
each obese patient.
The most frequent complications of postoperative and traumatic stress are reper-
cussions on the cardiovascular and pulmonary system: cardiac failure, pulmonary
Table 1.1 Comorbidities of Blood hypertension

obesity relevant for surgical Cardiovascular disease
risk definition Restrictive pneumopathy
Obstructive sleep apnea syndrome
Obesity hypoventilation syndrome
Type 2 diabetes mellitus
Nonalcoholic fatty liver disease
Chronic kidney disease
Malnutrition
Sarcopenia
insufficiency, deep venous thrombosis and pulmonary embolism. They are the most
frequent causes of death after bariatric surgery [35].
Arterial hypertension, CVD and obesity hypoventilation syndrome should be
considered in the assessment of the surgical risk [36–38]. Obstructive apnea syn-
drome contributes to worsening of cardiovascular and pulmonary function [39]. The
use of the STOP-bang questionnaire is a useful prognostic tool to evaluate the risk
of ventilation-related complications [40]. T2DM increases the risk of complications
after surgery [41, 42]. Obesity and T2DM independently increase the risk of SSI
[43–45], but perioperative correction of hyperglycemia is an effective preventive
measure [46, 47]. Malnutrition (detected by hypoalbuminemia) and sarcopenia
(detected on the basis of functional and morphological changes in muscle mass)
also indicate a higher risk of complications after surgery [48–50].
1.4 Risk Prediction in Emergency Surgery of Obese Patients
Elective bariatric surgery is associated with a low risk of complications (2–5%) and
mortality (0.18%) [51]. After elective general surgery, the rate of complications in
obese patients ranges from 10.8 to 13.8% with a mortality rate of about 1.2%.
Following trauma, they are 9.3% and 3%, respectively. Emergency abdominal sur-
gery is characterized by a substantial increase of the complications (17.2–27.7%)
and mortality (3.8–4.9%), depending on the obesity class. The excellent results of
bariatric surgery depend on a careful selection of the patients, preventive measures
for enhanced recovery after surgery and intensive treatment of complications. ASA
physical status is the most used system for predicting the risk of surgical patients
[52]. Obese patients are classified as class 2 or 3 with substantial underevaluation of
the emergency surgery cases. In bariatric surgery, obese patient prognostic factors
include male gender, age >45, BMI > 50, hypertension and risk factors for pulmo-
nary embolism [53]. DeMaria elaborated the Obese Surgery Risk Mortality Score
(OSRMS) [53] following bariatric surgery by evaluating the prognostic factors
stated above scored 1 each. He considered 3 classes: A (score 0–1), 39–65% of the
cases, B (2–3), 35–52% of the cases and C (4–5), 2–11% of the cases [52–55],
which correlate with progressive mortality rates of 0.31%, 1.90% and 7.56% [52].
The most frequent causes of death were pulmonary failure, pulmonary embolism
and cardiac events (60.6%). The OSRMS was validated for mortality in several
studies but failed to predict the risk of complications [53–56] and was not validated
for general elective or emergency surgery.
A further predictive factor was identified in a multi-centric prospective cohort
study by the StarSurg group [57], which found a significant relationship between
BMI and major complications in patients affected by gastrointestinal malignancies.
All obese patients affected by these cancers are at a high risk of complications and
mortality, especially when associated sarcopenia is present.
Finally, we have to consider the role of emergency surgery. In their revision of
the ACS-NSQIP, Hyder et al. [58] examined 56,942 emergency and 136,311 elec-
tive interventions and found that the mortality rate was 3.97% in the first group and
0.4% in the latter. In a separate paper, Bohen et al. [59] confirmed that major
8 D. Foschi et al.
morbidity and mortality were higher following emergency surgery (16.75% vs.
9.73% and 3.74% vs. 1%, p < 0.001). Bohen et al. [59] and Nandan et al. [60]
identified 22 risk factors for adverse events after emergency surgery and elaborated
the Emergency Surgery Acuity Score. The mortality rate was 22.8% for score 10,
59.1% for score 15 and 100% for score 22. The risk factors were demographic
(age > 60 years), clinical or determined by laboratory tests. Most of them are fre-
quently associated with obesity (hypertension, dyspnea, ventilator requirement,
congestive heart failure, infection and sepsis), with longer stay in hospital, higher
rate of complications, reoperation and death [61]. Under these conditions, optimal
resuscitation and perioperative care strategies (see Chaps. 2–5) are essential to
achieve the best results we can.
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Emergency Anesthesia
and Resuscitation in the Obese Patient 2
Rita Cataldo, Ida Di Giacinto, Massimiliano Sorbello,
and Flavia Petrini
2.1 athophysiological Peculiarities of Anesthesiological

P
Interest in Obese Patients: Preoperative Assessment
in Emergency
Obesity is considered an important risk factor for cardiovascular disease, type 2

diabetes mellitus, dyslipidemia, hypertension and respiratory diseases affecting
especially pulmonary function. Body mass index (BMI) by itself, though included
in the new ASA classification [1], does not provide information about adipose tissue
distribution and function, key factors in the onset of comorbidities.
2.1.1 Respiratory Function
One of the causes of respiratory impairment in obese patients is elevation of the

