Anesthetic Aspects of Bariatric Surgery–NEW COLUMN!

Column Editor: Stephanie B. Jones, MD
Dr. Jones is Vice Chair for Education, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts

This Month: An Update on Anesthesia

by Mike Margarson, FRCA, MD

Dr. Margarson is from St Richard’s Hospital, Chichester, United Kingdom.

A report from the XVI World Congress of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO 2011) August 31–September 3, 2011, Hamburg, Germany

This ongoing column is authored by members of the International Society for the Perioperative Care of the Obese Patient (ISPCOP), an organization dedicated to the bariatric patient.

Bariatric Times. 2011;8(10):10–11

The XVI World Congress of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO 2011) meeting in Hamburg, Germany, included, for the first time in its history, sessions on anesthesia and perioperative care. This column summarizes the topics and key points of these sessions.

IFSO 2011 covered many areas of interest to the perioperative physician, for example, information on which procedure is best suited to which patient was extremely useful as many of us perioperative physicians provide care in multidisciplinary preassessment clinics. Updates on behavioral issues and preoperative psychological evaluation were also useful.

A session on special conditions, including a series of presentations on outcomes of surgery in the patient population 60 years of age and older with obesity, was also very informative. Further useful information was gleaned from sessions discussing the impact of obesity surgery on chronic diseases, or, in some cases, the lack of impact. The message in these sessions was to beware of overestimating the benefits of surgery. Some attendees reacted with surprise to the data presented on the small reduction in the need for antihypertensive therapy and for continuous positive airway pressure (CPAP) in the older patient. The dangers of stopping aspirin and statins in older patients were also highlighted. These sessions clarified the need for more detailed work in this area.

The most focused session was the dedicated Anesthesiology and Intensive Care in Obesity Surgery Symposium, coordinated and chaired by Dr. Jan Mulier from Brugge, Belgium. An attentive audience of approximately 50 meeting attendees listened to a series of lectures that were interspersed with live televised visits to the linked bariatric surgery sessions in four operating theaters at Eppendorf Hospital, Hamburg, Germany.

The session included two brief talks on preoperative assessment and the pros and cons of standardized protocols were heard and debated. Dr. Robert Rutledge, a surgeon from Las Vegas, Nevada who has performed over 3,000 mini-gastric bypass procedures, gave his views and experiences on the analgesic roles of ketamine and dexmedetomidine. This talk stimulated a discussion surrounding the fact that in treating his patients, his team does not administer further muscle relaxants after induction. During the discussion, Dr. Rutledge attributed the median length of stay of one day for mini-gastric bypass surgery to excellent anesthesia, but his report of more than 200 same-day discharges in recent years shows what can potentially be achieved. The discussion made apparent the huge variation worldwide in availability of many analgesic adjuncts and the need for hard data from well-designed studies to identify the real benefit.

Attendees then video-linked to the anesthetists in one of the four operating theatres to watch and discuss the induction of a patient undergoing revisional surgery. During our first link, the audience observed as Professor Christian Zoellner supervised and commentated on the induction technique utilized by his team for a patient undergoing revisional surgery. In Hamburg, there is still a traditional approach using succinlycholine and rapid sequence induction for all bariatric patients, an aspect that was discussed further in the auditorium. A quick and simple survey of the anesthetists present at the meeting showed that less than 20 percent routinely use rapid sequence techniques for patients without symptomatic reflux. A discussion developed around the role of rocuronium and sugammadex, both in terms of use in rapid sequence induction and general availability. Only one member of the audience responded that he or she used it on a regular basis for reversal. The rest of the audience reserved it for emergencies only.

The lectures continued with Dr. Mulier’s discussion of general tips on induction and maintenance, followed by his discussion on abdominal compliance and how to facilitate surgical access. Dr. Mulier described the role of plotting the pressure volume curve during insufflation of the abdomen in the completely paralyzed patient, and how knowledge of the abdominal compliance helps predict further relaxant requirements. The process was demonstrated through a live link to an operating theater. The technique and its limitations were illustrated by the patient with a massive abdominal hernia, showing how, on occasion, much larger volumes of gas need to be delivered. Dr. Mulier’s lecture finished with tips on manipulating the gastric tube and leak testing. Live video from the operating room was shown. This demonstrated how inducing hypertension and a high cardiac output by elevating arterial CO2 toward the end of the case to reveal any bleeding points prior to closure can reduce the incidence of significant postoperative bleeding. These tips and tricks demonstrate how teamwork can potentially improve patient outcomes.

The final part of the session looked at fast-track anesthesia and enhanced recovery with the focus on aspects of analgesia, especially opioid-sparing strategies. Dr. David Torres (Chile) presented a meta-analysis of intraperitoneal local anesthesia, suggesting that it was of very limited effectiveness. Dr. Mike Margarson (United Kingdom) discussed the use of paracetamol and nonsteroidals as co-analgesics and the importance of achieving adequate plasma levels in the population with obesity. Dr. Margarson’s discussion sparked a lively debate on risk-benefit ratios.  Dr. Gislason (Norway) presented the anesthetic technique used for gastric bypass surgery, which has been replicated in many Scandinavian centers. This technique achieves single-night stay rates of 90 percent or more in urban areas. A number of audience members seemed very impressed by the rapidity of discharge in populations of patients with median body mass indices (BMIs) below 40kg/m2 and were reassured to hear that in populations with superobesity, 2 to 3 day stays are not unusual.

The next two IFSO meetings, which will take place in New Delhi, India and Istanbul, Turkey, respectively, will have anesthetic sessions and will include a message to attendees about raising awareness of bariatric anesthesia in their own countries.
We hope to see poster presentations of work involving perioperative management of the patient with obesity at these future meetings. With the support and cooperation of the anesthesia societies already established, namely the European Society for the Perioperative Care of the Obese Patient (www.espcop.org), International Society for the Perioperative Care of the Obese Patient (www.ispcop.org), and the United Kingdom Society of Bariatric Anesthetists (www.sobauk.com), we hope to further develop skills and techniques for the benefit of all patients in this unique population.

Photos from IFSO

Category: Anesthetic Aspects of Bariatric Surgery, Past Articles