Post-anesthesia Recovery after Infusion of Propofol with Remifentanil or Alfentanil or Fentanyl in Morbidly Obese Patients

Background: The type of opioid used during general anesthesia in the morbidly obese influences recovery and the postoperative period. In a randomized clinical trial, the postoperative recovery profile and early period after general anesthesia with remifentanil, fentanyl and alfentanil were compared in morbidly obese patients. Material and Method: 60 morbidly obese patients with BMI >35 kg/m² (mean 43.31) undergoing open Roux-en-y gastric bypass were randomly divided into 3 groups: remifentanil (R), fentanyl (F), and alfentanil (A). Dosage of opioids was based on ideal body weight (IBW): fentanyl 5 mcg/kg for intubation followed by infusion of 0.025-0.05 mcg/kg/min; alfentanil 15 mcg/kg initially, then 1.0-1.5 mcg kg/min; and remifentanil 1 mcg/kg followed by infusion of 0.25-1.5 mcg/kg/min. Anesthesia was induced with infusion of propofol and oxygen with N₂O (1:1). After anesthesia, the duration to response to verbal command, spontaneous respiration, adequate respiration, and safe extubation were recorded.The incidence of postoperative nausea and vomiting were recorded. Using verbal scale for evaluation of postoperative pain, the early postoperative analgesia requirements were assessed. Results: Demographic profiles and duration of procedure did not differ between groups. A total dose of propofol was significantly lower in Group R compared with Groups A and F (P <0.05). Duration to spontaneous respiration, adequate respiration and safe extubation were significantly shorter in Group R compared with Group F (P <0.05). Shortly after anesthesia, significantly more patients in Group R required additional dose of analgesic than in Group F (P <0.05). Postoperative nausea and vomiting (PONV) occurred significantly more often in Group R compared with Group F (P <0.05). Recovery profile of Group A was more similar to Group R, and postoperative pain and PONV evaluation more similar to Group F. Conclusion: In morbidly obese individuals, alfentanil or fentanyl and remifentanil can be safely used, but there is a higher rate of PONV and postoperative pain in the remifentanil group.     

Anesthetic Management of Morbidly Obese and Super-Morbidly Obese Patients Undergoing Bariatric Operations: Hospital Course and Outcomes

Background: Although the implications for the anesthetic and perioperative care of severely obese patients undergoing weight loss operations are considerable, current anesthetic management of super-obese (SO) patients (BMI ≥50 kg/m²), including super-super-obese (BMI ≥60) derives from experience with morbidly obese (MO) patients (BMI 40-49.9 kg/m²). We compared anesthetic and perioperative data of SO patients and MO patients undergoing weight loss operations to evaluate if anesthetic management influenced outcome. Methods: A retrospective analysis was performed on data from 150 consecutive patients (119 MO, 31 SO) undergoing bariatric surgery between May 2000 and March 2005. Data analyzed included preoperative anesthetic assessment, anesthetic management, postoperative care, and intra- or postoperative complications. Results: There were no differences in anesthetic management or in postoperative course or outcome between MO and SO patients. Intraoperative surgical complications occurred in 26% (n=8) in the SO group and 14% (n=15) in the MO group (P<0.01). Conclusions: No differences in outcome occurred between MO and SO patients undergoing bariatric operations under similar anesthetic management. Anesthesia for weight loss surgery can be safely performed on SO patients with the understanding that these patients are not at risk per se due to their higher BMI. The degree of obesity influenced only the incidence of intraoperative surgical complications.     

Estimating Blood Volume in Obese and Morbidly Obese Patients

Preoperative assessment of blood volume (BV) is important for patients undergoing surgery. The mean value for indexed blood volume (_InBV) in normal weight adults is 70 mL/kg. Since _InBV decreases in a non-linear manner with increasing weight, this value cannot be used for obese and morbidly obese patients. We present an equation that allows estimation of _InBV over the entire range of body weights.     