diaphragm by the abdominal fat. This results in increased respiratory work related
R. Cataldo
Unit of Anesthesia, Intensive Care and Pain Management, Department of Medicine, Campus
Bio-Medico University, Rome, Italy
e-mail: r.cataldo@unicampus.it
I. Di Giacinto
Anesthesiology, Polyvalent Intensive Care and Transplantation Unit, Department of Organ
Failure and Transplantation, S. Orsola-Malpighi University Hospital, Bologna, Italy
e-mail: digiacintoida@gmail.com
M. Sorbello
Anesthesia and Intensive Care Unit, Policlinico-Vittorio Emanuele University Hospital,
Catania, Italy
e-mail: maxsorbello@gmail.com
F. Petrini (*)
Department of Perioperative Medicine, Pain Therapy, Rapid Response Systems and Intensive
Care, University of Chieti-Pescara and ASL2 Abruzzo, Chieti, Italy
e-mail: flavia.petrini@unich.it
© Springer Nature Switzerland AG 2020 11
D. Foschi, G. Navarra (eds.), Emergency Surgery in Obese Patients,
Updates in Surgery, https://doi.org/10.1007/978-3-030-17305-0_2
12 R. Cataldo et al.
to the decreased compliance and higher resistance of the airways: an obese patient
uses about 15% of his oxygen reserve to breathe as compared to 3% in a lean patient.
Obese patients have reduced functional residual capacity (FRC) and therefore a
tendency to rapidly develop atelectasis with alteration of the ventilation/perfusion
(V/Q) ratio, hypercapnia, increased expiratory resistance, wheezing, tachypnea and,
most importantly, rapid desaturation.
These problems are often exacerbated in emergency and cause the respiratory
system of the obese to work at its maximum even under standard conditions,
with no reserve in the event of a critical situation. The reduced reserve compro-
mises the patient’s ability to tolerate respiratory insults such as pneumonia.
Furthermore, an obese person has increased airway pressure due to increased
airway resistance (heavier chest wall and abdomen, lung base atelectasis). All of
these will lead to a reduced oxygen supply, increased respiratory work, and a
very short desaturation time at the induction of anesthesia with a short safe
apnea time.
2.1.2 Cardiovascular Function
Obesity and the related metabolic syndrome also interfere negatively with the
patient’s cardiovascular function. The metabolic syndrome makes the patient more
susceptible to risk factors for ischemic heart disease. Furthermore, obesity is an
inflammatory syndrome that also involves the endothelium, placing the arteries at
greater risk of atheromas. Finally, the additional work needed to perfuse the
increased body surface can result in progressive ventricular dysfunction. The risk of
heart failure is elevated in obese patients, and its genesis is complex and often mul-
tifactorial. Ventricular hypertrophy and hypertension lead to a higher systolic work-
load, which is associated with an increase in circulating blood to perfuse the adipose
tissue. As soon as the system gets “out of breath”, left ventricular dysfunction sets
in, associated with cardiovascular decompensation and heart failure. The obese
patient is often affected by coronary disorders and arrhythmias such as atrial fibril-
lation, which worsen cardiac function especially in emergency conditions (altered
volemia, pain, respiratory failure and hypoxia) where preoperative optimization is
desirable but impossible.
The pulmonary and cardiovascular systems are so closely connected that altera-
tions in their functioning reinforce each other. In the obese patient, the clinical pre-
sentation of “obesity cardiomyopathy” can be exacerbated by the pulmonary
hypertension commonly associated with obstructive sleep apnea (OSA) and obesity
hypoventilation syndrome (OHS) (sometimes combined in an overlap syndrome)
and right ventricular dysfunction.
In patients with specific problems (BMI >50, overlap syndrome, obesity cardio-
myopathy), rapid echocardiographic assessment is recommended if time permits,
even directly on the operating table or in the emergency department.
2 Emergency Anesthesia and Resuscitation in the Obese Patient 13
2.1.3 Risk of Thromboembolism
Because it induces an inflammatory state, obesity is a risk factor for deep venous
thrombosis (DVT) and pulmonary embolism (PE). The risk is increased by trauma,
emergency abdominal and pelvic surgery, and hospitalization in the intensive care
unit (ICU). Prophylaxis against DVT/PE is mandatory and the use of pharmacologi-
cal strategies must not exclude active mechanical pressure, which can be started in
the operating room (OR). Every therapeutic effort must be made towards early post-
operative mobilization. A vena cava filter is not routinely recommended for primary
prophylaxis.
2.1.4 Risk of Difficult Airway
Obese patients are also at risk of a difficult airway. Although this does not necessar-
ily mean difficult intubation, problems can arise in the perioperative maintenance of
adequate oxygenation. Obese patients may not have an increased risk of difficult
intubation per se but are likely to present difficulties in face mask and supraglottic
airway device (SAD) ventilation in linear relation to their BMI. In the case of a
“can’t intubate, can’t oxygenate” (CICO) scenario, the obese patient’s anatomy
involves an increased risk of difficult cricothyroidotomy because of problems with
landmark identification and pretracheal tissue thickness. Therefore, in emergency
surgery even more than elective surgery, it is essential to be prepared for a difficult
airway and explore and identify predicting indexes.
Standard difficult airway indexes can be easily and quickly assessed even in an
emergency setting if the patient is conscious and cooperative (Mallampati score,
neck extension, thyromental distance, interincisor distance, presence or absence of
teeth or fixed dentures). In addition, there are specific scores such as neck circumfer-
ence and waist-to-hip ratio (WHR). Neck circumference should be measured (raising
an alert above 41 and 43 cm in female and male patients, respectively) or indirectly
assessed (shirt collar size), whereas patients with android (apple-shaped) or gynoid
(pear-shaped) obesity can be easily identified. Whenever possible, a STOP-Bang
questionnaire is recommended: a score ≥5 is highly suggestive of severe OSA,
resulting in a higher risk of difficult ventilation and intubation. Especially in such
cases (obese patient with metabolic syndrome, high OSA risk, android obesity,
increased neck circumference), preparing an adequate airway management strategy
(including spontaneous breathing techniques) is of paramount importance. Adequate
preoxygenation aiming for an EtO2 >90% with the patient in the ramped position is
always imperative; depending on the clinical setting and the time available, positive-
pressure ventilation by face mask or a high-flow nasal cannula can be used, taking
into account that positive pressure oxygenation is the gold standard in obese patients.
Apneic oxygenation during airway instrumentation (the so-called NO-DESAT tech-
nique) [2, 3], preferably with a high-flow nasal cannula, should be considered.
