• Bariatric surgery
    • Obesity linked with IHD, DM, OSAS, HT, restrictive lung disease, gallstones, some cancers, OA
    • Surgical treatment indications
      • BMI > 40
      • 35-40 with coexisting disease that could be improved with weight loss
      • Conservative measures failed
      • Patient is fit for surgery/anaesthesia
      • Committed to the need for long term follow up
    • Medical therapy
      • Orlistat - decreased absorption of fat soluble vitamins
      • Sibutramine (centrally acting)
        • Withdrawn due to CVS side effects
    • Contraindications
      • Crohn's disease
      • Upper GI bleeding
      • Cirrhosis
      • Portal HT
      • Chronic pancreatitis
      • Weight >180kg relative CI
    • Types of surgery
      • Restrictive
        • Reduce volume of gastric cavity
        • Adjustable gastric band (AGB)
          • Safe
          • Problems: slippage, pouch dilation, obstruction, dysphagia, reflux, port leak, oesophagitis, obstruction
          • Minimall invasive
          • Adjustable
          • Reversible
          • Effective in long term weight loss
        • Others eg sleeve gastrectomy, gastric balloon have been superseded
      • Malabsorptive
        • Also shortens gut
        • Roux-en-Y gastric bypass (RYGB)
          • Laparascopic
          • Surgical proximal gastric pouch is anastomoses to the jejenum
          • Longer and more demanding procedure than AGB
          • Dumping occurs in 10%
          • Anastomotic leak, obstruction and strictures can all occur
    • Anaesthetic considerations
      • Pre-op evaluation
        • Dieticians, endocrinologists, psychologists, specialist nurses, surgeons and anaesthetists
        • Look for associated conditions
        • Risk of difficult intubation ?AFOI
        • OSAS common ?CPAP pre-op
        • H2 receptor antagonist and prokinetic pre-op
        • Check B12, folate and coagulation pre-op
      • Intra-op considerations
        • Position pre-induction
        • Ensure adequate personell present
        • Strap patient to table (Trendelenberg)
        • Consider art line/CVP line
        • Weak/moderate lipophilic drugs given according to IBW (eg NDMRs). A exception is remifentanil and sux (given according to actual BW)
        • Consider RSI or AFOI
        • Stack the patient up and use platform
        • Consider using desflurane
        • Thromboprophylaxis is essential and prophylactic antibiotics for wound infections
      • Post op management
        • Consider HDU/ITU if Montefiore Obesity Surgery Score (MOSS) suggestive.
        • 4 or more of the following
          • Gastric bypass surgery
          • Male
          • >50 yrs old
          • BMI > 50
          • Confirmed OSAS
          • Significant medical/surgical comorbidity
          • Previous abdominal surgery
        • Nurse 45 degrees head up
        • Multimodal analgesia
        • Post-op CPAP or humidified O₂
        • PPI, antibiotics, TED prophylaxis
        • Patients remain high risk of aspiration for future procedures

    • Link:ceaccp.oxfordjournals.org/content/10/4/99.full.pdf