Postural Changes in Morbidly Obese Patients

Background: Postural deviations in morbidly obese individuals may contribute to low self-esteem and to long-term adverse effects on bones and joints. In a case-control study, the axial skeleton was investigated, to disclose the main abnormalities found in obese compared to non-obese groups. Methods: 2 groups were compared. Group 1, severely obese patients (n= 32), age 41.5 ± 8.2 years, BMI 49.4 ± 6.6 kg/m², 93.8% females, and group 2 non-obese (n= 30), age 43.5 ± 5.8 years, BMI 24.6 ± 5.1 kg/m², 96.7% females, had their posture analyzed through clinical examination and radiological imaging. Variables measured were anterior, lateral and posterior angular deviation from the vertical body axis at the head, shoulders, pelvis, Thales triangle, spine, knees, ankles and feet. Data are shown as a percentage of abnormal angles in the 2 groups. Results: On anterior analysis of the 2 groups, disturbances affected head (37.5% vs 13.3%), Thales angle (78.1% vs 53.3%), knees (84.4% vs 33.3%), legs (59.4% vs 30.0%) and support base (59.4% vs 26.7%) (P<0.05). On posterior view, the spine was the deranged segment (87.5% vs 36.7%) (P<0.05), and on lateral assessment, 100% of the results were abnormal. Conclusions: 1) Individuals with morbid obesity present important postural alterations. 2) Seriously altered posture was the rule for the obese population in this study, especially in the spine, knees and feet. 3) Most patients had compatible clinical complaints, but they rarely associated the bone and joint pain with the obesity and axial skeleton deviations. 4) Planned physical activity should be part of the treatment of severe obesity, in order to correct deviations, prevent new ones, and improve quality of life.     

Psychotherapeutic Treatment of Morbidly Obese Patients after Gastric Banding

Background: Surgery is the most effective therapeutic option for weight reduction in carefully selected patients with morbid obesity resistant to conventional treatment. However, surgical treatment is not the solution but an important precondition for successful management of morbid obesity. Methods: All patients undergo a psychiatric examination before laparoscopic gastric banding. At the first examination we inform all patients about the various forms of psychological support offered before and especially after gastric banding. Results: A majority of the obese individuals are interested in psychological support postoperatively, but only a minority of this patient group (about onequarter) ultimately enlists psychological support on a regular or irregular basis. Some specific psychological topics have proved to be particularly important such as change of self-esteem as a consequence of weight loss, problems in adopting new eating behaviors and the risk for developing a new eating disordered behavior, and problems involving adequate problem-solving. Conclusions: In many cases, some form of psychological support is necessary in order to cope with the new postoperative demands and to find more adequate coping strategies for underlying psychological, psychosocial and environmental problems. The different kinds of psychological support and psychotherapeutic treatment available at Innsbruck University Hospital for obese patients after gastric banding are discussed here.     

Positioning of Intragastric Balloon under Sedation in Super-Super-Obese Patients

A safe protocol for conscious sedation and control during placement (or extraction) of an intragastric balloon in massively obese patients is described.     

Changes in Insulin Sensitivity in Morbidly Obese Patients with or without Metabolic Syndrome after Gastric Bypass