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expect nearly every one in the village will be there. Shall you feel nervous?"
"I am afraid so, Rosie. I only hope I shall not break down."
"Oh, I don't fancy you'll do that. I envy you your voice, Mavis—at least, I don't envy it
exactly, but I wish I had a talent of some sort. I'm so very stupid; I can't do anything to
give people pleasure."
"Oh, Rosie, I am sure that is not true. Miss Matthews said the other day that you were the
kindest girl in the school. I told Aunt Lizzie that; she was pleased, though she didn't say
much. How can you be stupid, when you always manage to find out how to make people
happier by doing little things to please them?"
"Oh, that's nothing," exclaimed Rose. The colour on her cheeks had deepened as she had
listened to her cousin's words. "It would make me very unhappy to be unkind to any one,"
she added.
"I am certain it would."
"But I wish I had just one talent," Rose sighed. "If God had given me only one, I would
have been content."
Mavis looked troubled for a minute; then her face brightened as she responded hopefully—
"I think you're sure to have one, Rosie, only you haven't found it out."
CHAPTER IX
CHRISTMAS TIME
"THERE, now I have all my presents ready," Mavis declared in a satisfied tone, one
morning a few days before Christmas, as she dropped great splashes of red sealing-wax on
the small parcel she had already secured firmly with cord. "I do hope Miss Tompkins will
like the handkerchief sachet I'm sending her."
"I should think she will be sure to like it," said Rose, who was standing looking out of the
parlour window at the birds she had been feeding with bread-crumbs. "I wonder when Miss
Dawson's Christmas-box will arrive, Mavis."
"Soon, I expect. I should not be surprised if it came at any time now, for it's getting very
near Christmas, isn't it?"
The little girls' holidays had commenced two days before, and since then, they had been
very busy preparing for Christmas. Mr. Grey had kindly driven them into Oxford, one
afternoon, to make their various purchases, and but a shilling or so remained of Mavis'
pound, the rest having been spent in presents which were hidden in the bottom of her
trunk in her bedroom, to be kept secret from every one but Rose, until Christmas Day. For
kind Miss Tompkins she had bought a pink silk handkerchief sachet with birds painted on it,
and this, with a carefully-written note, she had packed in readiness to send off that
evening.
"I wonder what mother is doing in the kitchen," remarked Rose, presently. "She said at
breakfast she would have a leisureable day, as the puddings are boiled and the mincemeat
is made, and we're to have a cold dinner. But I've heard her bustling about as though she's
very busy. Let us go and see what she's doing."
Accordingly, the little girls repaired to the kitchen, where they found Mrs. John in the midst
of packing a hamper with Christmas cheer.
"I dare say I'm very foolish to do this," she was remarking to Jane, who was watching her
with a half-smile on her countenance, "but it's your master's wish, and I won't go against
him in the matter. There'll be ten shillings' worth in this hamper, if a penny, what with that
nice plump chicken, the pudding, a jar of mincemeat, a pound of tea, a pound of butter,
and—well children?" she said inquiringly, as the little girls came forward.
"Who is that hamper for, mother?" asked Rose, her curiosity alive in a moment.
"For Richard Butt's wife," was the brief answer.
"Oh, how kind of you, Aunt Lizzie!" cried Mavis. "How pleased she will be, won't she?"
"It's to be hoped so, and I dare say she will. But the kindness is not mine, child, it's your
uncle's. 'Fill in the corners of the hamper, Lizzie,' he said, and you see I'm doing it."
"I should like to be looking on when that hamper's opened," observed Jane, as her
mistress placed down the cover and began to cord it. "It'll arrive as a blessing, I reckon.
Butt was talking to me about his wife and child yesterday, and—"
"His child, Jane? I didn't know he had one," broke in Mrs. John, greatly astonished.
"The baby's only a fortnight old, ma'am. I didn't know there was one myself till yesterday."
"Is it a girl or a boy?"
"A boy, a fine healthy little chap, so Butt's mother-in-law has written to tell him."
"How he must wish to see the baby!" exclaimed Mrs. John, with a softening countenance.
"He's hoping to, before long, ma'am, for there'll be a cottage vacant in the village at
Christmas, and he means to take it. Then, as soon as he possibly can, he's going to ask
master to allow him a couple of days' holiday to fetch his wife and baby."
"He appears to have taken you into his confidence, Jane."
Jane nodded. The hamper was corded by this time, and all that remained to be done was
to address a label.
Mrs. John glanced out of the window, then turned to Rose.
"There's Butt in the yard now; he's going into Oxford with the waggon presently, so he can
send off the hamper himself from the station. Tell him I want him."
Rose went to do her mother's bidding, and a few minutes later returned, followed by
Richard Butt, who had greatly improved in appearance since the afternoon he had begged
from Mavis, and she had impulsively sent him around to the back door. Then he had looked
ragged, cold, and dispirited; now he was comfortably clad, and held his head erect once
more.
"What is your wife's address, Butt?" inquired Mrs. John.
"My wife's address, ma'am!" the man exclaimed, in amazement.
"Yes. This hamper is to go to her; it contains a chicken, and a pudding, and a few other
things, and you're to send it off from Oxford. Here's the money to pay the carriage. Tell me
the address."
He did so, and Mrs. John wrote it on the label, which she proceeded to affix to the hamper.
"Ma'am, I can never thank you properly," the young man stammered, quite overcome with
gratitude and surprise. He looked at the shilling Mrs. John had given him, then at the
hamper. "God bless you for your goodness!" he added fervently.
"It's your master's doing. It's nothing to do with me. There, take the hamper away with
you. By-the-by, I hear you've a little son, Butt; I hope his father will be a good example to
him."
The tone in which this was said was more cordial than the words, and Butt carried off the
hamper with a radiant countenance.
"I think I never saw any one look more pleased," observed Jane. "Who comes now?" she
exclaimed, as there was a loud knock at the back door.
She went to see, and reappeared bearing a large wooden box which she deposited on the
kitchen table, saying—
"It's come by the railway van, and it's directed to you, Miss Mavis. There's nothing to pay,
but you must please sign this book, to show it's been delivered safely."
"Oh, it's Miss Dawson's Christmas-box, for certain!" cried Rose.
Whilst Mavis, feeling very important and excited, signed the delivery book under Jane's
directions.
"Oh, Mavis, open it quickly and see what's inside! Here's a knife to cut the cord."
"Not too fast, Rose," said her mother. "Better untie the knots, then the cord will come to
use again—it's a good strong piece. Here, let me help," and she effected the task herself.
