Anesthesia for Bariatric Surgery:

Dr Dileep Kumar
Senior Instructor Aga Khan University Hospital, Karachi
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CASE:
A 25 year old girl is scheduled for bariatric surgery secondary to morbid obesity (her BMI is 49)

She is very scared of general anesthesia & very anxious about pain in postoperative period How would you evaluate & proceed with the case?
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Bariatric surgery & Anesthetic Concerns: Pre-operative Intra-operative Post-operative

Bariatric Surgery
Bariatric is the field of medicine that specializes in treating the obesity. Bariatric surgery is a surgical subspecialty that perform operations to treat morbid obesity. Most of the patho-physiology & medical conditions associated with extreme Obesity are reversible with sustained weight lose following Bariatric Surgery. Mortality rate for Bariatric surgery is 0.5% - 1%
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Indications for Bariatric Surgery

In 1991, The National Institutes of Health Consensus Development Conference Panel has outline the indication:

BMI >40 BMI >35 with high risk cardiorespiratory comorbidity:

(sleep apnea, OHS, cardiomyopathy), DM2.
Failed attempts at behavioral or medical rx Commitment to long-term follow-up (Vitamins & Nutritional supplements related Malabsorption)
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Type of Bariatric Surgeries

Jejunoileal bypass Biliopancreatic diversion (BPD) BPD with duodenal switch

MALABSORPTIVE

Vertical Banding

RESTRICTIVE

Laparoscopic Adjustable Gastric Banding Gastric pacing

COMBINATION
Roux-en-Y Gastric Bypass
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MALABSORPTIVE

JEJUNOILEAL BYPASS:
Jejunum is transected just beyond the ligament of Trietz
and very long blind loop remains as short portion of small bowel anastomosed just proximal to ileocecal valve High mortality rate (>50%) from fulminant liver failure; no longer is performed
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BILIOPANCREATIC DIVERSION:
Partial gastrectomy with remainder of stomach anastomosed to ileum Long Roux limb (bypassed portion) with short common channel (food + secretions) BPD W/ DUODENAL SWITCH: Similar to BPD, but gastrectomy preserves pylorus, creating gastric sleeve

MALABSORPTIVE

RESTRICTIVE

VERTICAL BANDING (VBG):

Stomach stapling
Small upper portion of stomach partitioned and stapled, reinforced with mesh.

RESTRICTIVE

ADJUSTABLE GASTRIC BANDING (ABG):

Prosthetic band (ring-shaped) placed around entrance to stomach Band connected via tubing to port placed in subQ tissue; tightness of band adjusted by injecting saline into the band thereby reducing its diameter

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RESTRICTIVE

Implanted gastric stimulator (gastric pacing)

Electrical impulses stimulate smooth muscles of the stomach to stop peristalsis so that the patient feels fullness. A lead with two electrodes implanted in the lesser curvature of the stomach is connected to an electrical pulse generator implanted subcutaneously on the abdominal wall

Problems with electrodes displacement, limiting this method. 11

COMBINED

ROUX-EN-Y GASTRIC BYPASS

RYGB is the gold standard of bariatric procedures, It is combination of gastric restriction with minimal degree of malabsorption: Small proximal gastric pouch divided and separated from rest of stomach; food passes through this pouch

Larger portion receives no food but secretion of gastric acid, pepsin, intrinsic factor
Short proximal (biliopancreatic) limb, Y-loop, transports secretions from pancreas, liver and gastric remnants Longer distal portion, Roux limb, anastomosed to small pouch and receives foods Y-loop and Roux limb connected distally to feed into jejunum; most of digestion done in this common channel
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Open Vs laproscopic bariatric

VBG, ABG and RYGB can be done under laproscopically if pt: weight is less than 180 Kg because of technical consideration & instrumentation technology limitation. Laproscopic technique has advantages: Less pain intensity & reduced pain med: requirement Improved pulmonary function Reduced hospital stay & early mobilization Improved cosmesis Less incidence of incisional hernia and wound infection

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Anesthesia & laproscopy

Pneumoperitoneum causes systemic changes during laparoscopy. IAP SVR

At an IAP <10 mm Hg, there is an increase in venous return, probably from a reduction in splanchnic sequestration of blood, with a subsequent increase in cardiac output and arterial pressure.

Compression of the inferior vena cava occurs at an IAP >20 mm Hg, with decreased venous return from the lower body and consequent decreased cardiac output. Increased renal vascular resistance at an IAP >20 mm Hg decreases renal blood flow and GFR . Femoral venous blood flow can be reduced by both pneumoperitoneum and Trendelenburg positioning, with an increased risk of lower-extremity thrombosis
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Anesthesia & laproscopy

Pneumoperitoneum causing reduction in vital capacity by Cephalad displacement of the diaphragm Placement of surgical packs Surgical retractors in the upper abdomen Hypercarbia and hypoxemia Cephalad displacement of the diaphragm and carina from pneumoperitoneum caused a firmly secured endotracheal tube to be displaced into a bronchial mainstem. Catastrophic complications that should be kept in mind include massive gas embolism, pneumothorax, and mediastinal emphysema.
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Pulmonary System
O2 consumption & CO2 production increased WOB increased Chest wall compliance & FRC are low.