Background: We evaluated the medium term changes in insulin sensitivity in morbidly obese patients with and without metabolic syndrome before and after Roux-en-Y gastric bypass (RYGBP) with silastic ring (Capella-Fobi). Methods: A longitudinal, clinical intervention study was conducted in 40 patients between 18 and 65 years old, with obesity class II and III (BMI ≥35-52 kg/m²), divided into 2 groups: no metabolic syndrome (NMS, n=21) and metabolic syndrome (MS, n=19). Anthropometric measurements, biochemical tests and classification of MS according to the NCEP criteria, were performed pre-operatively and at 3 and 6 months postoperatively. Results: In the preoperative period, 87% of the patients presented obesity class III (BMI 47±5 kg/m²) while 13% of the patients had obesity class II (37±2 kg/m²), and 19 patients (47.5%) presented MS. In the preoperative period, there were no differences among patients with MS and NMS in relation to the anthropometrics and body composition measurements. However, triglyceridemia, glycemia and insulinemia were higher in the MS group compared to the NMS group (P<0.05), although there was no difference in HOMA between the groups. HDL-cholesterol was lower in the MS group (p<0.05). In both postoperative study periods, all patients had significant reduction of anthropometric variables, body composition and biochemical variables. There were no differences between MS and NMS (p>0.05) groups. However, insulinemia decreased more in the postoperative period in the MS group compared to the NMS group (p<0.05). MS frequency in the MS group diminished to 26% after 3 postoperative months and no patient presented features of MS after 6 months postoperatively. Conclusions: Based on these observation: 1) patients of class II and III obesity present peripheral resistance to hyperinsulinemia without hyperglycemia; 2) RYGBP is able to reduce anthropometric measurements and body composition in a similar way for patients who have, or have not, MS; 3) there is rapid normalization of biochemistry of carbohydrates and lipids; 4) patients with previous MS lose the criteria needed for this diagnosis after 6 postoperative months.     

Gastro-esophageal Reflux and Esophageal Motility Disorders in Morbidly Obese Patients

Background: Morbid obesity has long been considered as a contributing factor to gastro-esophageal reflux, but the literature contains conflicting data on the subject. The authors studied a large number of morbidly obese candidates for bariatric surgery with objective means, in order to better define the incidence of gastro-esophageal reflux disease (GERD) and esophageal motility disorders in this population. Methods: Morbidly obese patients, in whom indication for bariatric surgery was confirmed after complete evaluation, were included consecutively during a 4-year period. The evaluation included history of reflux symptoms, upper GI endoscopy, 24-hour pH monitoring, and stationary esophageal manometry. Results: 345 patients were studied, of whom 35.8% reported reflux symptoms. Endoscopy showed a hiatus hernia in 181 patients (52.6%), and reflux esophagitis in 108 (31.4%). 24-hour pH monitoring revealed an elevated De Meester score in 163 patients (51.7%). Manometry was normal in 247 patients (74.4%), and showed a decreased lower esophageal sphincter pressure in 59 (17.7%). Esophagitis and abnormal pH testing were more common in patients with symptoms or hiatus hernia, and the incidence of esophagitis was higher with abnormal pH testing. Esophagitis was associated with increased weight and abdominal obesity. Conclusions: This study confirms the increased prevalence of GERD in the morbidly obese population. Upper GI endoscopy should be performed routinely during evaluation of morbidly obese patients for bariatric surgery. When both conditions coexist, effective treatment is probably best provided by Roux-en-Y gastric bypass, which produces effective weight loss and correction of pathological reflux.     

Induction of Pneumoperitoneum in Morbidly Obese Patients

Background: Induction of pneumoperitoneum can be a difficult, time-consuming, and occasionally hazardous task in a morbidly obese patient. Methods: We have induced pneumoperitoneum in 600 consecutive morbidly obese patients using a 120 mm Veress needle inserted <1 mm beneath the left costal margin, between the mid-clavicular and anterior axillary lines. Absolute muscular relaxation was necessary. Results: A distinct "pop" was felt on entering the peritoneal cavity. The expected intraperitoneal pressure was 7-14 mmHg. A pressure >20 mmHg indicated that the Veress needle was in the abdominal wall. CO2 infusion began at a flow of <1 L/min. "Shaking" the Veress needle to-and-fro improved flow to 1-2 L/min. Complete filling of the abdomen occurred at 4.0 L or more at a pressure limit of 15 mmHg. Increasing the pressure limit to 17 mmHg did not change the rate or final volume of CO₂ infusion. After initial trocar placement, the Veress needle was observed. Frequently it was in the omentum and there was CO₂ beneath the omentum. There was one visceral injury in the 600 patients - a puncture wound to the muscularis, but not the lumen, of the transverse colon. It was repaired laparoscopically with a single stitch. There have been no episodes of perforation of a hollow viscus, no unusual bleeding from the abdominal wall or viscera, and no injuries to the liver or spleen. Conclusion: Percutaneous induction of a pneumoperitoneum with the Veress needle in the left upper quadrant is a safe and effective technique in morbidly obese patients.     