"There, Mavis, now you can set to work and unpack."
Mavis lifted the lid of the box, her hands trembling with excitement, and drew out several
packages, which, upon examination, proved to contain preserved fruits and sweetmeats in
pretty boxes, such as she had often seen in the shops at Christmas-time, but had never
dreamed of possessing. Then came a beautifully bound and illustrated story-book, and
several new games, at the sight of which Rose expressed much gratification, and, last of
all, a cardboard box, which, upon being opened, revealed to sight a seal-skin cap and a
muff to match.
"Oh!" exclaimed Mavis, quite incapable of finding words in which to express her delight.
"Put on the cap, Miss Mavis," said Jane. "Let us see how you look in it."
So Mavis placed the cap on her curly head, and glanced from one to the other with the
happiest of smiles on her pretty, flushed countenance.
"Yes, it suits you capitally," declared Jane. "Doesn't it, ma'am?" she questioned, turning to
her mistress.
"Yes, indeed," agreed Mrs. John. "I think, Mavis, that you are a very fortunate little girl,"
she proceeded, as she took up and examined the muff. "It is real seal-skin, I see, and
must have cost a pretty penny."
"There's Bob!" cried Rose, catching the sound of her brother's footsteps in the passage.
"Come and see Mavis' Christmas-box," she said, as he opened the door and entered the
kitchen. "Look at her seal-skin cap and muff, and all the rest of the presents she has had
sent her."
"What will you do with them all, Mavis?" asked Bob, as he came to the table and stood
with his hands behind his back, not liking to touch anything.
"We'll share all the sweeties, Bob," said Mavis; "of course we shall do that. I only want one
box of preserved fruit for myself, to give to Mrs. Long, and the rest I should like Aunt Lizzie
to put with the nice things she has bought for Christmas."
"Very well," Mrs. John agreed, pleased at the suggestion, "I will do so. You shall have some
of the fruit on Christmas Day and the rest later on, or we shall be having all the good
things at once. By the way, what makes you wish to give a present to Mrs. Long, Mavis?"
Mrs. Long was the stout, rosy-cheeked washerwoman Mavis had first seen on the day she
had said good-bye to her mother. On subsequent occasions, the little girl had held
conversations with her, but Mrs. John did not know that.
"She has been very kind to me, Aunt Lizzie," Mavis answered.
"Oh, I don't mean that she's done anything for me, you know," she continued, as she met
her aunt's glance of surprise, "but she's spoken to me so nicely about mother that I quite
love her. She says she knows what it is to be separated from some one, one loves very
dearly, for her only daughter married and went to New Zealand, and her husband's dead,
so that now she's all alone. I should like to give her a little present for Christmas, if you do
not mind."
"Of course I do not mind, child. All these things are your own, to do as you like with."
"I want other people to enjoy them too," Mavis said earnestly. "I never had anything to
give away before this Christmas."
She selected one of the prettiest of the boxes of preserved fruits, and, later in the day, she
and her cousins called at Mrs. Long's cottage in the village and presented it to the kind-
hearted washerwoman, who, needless to say, was exceedingly pleased.
What a happy Christmas that was, and yet how Mavis had dreaded it! It brought her
nothing but joy from the moment she opened her eyes on Christmas morning till, wearied
out, she closed them at night.
Afterwards, she wrote to her mother all about it, and told her how rich she was in
presents, for, besides Miss Dawson's Christmas-box, she had received remembrances from
every member of the household at the Mill House, and from Miss Tompkins too, as well as
Christmas cards from several of her schoolfellows.
"I have so many friends now," she wrote, "and last Christmas I had so few. When we meet
I shall have such a lot to tell you, dear mother. I can't write everything. I believe Aunt
Lizzie has written and told you that I am to sing at a concert on New Year's Eve; I am to
sing your favourite psalm. Mr. Moseley says my voice is a great gift. He is a very nice man,
and has been very kind to me—I think there are a great many kind people in the world."
Mavis had never so much as hinted to her mother that she was not on such cordial terms
with her aunt as with her other relations, for she could not explain why that was the case,
and, lately, she had got on with her rather better. Mrs. John had been obliged to admit to
herself that Mavis was not selfish, that she did not try to put herself before her cousins in
any way, and that she was quick to show gratitude for a kindness, and to respond to
affection. But what she did not understand in the child, was her capability of laying aside
trouble.
"She has just the nature of a song-bird," she would think, when Mavis' voice, lilting some
simple ditty, would fall upon her ears. "She's such a light-hearted little thing."
The concert, which was held in the village schoolroom on New Year's Eve, proved a very
great success. The performers were all well-known inhabitants of the parish, in whom the
audience—composed mostly of the labouring classes—took great interest.
Mavis' part of the programme did not come till nearly the conclusion of the concert, and
when the Vicar took her by the hand and led her on the platform, she felt it would be quite
impossible for her to keep her promise, and she was inclined to run away and hide. But, a
moment later, she had overcome the impulse which had prompted her to go from her
word, and looking above the many faces which were smiling up at her encouragingly, she
summoned up her courage and commenced to sing. Her voice was rather tremulous at
first, but it gained strength as it proceeded. She forgot the people watching her, forgot her
fear of breaking down, and thought only of what she was singing, of "pastures green" and
the Good Shepherd leading His flock by streams "which run most pleasantly." As her
sweet, clear voice ceased, there was a murmur of gratification from the audience, which
swelled into rounds of applause.
"Sing us something else, do, missie!" she heard some one shout from the back of the
schoolroom, and, looking in the direction from whence the voice came, she recognized
Richard Butt.
The rest took up the cry, and from all sides came the demand, "Sing us something else!"
"What else do you know, Mavis?" the Vicar hastened to inquire, when he saw she was
willing to comply with the general request.
"I know some carols," she replied. "Shall I sing one of those?"
"Yes, do," he said, as he moved away.
She was not feeling in the least nervous now. Her heart throbbed with happiness, as she
realized her capability of giving pleasure, and a brilliant colour glowed in her cheeks, whilst
her hazel eyes shone brightly.
The carol she sang was one she had heard in the little mission church in London during the
previous Christmas season, but it was new to her audience.
"'When shepherds were abiding,