Effects of obesity, positioning, and anesthesia on lung volumes. FRC, functional residual capacity; CC, closing capacity; CV, 16 closing volume; RV, residual volume.

The degree of cardiac abnormality is correlated with the degree of obesity. LV dysfunction is often present in young asymptomatic patient HTN Increased Pre-load & After-load Increased PAP (dyspnea, fatigue, syncope).

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Anesthetic Concerns/Goals

Preoperative

Intraoperative

Postoperative
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PRE-OPERATIVE

Glowing Gold Stars

Patient evaluation
Patient preparation

Theatre preparation
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Pre-operative
Evaluation
Comorbity

OSA & OHS

Previous anesthetic history

Airway assessment

Others
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Medical co-morbidities associated with obesity NIDDM HTN & IHD OSA Pulmonary HTN Liver & Gallbladder diseases Arthritis Depression, social incompetence, etc.

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Obstructive Sleep Apnea: Excessive daytime sleepiness, Inability to concentrate, Snoring and Awakening during sleep Obesity Hypoventilation Syndrome. Pickwickian syndrome: a) Hypercapnia b) Severe hypoxemia c) Periodic breathing d) Biventricular enlargement (RT>LT) e) Dependent edema. f) Polycythemia and Pulmonary edema.
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Airway abnormalities:
a) Limitation of extension and flexion of the C-spine. b) Restricted mouth opening from submental fat. c) Large tongue. d) Redundant intra oral tissue/ causing difficult VC e) Thyromental distance should be assessed.
The neck circumference is the single best predictor of problematic intubation.

The probability of a problematic intubation is approximately 5% with a 40-cm neck circumference, compared with a 35% probability at 60-cm neck circumference.
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Pre-operative
Preparation: Patient must undergo following tests prior to surgery:
Chest Xray ECG Pulmonary function tests and Room Air Blood Gas Blood tests Complete blood count Serum electrolytes, renal and liver function tests, calcium and phosphate levels, uric acid Glucose tolerance test (unless already known to be diabetic) Thyroid function tests PT, INR, APTT

Patient may require additional tests. including more elaborate testing for heart and lungs, testing for sleep apnea, or other blood tests
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Pre-operative
Preparation
Patient should be optimized according to comorbities: Council for awake intubation & invasive monitoring if needed:

DVT, Antibiotic and aspiration prophylaxis should be advised:

Midazolam is the drug of choice to relieve anxiety, (be careful for patient with difficult airway) Bipap / ICU bed (if patient has own Bipap)
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Theatre preparation
Difficult intubation trolley if required

Invasive monitoring devices if needed

Drugs preparation according to patient Operating room table (Routine table capability is 205 kg) Special table for obese, weight bearing capability is 455 Kg with extra width if available should be placed in OR. Two routine table can be joined if needed

Bean bags may be needed for morbid obese patient

Intubation pillow may require (if not available then bed sheets can be adjusted to make the proper position)
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Head-elevated laryngoscopy position (HELP)

Stacking maneuver

Glowing old Stars

Objective of this position is that the tip of the chin is keep at a higher level than the chest, to facilitate laryngoscopy and intubation.

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Intraoperative
Maintenance Positioning

Induction
Drugs Intubation Emergence

Monitoring

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Positioning Bariatric surgical patients are prone to slipping off the operating table during table position changes; although they are well strapped .

Glowing Gold Stars

The use of a bean bag is also recommended. Bean bags are soft pads available in various sizes and shapes that are filled with thousands of tiny plastic beads.

Pressure are should be secured to prevent peripheral nerve injuries (Brachial plexus, Sciatic nerve, Ulnar nerve)

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Bean Bags

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Monitoring

Routine: ECG, SpO2, Temp, NIBP (can be obtained from the wrist or ankle)
A-line highly recommended in super morbidly obese patient, Cardio respiratory disease and inappropriate NIBP cuff size. CVP line is indicated in patient with Cardio respiratory illness and difficult peripheral I/V access.

Nerve stimulator: to monitor the muscle relaxant effects

Urine output
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Induction Pharmacology:
Highly lipophilic drugs are significantly increased in volume of distribution (VD) for obese individuals relative to normal-weight individuals. Less-lipophilic compounds have little or no change in VD with obesity.