In Beth'lem's lonely field,
They heard the joyful tidings
By the heavenly host revealed.
At first they were affrighted,
But they soon forgot their fear,
While the angel sang of Christmas,
And proclaimed a bright new year.'"
That was the first verse; several others followed, concluding thus—
"'When he who came to Bethlehem

Returns to earth again,
Ten thousand thousand angels
Shall follow in His train:
Then saints shall sing in triumph,
Till heaven and earth shall hear;
The year of His redeemed shall come,
A bright immortal year.'"
The carol was as successful in pleasing as had been the psalm, and Mavis stepped from the
platform and returned to her seat with the Mill House party, hearing commendatory
remarks on all sides.
"Oh, Mavis," whispered Rose, "you sang beautifully, you did indeed!"
And she expressed the opinion of the whole room, including Mrs. John, who, for the first
time, acknowledged that really Mavis owned a very sympathetic voice, and that the words
she had sung had seemed to have come from her heart.
CHAPTER X
SICKNESS AT THE MILL HOUSE
"OH, Mavis! Oh, Bob! Mother's very ill! Oh, isn't it dreadful? The doctor's going to send a
hospital nurse to take care of her, for he says she'll be ill for weeks, if—if she recovers!"
And Rose finished her sentence with a burst of tears.
The scene was the parlour at the Mill House one afternoon during the first week of the new
year. Rose had crept quietly into the room with a scared look on her face, having
overheard a conversation between her father and the village doctor, the latter of whom
had been called in to prescribe for Mrs. John, who had been ailing since the night of the
concert, when she had taken a chill.
No one had thought her seriously ill until that morning, when she had declared herself too
unwell to rise, and had been unable to touch the breakfast which her little daughter had
carried upstairs to her. Then it was that her husband had become alarmed, and the doctor
had been sent for. The medical man's face had worn a grave expression as he had left the
sick-room, and he had immediately informed Mr. Grey that his wife was seriously ill with
pneumonia, the result of a neglected cold.
"If she recovers?" echoed Bob, questioningly. "What do you mean, Rose? It's only a cold
that mother has, isn't it?"
"No, it's something much worse than that—pneumonia. Mrs. Long's husband died from
pneumonia." And poor Rose's tears and sobs increased at the remembrance.
"Oh, don't cry so dreadfully, Rosie," implored Mavis. "People often recover from
pneumonia, indeed they do! Mother has nursed several pneumonia patients since I can
remember, and not one of them died. You mustn't think Aunt Lizzie won't recover."
"But she's very ill—the doctor said so," returned Rose, nevertheless checking her sobs, and
regarding Mavis with an expression of dawning hope in her blue eyes. "He said she would
require most careful nursing, and he couldn't tell how it would go with her."
"Doctors never can tell," said Mavis, sagely. "Mother says they can only do their best, and
leave the result to God. Poor Aunt Lizzie! How sorry I am she should be so ill!"
"The doctor says we are not to go into her room again," sighed Rose. "I heard him say to
father, 'Don't let the children into her room to worry her; she must be kept very quiet.'"
"As though we would worry her!" cried Bob, in much indignation. He felt inclined to follow
his sister's example and burst into tears. But he manfully, though with much difficulty,
retained his composure.
Before night, a trained nurse from a nursing institution at Oxford was installed at the Mill
House, and took possession of the sick-room. And during the anxious days which followed,
the miller's wife approached very near the valley of the shadow of death, so that those
who loved her went in fear and trembling, and stole about the house with noiseless
footsteps and hushed voices.
But at length, a day arrived when the patient was pronounced to have taken a turn for the
better. And after that, she continued to progress favourably until, one never-to-be-
forgotten morning, the doctor pronounced her life out of danger.
"We shall be allowed to see her soon now, father, shan't we?" Rose inquired eagerly, after
she had heard the good news from her father's lips.
"I hope so, my dear," he answered. "It will not be long before she will be asking for you, if
I'm not mistaken. But she's been too ill to notice anything or any one. You won't forget to
thank God for His goodness in sparing your mother's precious life, will you, Rosie?"
"No, indeed, father," she responded, earnestly. "We prayed—Bob, and Mavis, and I—that
God would make dear mother well again, and you see He is going to do it. I felt so—so
helpless and despairing, and there was only God who could do anything, and so—and so—"
"And so you were driven to Him for help and consolation? Ah, that's the way with many
folks! They forget Him when things go smooth, but they're glad to turn to Him when their
path in life is rough. But His love never fails. You found Him a true Friend, eh, my Rose?"
"Yes, father, I did. Mavis said I should; she said I must remember that Jesus Himself said,
'Let not your heart be troubled, neither let it be afraid,' and that I must trust in Him. And I
tried not to be afraid. I couldn't do anything but pray; and after a while I began to feel that
God really did hear my prayers, and I don't believe He'll ever seem quite so far off again."
Mr. Grey had guessed rightly in thinking his wife would soon desire to see her children, for
the day following the one on which the doctor had pronounced her life out of danger, she
asked for them, and they were allowed into the sick-room long enough for each to kiss her
and be assured, in a weak whisper from her own lips, that she was really better.
The next day, they saw her again for a longer time, but she did not inquire for Mavis, a
fact which hurt the little girl, though she did not say so, and strengthened her previous
impression that her aunt did not like her.
Before very long, Rose was allowed in and out of the sick-room as she pleased, and was
several times left in charge of the invalid. She proved herself to be so helpful and reliable
that, on one occasion, the nurse complimented her upon those points, and she
subsequently sought her cousin in unusually high spirits.
"Mavis, what do you think?" she cried, in great excitement. "Nurse says she is sure I have
a real talent for nursing! Fancy that! But for mother's illness, I should never have found it
out, should I? Oh, I'm so glad to know that I really have a talent for something, after all!"
Meanwhile, Mrs. John was gaining strength daily. Although she had not expressed a wish
to see Mavis, she thought of her a good deal, and she missed the sound of her voice about
the house.
"Where is Mavis?" she asked Rose, at length. Then, on being informed that the little girl
was downstairs in the parlour, she inquired, "How is it I never hear her singing now?"
"Oh, mother, she would not sing now you are ill," Rose replied.
"She would not disturb me—I think I should like to hear her. It must be a privation to her
not to sing."
"I don't think she has felt much like singing lately. We've all been so troubled about you—
Mavis too. Oh, I don't know how I could have borne it whilst you were so dreadfully ill, if it
had not been for Mavis!"
"What do you mean, Rose?"
"She kept up my heart about you, mother. And she's been so good to us all—helping Jane
with the housework, lending Bob her games and keeping him amused, and doing
everything she could to cheer us up. Wouldn't you like to see her?"
"Yes," assented Mrs. John, "to-morrow, perhaps."
So the following day found Mavis by her aunt's bedside, looking with sympathetic eyes at
the wan face on the pillow.
"I'm so glad you're so much better, Aunt Lizzie," she whispered softly. "You'll soon get
strong now."
"I hope so, Mavis. My illness has spoiled your holidays, I fear. You must have had a very
dull time."
"A very sad, anxious time," Mavis said gravely; "but never mind—that's past."
"And you will soon forget it," her aunt remarked, with a faint smile.
"Oh no, Aunt Lizzie, I'm not likely to do that! But I'd so much rather look forward to your
being well again. We were all so wretched when you were so terribly ill, and now God has
made us happy and glad. Why, I feel I could sing for joy!"
"I think you rarely find difficulty in doing that, Mavis; you are so light-hearted."
"Not always, Aunt Lizzie; but I do try to be."
"Why?" Mrs. John inquired, in surprise.
"Because Jesus said, 'Let not your heart be troubled, neither let it be afraid,'" Mavis
answered, seriously. "I try not to be troubled or afraid," she continued; "but it's very, very
hard not to be sometimes. I found that when mother went away; nothing seemed to
matter much when we were together, but after she'd gone—oh, then it was different. I felt
my heart would break, it ached so badly, but—are you sure I am not tiring you, Aunt
Lizzie?"
"No; I like to hear you talk. Go on—tell me all you felt when your mother went away."
Mavis complied. She would have opened her heart to her aunt before, if she had ever had
the least encouragement to make her her confidante. By-and-by, she became aware that
there were tears in the sunken eyes which were watching the varying expressions of her
countenance, and she ceased speaking abruptly.
"You must have been very lonely and sad, child," Mrs. John said. "I never realized you felt
the parting from your mother so much. I wish I had known; but I thought—"
She paused, and did not explain what she had thought. She was beginning to understand
that she had misjudged Mavis, and the knowledge that she had done so humiliated her,
whilst she was conscious that she had allowed her jealous heart to prejudice her against
the child. "I might have been kinder to you, my dear," she admitted, with a sigh.
"Oh, Aunt Lizzie, you have always been kind to me," Mavis said gratefully, unaware that
Mrs. John's conscience was reminding her not so much of actions as of thoughts.
"I don't know what I have said to make you cry," she added, as a tear ran down her aunt's
pale cheek. She wiped the tear away with her handkerchief as she spoke, and kissed the
invalid. She had never felt greatly drawn towards her before, always having been a little in
awe of her, but at that moment the barrier of misunderstanding which had stood between
them was swept aside.
"I have not heard you singing lately," Mrs. John remarked, by-and-by. "Rose tells me you
have been fearful of disturbing me. You need not be now, for I believe it will cheer me
greatly to hear you singing again. Our song-bird has been silent long enough."
Mavis smiled, and kissed her once more, and shortly after that, the nurse, who had been
absent, returned, and confidential conversation was at an end.
The young people had been back to school for several weeks before the mistress of the Mill
House was about again, and it was some time before she was well enough to undertake
her accustomed duties. But with the lengthening days, she gained strength more rapidly,
and the doctor said she needed only the spring sunshine to make her well.
In the meanwhile, Mavis continued to receive cheering news from her mother, who wrote
every mail. Miss Dawson was much better, and there was now every reason to hope that
she would return to England completely restored to health. But when that would be, Mrs.
Grey had not yet said, though in one letter she had remarked that perhaps it would be
sooner than Mavis expected. The little girl's heart had thrilled with happiness when she
had read that.
Almost the first news Mrs. John was told when she was about again after her illness, was
that Richard Butt, who had taken a cottage in the village, had been allowed a few days'
holiday, and the loan of a waggon, on which he had conveyed his household furniture and
his wife and baby from Woodstock to their new home.
"They're comfortably settled in now, ma'am," said Jane, who had explained all this to her
mistress. "I've been to see them. Mrs. Butt seems a nice, well-mannered young woman,
and the child's as fine a baby as you ever saw in your life."
"Yes," joined in Rose. "And father's very pleased with Butt, because he's so careful of the
horses, and he hasn't had the least cause of complaint against him yet. Aren't you glad to
know that, mother?"
"Butt thinks a great deal of father," Bob said, eagerly, "and no wonder! He told me he was
almost despairing when father gave him work. He said father was one of the few people
who wouldn't hit a man when he's down. I know what he means, don't you, mother?"
"Yes," was the brief assent.
"So do I," said Mavis. "I think the Good Samaritan in the parable must have been very like
Uncle John."
There was one piece of news which Rose had refrained from mentioning to her mother as
yet, and that was that she and Mavis were now in the same class at school. She dreaded
telling her this, and it was a decided relief when she learnt that it was not necessary for
her to do so, as Mavis had forestalled her.
Mavis had also told her aunt, how greatly Rose was troubled on account of her slowness in
learning, and how really painstaking she was, and this, coupled with Miss Matthews' report
that Rose was patient and industrious and always desirous of doing her best, caused Mrs.
John to reflect that she had been a little hard on her daughter.
"Although she's not quick like her cousin, she has many good qualities," she thought to
herself. "God does not endow us all with gifts alike, and I have been unwise to make
comparisons between the children."
So she spoke kindly and encouragingly upon the matter to Rose, who exclaimed, with a
ring of glad surprise in her voice—
"Oh, mother, I so feared you would be angry with me for allowing Mavis to catch up to me
in her lessons! Indeed, indeed, I have done my best. I know I'm slow and stupid in many
ways; but God has given me one talent, and, now I know that, I don't mind. Nurse said I
had a real talent for nursing, so I mean to be a nurse when I grow up. Mavis will be a
great singer, I expect, but I shall be quite content to be a nurse."
Mrs. John made no response, but she pressed a warm kiss on Rose's lips, and her little
daughter saw she was pleased, and added ingenuously—
"I asked God to make you understand I'd done my best, and He has."
CHAPTER XI
HAPPY DAYS
IT was a beautiful afternoon in May. The lilac and laburnum trees were in full bloom in the
Mill House garden. And fritillaries—snakes' heads, as some people call them—were plentiful
in the meadows surrounding W—, lifting their purple and white speckled heads above the
buttercups and daisies in the fresh-springing green grass.
"I think they are such funny flowers," said Mavis, who with Rose, had been for a walk by
the towpath towards Oxford, along which they were now returning. She looked at the big
bunch of fritillaries she had gathered, as she spoke. "And though they are really like
snakes' heads, I call them very pretty," she added.
"Yes," agreed Rose. "Look, Mavis, there's Mr. Moseley in front of us. He's been sending Max
into the water. I expect we shall catch up to him."
"And then I shall be able to tell him my news!" Mavis cried delightedly. "Oh, Rosie, I don't
think I was ever so happy in my life before as I am to-day!"
A few minutes later, the two little girls had overtaken the Vicar. And, after they had
exchanged greetings with him, Mavis told him her news, which she had only heard that
morning, that her mother and Miss Dawson were returning to England, and were expected
to arrive before midsummer.
"No wonder you look so radiant," he said, kindly.
Then, as Rose ran on ahead with Max, who was inciting her to throw something for him to
fetch out of the river, he continued: "I remember so well the day I made your
acquaintance, my dear. You were in sore trouble, and you told me you did not think you
could be happy anywhere without your mother. Do you recollect that?"
"Oh yes," Mavis replied. "And you said if there were no partings there would be no happy
meetings, and that we must trust those we love to our Father in heaven. And you asked
me my name, and, when I had told it, you said I ought to be as happy as a bird. I felt
much better after that talk with you, and I have been very happy at the Mill House—much
happier lately, too. I don't know how it is, but Aunt Lizzie and I get on much better now."
"You have grown to understand each other?" suggested the Vicar.
"Yes—since her illness," Mavis replied.
The Vicar was silent. He had visited Mrs. John during her sickness, and knew how very
near she had been to death's door. And he thought very likely her experience of weakness
and dependence upon others had softened her, and taught her much which she had failed
to learn during her years of health and strength.
"Mother says Miss Dawson is quite well now," Mavis proceeded. "I am looking forward to
meeting her again; I do wonder when that will be!"
She glanced at her companion as she spoke, and saw he was looking grave and, she
thought, a little sad.
"Is anything amiss, Mr. Moseley?" she asked, impulsively.
"No, my dear," he replied. "I was merely thinking of two delicate young girls who were
very dear to me. They died many years ago; but their lives might have been saved, if they
could have had a long sea voyage and a few months' sojourn in a warmer climate.
However, that was not to be."
"They did not go?"
"No. Their father was a poor man, with no rich friends to help him, and so—they died."
"Oh, how very sad!" exclaimed Mavis, with quick comprehension. "A trip to Australia and
back costs a lot of money, I know. Oh, Mr. Moseley, how dreadful to see any one die for
want of money, when some people have so much! How hard it must be! Didn't their poor
father almost break his heart with grief? I should think he never could have been happy
again."
"You are wrong, my dear. He is an old man now, with few earthly ties, but he is happy.
Wife and children are gone, but he knows they are safe with God, and he looks forward to
meeting them again when his life's work is over."
He changed the conversation then. But Mavis knew he had been speaking of himself, and
that the young girls he had mentioned had been his own children, and her heart was too
full of sympathy for words. Silently, she walked along by his side, till they overtook Rose.
When Max created a diversion by coming close to her and shaking the water from his
shaggy coat, thus treating her to an unexpected shower-bath.
"Oh, Max, you need not have done that!" cried Rose, laughing merrily, whilst the Vicar
admonished his favourite too.
But Max was far too excited to heed reproof. He kept Rose employed in flinging sticks and
stones for him to fetch, until the back entrance to the mill was reached, where the little
girls said good-bye to the Vicar, and the dog followed his master home.
The next few weeks dragged somewhat for Mavis. But she went about with a radiant light
in her eyes and joy in her heart. Would her mother come to her immediately on landing?
she wondered. Oh, she would come as soon as she possibly could, of that she was sure.
"I expect she wants me just as badly as I want her," she reflected, "for we have been
parted for nine months, and that's a long, long time—though, of course, it might have
been longer still."
So the May days slipped by, and it was mid-June when, one afternoon, on returning from
school, the little girls were met at the front door by Mrs. John, who looked at Mavis with
the kindest of smiles on her face.
"You have heard from mother!" cried Mavis, before her aunt had time to speak. "Has the
vessel arrived? Have you had a telegram or a letter?"
"Neither," Mrs. John answered; "but the vessel has arrived, and there's some one in the
parlour waiting for you, Mavis. Go to her, my dear."
Mavis needed no second bidding. She darted across the hall and rushed into the parlour,
where, the next moment, she found herself in her mother's arms, and clasped to her
mother's breast.
"Mother—mother, at last—at last!" was all she could say.
"Yes, at last, my darling," responded the dearly loved voice.
Then they kissed each other again and again, and Mavis saw that her mother was looking
remarkably well. And Mrs. Grey remarked that her little daughter had grown, and was the
plumper and rosier for her sojourn in the country. It was a long while before Mavis could
think of any one but themselves. But at last, she inquired for Miss Dawson, and heard that
her mother had left her in her own home in London that morning.
"I expect she's glad to be back again, isn't she, mother?" Mavis asked.
"Very glad, dear. You can imagine the joyful meeting between her and her father. I shall
never forget the thankfulness of his face when he saw how bright and well she was
looking. Poor man, I believe he had made up his mind that he would never see her again.
She does not require a nurse now, but I have promised to stay with her for a few months
longer, and during that time, Mavis, I want you to remain at the Mill House. Shall you
mind?"
"No," Mavis answered, truthfully. "But you are not going right back to London, mother, are
you?" she asked, looking somewhat dismayed.
"No, dear. I have arranged to stay a few days with you."