Muscle Relaxants
Higher doses of succinylcholine 1.5mg/kg are used. Neuromuscular recovery time is similar in obese & non-obese patient with CISATRACURIUM and Atracurium.

Complete muscular relaxation is crucial during laparoscopic bariatric surgery to facilitate the ventilation and to maintain adequate working space for visualization and for safe manipulation of laparoscopic instruments. 32

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Fat has poor blood flow, and doses calculated on actual body weight could lead to excessive plasma concentrations. Reasonable approach is to calculate the initial dose based on lean body weight and with subsequent doses determined by pharmacologic response to the initial dose. Cautious for repeated injections, may accumulate in fat, leading to a prolonged response because of subsequent release from this large depot.
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Tracheal Intubation
Increasing weight or BMI is not a risk factor for difficult laryngoscopy. FOB intubation is rarely necessary. Rapid sequence induction with Propofol &Succinylcholine and HELP is the best way for establishing an airway in obese. Since mask ventilation can be difficult a second person experienced with airway management should be present to assist. LMA should be available and can serve as a bridge until an ETT is placed.
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Maintenance

Ventilation
VT 10-12mL/KG with IW FiO2 up to 100% may be needed High PiP may be allowed PEEP = 5cm H2O or greater according to patient hemodynamics Isoflurane/ Sevoflurane +O2 +N20 Atracurium infusion or boluses Epidural/Morphine/Pethidine/Fentanyl infusion or at boluses

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Technical Issues
NG tube initially placed to decompress the stomach

Intragastric balloon will be asked to place to help the surgeon size the gastric pouch (15mls-30mls)

The leak tests will be required with saline or methylene blue through NG tube to see anastomotic leak Care should be taken to ensure a tight seal of the endotracheal tube cuff, otherwise aspiration of saline or methylene blue can occur.
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Technical Issues
All endogastric tubes should be completely removed before gastric division to avoid unplanned stapling and transection of these devices

After the gastric pouch is created, blind insertion of an NG tube should be avoided and inserted under direct laparoscopeically and carefully watching to avoiding the disruption of anastomosis.

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INTRAGASTRIC BALLOON

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Emergence Patient should be positioned by elevating the upper body at 30-45 degree. Neuromuscular blockade must be completely reversed before extubation. Extubated when follow commands & making adequate tidal ventilation.

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Postoperative
Incentive spirometry & Chest physiotherapy

Early mobilization+ continuation of DVT prophylaxis

Bipap if needed or patient is use to be on Bipap then should be available in recovery room
Retrospective chart review by Helling et al: showed that the increased ICU/ventilatory requirements was in:
--males, --BMI >60, --age >50 --underlying pulmonary comorbidity --complications requiring re-operation
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Postoperative pain Management Multimodal Analgesia

Epidural infusion

PCIA Morphine Pethidine Tamadol

Infusion

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Immediate post-op complications:

Medical:
Pulmonary embolism

Surgical:

(1%) Myocardial infarction Respiratory failure Pneumonia Urinary tract infection

Anastomotic leak (2-3%) Postop bleeding Bowel perforation Bowel obstruction Wound infections

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REFERENCES:
Mokdad AH, Serdula MK, Dietz WH, et al. The spread of the obesity epidemic in the United States 19911998. JAMA1999;282: 151922. Abstract/FREE Full Text Quetelet LAJ. A treatise on man and the development of his faculties: Edinburgh 1842, reprinted. Obes Res1994;2: 7285. Medline Wing RR, Koeske R, Epstein LH, et al. Long-term effects of modest weight loss in type II diabetic patients. Arch Intern Med1987;147: 174953. Abstract/FREE Full Text Stevens V, Corrigan S, Obarzanek E, et al. Weight loss intervention in phase I of the trials of hypertension prevention. Arch Intern Med1993;153: 849 58. Abstract/FREE Full Text Dattilo A, Kris-Etherton PM. Effects of weight reduction on blood lipids and lipoproteins: a meta-analysis. Am J Clin Nutr1992;56: 3208. Abstract/FREE Full Text Provost DA, Jones DB. Minimally invasive surgery for the treatment of severe obesity. Dallas Med J1999;87: 1103. Balsiger BM, Murr MM, Poggio JL, Sarr MG. Bariatric surgery: surgery for weight control in patients with morbid obesity. Med Clin North Am2000;84: 47789. CrossRefMedline Scott DJ, Provost DA, Jones DB. Laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Rounds2000;23: 17789. Wittgrove AC, Clark GW, Schubert KR. Laparoscopic gastric bypass, Roux-en-Y: technique and results in 75 patients with 330 months of follow-up. Obes Surg1996;6: 5004. CrossRefMedline Schirmer BD. Laparoscopic bariatric surgery. Surg Clin North Am2000;80: 125367. CrossRefMedline

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