What a happy few days those were to Mavis! She was allowed a holiday from school, and
showed her mother her favourite walks, and spent a long afternoon with her in Oxford,
where they visited T— College and the haunts her father had loved. And oh how Mavis
talked! There seemed to be no end to all she had to tell about the household at the Mill
House, and the Vicar, and Richard Butt and his wife and baby, and kind Mrs. Long, to all of
which her mother listened with the greatest interest and attention.
"Why, how many friends you have made!" Mrs. Grey said, on one occasion when Mavis had
been mentioning some of her schoolfellows. "You will be sorry to have to say good-bye to
them; but I do not know when that will be, for I have not decided upon my future plans. I
hope we shall never be parted for such a long time again."
"Indeed I hope not," Mavis answered, fervently. "Shall we go back to live at Miss
Tompkins'?" she inquired.
"I don't know, dear," was the reply. "Perhaps we may—for a time."
Every one at the Mill House was very sorry when Mrs. Grey left and returned to town. Her
former visit had naturally been overshadowed by the prospect of separation from her little
daughter. But this had indeed been a visit of unalloyed happiness, with no cloud of
impending sorrow to mar its joy.
After her mother's departure, Mavis went back to school with a very contented heart, and
in another month came the summer holidays. Her feelings were very mixed when she
learnt that it had been arranged for her to stay at W— until the end of another term, for
Mr. Dawson had earnestly requested Mrs. Grey to remain with his daughter till Christmas,
and she had consented to do so. And she expressed her sentiments to her aunt in the
following words—
"I'm glad, and I'm sorry, Aunt Lizzie. Glad, because I can't bear the thought of saying
good-bye to you all, and sorry, because I do want mother so much sometimes. Still,
London's quite near; it isn't as though mother was at the other end of the world, and time
passes so quickly. Christmas will soon be here."
* * * * *
"I feel as though I must be dreaming," said Mavis, "but I suppose it's really, really true. I
can hardly believe it."
It was Christmas Eve, and a few days before the little girl had been brought up to town by
her uncle, who had delivered her to her mother's care. To her surprise, however, she had
not been taken to Miss Tompkins' dingy lodging-house, but to Mr. Dawson's house in
Camden Square, where she had received a hearty welcome from Mr. Dawson and his
daughter.
She was with her mother and Miss Dawson now, in the pretty sitting-room where, fifteen
months previously, she had made the latter's acquaintance. But there was nothing of the
invalid about Miss Dawson to-day; she looked in good health and spirits, and laughed
heartily at the sight of Mavis' bewildered countenance.
"What is it you can hardly believe, eh?" asked Mr. Dawson, as he entered the room.
"I have been telling her that you mean to build and endow a convalescent home in the
country for girls, as a thanks-offering to God for my recovery, father," Miss Dawson said,
answering for Mavis, "and that her mother is to be the matron, and she can scarcely credit
it. Still, I think she approves of our plan."
"Oh yes, yes!" cried Mavis. "It's just what I should wish to do if I were you," she proceeded
frankly, looking at Mr. Dawson with approval in her glance, and then turning her soft hazel
eyes meaningly upon his daughter, "and you couldn't have a better matron than mother—"
"Mavis! My dear!" interrupted Mrs. Grey.
"It's quite true," declared Miss Dawson. Then she went on to explain to Mavis that the
home was to be within easy reach of London, and it was to be a home of rest for sick
working-girls, where they would have good nursing.
"I think it's a beautiful plan," said Mavis, earnestly. She realized that it meant permanent
work for her mother, too; and turning to her she inquired, "Shall I be able to live with you,
mother?"
"Yes, dear, I hope so," Mrs. Grey answered, with a reassuring smile.
"Oh yes, of course," said Miss Dawson.
And the little girl's heart beat with joy.
She remained silent for a while after that, listening to the conversation of her elders, and
meditating on what wonderful news this would be for them all at the Mill House. Then her
mind travelled to Mr. Moseley, and her face grew grave, as she thought of those two
delicate girls so dear to him, who had faded and died. But it brightened, as she reflected
how nice it must be to be rich, like Mr. Dawson, to be able to help those not so well off as
himself.
She was aroused from her reverie by Miss Dawson, who asked her to sing a carol to them,
and she willingly complied, singing the same she had sung at the village concert at W—
nearly a year before. Afterwards, she gave them an account of the concert, and expressed
the hope that she would be a great singer some day.
"Why, Mavis, I never knew such an idea had entered your head!" exclaimed her mother,
greatly surprised.
"It never did, mother, until Mr. Moseley told me I had a great gift, and that God expected
me to use it for the benefit of others," the little girl replied, seriously.
"Surely he was right!" said Miss Dawson.
And with that Mrs. Grey agreed.
Later in the evening, when Mavis went to the window and peeped out to see what the
weather was like, she felt an arm steal around her shoulders, and Miss Dawson asked—
"What of the night? Are we going to have a fine Christmas?"
"I believe we are," Mavis answered. "The sky is clear and the stars are very bright. Look!"
Miss Dawson did so, pressing her face close to the window-pane. Then she suddenly kissed
Mavis, and whispered—
"God bless you, dear, for all you've done for me. I carried the remembrance of your sweet
voice singing, 'The Lord is only my support,' to Australia and back again, and it cheered
and strengthened me more than you will ever know. I wish you a happy Christmas, little
song-bird, and many, many more in the years to come."
THE END
PRINTED BY
WILLIAM CLOWES AND SONS, LIMITED,
LONDON AND BECCLES.

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Emergency Surgery in Obese Patients

Bariatric surgery patients: a nutritional guide 1st

Core Topics in General & Emergency Surgery: A Companion

Emergency General Surgery, An Issue of Surgical

Gun Control Policies in Latin America Diego Sanjurjo

Diagnostic Imaging in Polytrauma Patients 1st Edition

Oral and Maxillofacial Surgery (Oxford Specialist

Anesthesia in High-Risk Patients 1st Edition Jean-Luc

Hazard Mitigation in Emergency Management 1st Edition

More information about this series at http://www.springer.com/series/8147

ISSN 2280-9848 ISSN 2281-0854 (electronic)

© Springer Nature Switzerland AG 2020

Revision and editing: R. M. Martorelli, Scienzaperta (Novate Milanese, Italy)

The incidence and prevalence of obesity have increased worldwide; in particular,

Milan, Italy Diego Foschi

Part I Anesthesia and Resuscitation in Obese Patients

Part II Clinical Settings in Obese Patients

10 Bowel Obstruction in Obese Patients ������������������������������������������������������ 73

Part III Clinical Settings After Bariatric Surgery

24 Emergencies After Bariatric Surgery: The Role of Flexible

Luca Busetto Department of Medicine, University of Padua, and Clinica Medica 3,

Paolo Dionigi Division of General Surgery 1, Department of Surgery, Policlinico

Gennaro Nappo Pancreatic Surgery Unit, Humanitas Research Hospital, Rozzano,

Andrea Rizzi Unit of General Surgery, Hospital of Tradate, Varese, Italy

Alessandro Zerbi Pancreatic Surgery Unit, Humanitas Research Hospital,

Diego Foschi, Marcello Lucchese, Giuliano Sarro,

Obesity is a metabolic disease characterized by abnormal or excessive adipose tis-

• class I: BMI 30–34.9

© Springer Nature Switzerland AG 2020 3

1.2 The Obesity Paradox

1.3 The Obesity Paradox Revised

cytokines, which mediate inflammatory cell activation causing endothelial cell

Obesity leads to an increase in body mass by augmenting adipose tissue and

Table 1.1 Comorbidities of Blood hypertension

1.4 Risk Prediction in Emergency Surgery of Obese Patients

2.1  athophysiological Peculiarities of Anesthesiological

Obesity is considered an important risk factor for cardiovascular disease, type 2

2.1.1 Respiratory Function

One of the causes of respiratory impairment in obese patients is elevation of the

2.1.2 Cardiovascular Function

2.1.3 Risk of Thromboembolism

2.1.4 Risk of Difficult Airway

"Oh, do come in and listen to all my news!"

"Of course I will," agreed her cousin. "How is Aunt Margaret?"

"I am certain it would."

"For Richard Butt's wife," was the brief answer.

"Is it a girl or a boy?"

"He appears to have taken you into his confidence, Jane."

Mrs. John glanced out of the window, then turned to Rose.

"What is your wife's address, Butt?" inquired Mrs. John.

"My wife's address, ma'am!" the man exclaimed, in amazement.

"Oh, it's Miss Dawson's Christmas-box, for certain!" cried Rose.

"Yes, do," he said, as he moved away.

"'When shepherds were abiding,

"'When he who came to Bethlehem

"What do you mean, Rose?"

"Yes," assented Mrs. John, "to-morrow, perhaps."

"Not always, Aunt Lizzie; but I do try to be."

Part I Anesthesia and Resuscitation in Obese Patients

Part II Clinical Settings in Obese Patients

10 Bowel Obstruction in Obese Patients �� 73

Part III Clinical Settings After Bariatric Surgery

24 Emergencies After Bariatric Surgery: The Role of Flexible

1.2 The Obesity Paradox

1.3 The Obesity Paradox Revised

1.4 Risk Prediction in Emergency Surgery of Obese Patients

2.1 athophysiological Peculiarities of Anesthesiological

2.1.1 Respiratory Function

2.1.2 Cardiovascular Function

2.1.3 Risk of Thromboembolism

2.1.4 Risk of Difficult Airway