Altered Olfactory Acuity in the Morbidly Obese

Background: Obese individuals have been reported to have a heightened desire for and ability to identify sweets when compared with leaner persons. Smell, like taste, may also be altered in obese persons compared with leaner subjects. This study was designed to determine if the sense of smell is different between morbidly obese and moderately obese individuals. Methods: 101 adult volunteers undergoing preoperative evaluation completed the 12-item Cross-Cultural Smell Identification Test (CC-SIT) before surgical intervention. Age, BMI, and smoking history were also obtained. Results: 101 subjects completed the preoperative CC-SIT (87 female, 14 male). Mean age of the subjects was 40 ± 12 years. Mean BMI was 42.5 ± 12.5 kg/m². 46 subjects (46%) had a BMI >45. 21 were smokers (21%). 9 subjects (9%), all female non-smokers, had a CC-SIT score representing olfactory dysfunction. Subjects with BMI >45 were more likely to have olfactory dysfunction than subjects with BMI <45 (16% vs 4%, P <0.05). Conclusion: Morbidly obese individuals are more likely than moderately obese individuals to demonstrate CC-SIT scores consistent with olfactory dysfunction. The reason for this is unclear but is probably related to metabolic changes occurring in morbidly obese individuals.     

Results of Laparoscopic Sleeve Gastrectomy (LSG) at 1 Year in Morbidly Obese Korean Patients

Background: In Asia, the type and main cause of obesity is different than in western society. Therefore, the treatment plan should be differentiated, and the surgery for morbid obesity should be carefully chosen. The early results of laparoscopic sleeve gastrectomy (LSG) without duodenal switch that has been performed in the Korean population is reported. Methods: We retrospectively reviewed 130 patients who underwent LSG from January 2003 to May 2004. 60 of these patients now had >1 year of regular follow-up, and are the subject of this report. LSG was performed through 4 12-mm ports and 1 15-mm port, using the Endo-GIA stapler to create a lesser curve gastric tube over a 48-Fr bougie. Results: For the 60 patients, the postoperative EWL was 71.6±21.9% at 6 months and 83.3±28.3% at 12 months. At 12 months after LSG, decrease in BMI was 9.2±3.7 kg/m², and median weight loss was 24.6±10.0 kg. Dyslipidemia resolved in 75% of patients within 12 months. Diabetes resolved in 100% of patients within 6 months of operation. Hypertension resolved in 92.9% and improved in 100%. Joint pain resolved in 100% within 12 months. Weight loss plateaued at 12 months in the majority of patients. One patient has undergone a malabsorption procedure (duodenal switch) as a second-stage operation. Conclusion: Additional studies and follow-up are needed to determine the best surgical treatment for morbidly obese Asian patients. However, LSG without the second-stage duodenal switch operation has been an effective weight loss operation thus far, in most of the Korean patients.     

Gastric Bypass for Morbidly Obese Patients with Established Cardiac Disease

Background: Bariatric surgery has often been avoided in patients with known cardiac disease because of the risks inherent in this patient population. This study was done to evaluate both the risks and benefits of Roux-en-Y gastric bypass (RYGBP) in morbidly obese patients with established cardiac disease. Methods: Data were analyzed to compare preoperative with postoperative co-morbid cardiac risk factors, peri-operative and postoperative complications, and change in body mass index (BMI) in 77 consecutive patients who had a preoperative diagnosis of cardiac disease and underwent RYGBP between March 1998 and January 31, 2006. Findings were compared to a concomitant control group without cardiac disease. Results: The preoperative presence of cardiac disease was manifested primarily as coronary artery disease (CAD) (45 patients) or as congestive heart failure (CHF) (32 patients). Of the patients with CAD, 60% had diabetes, 91% had hypertension and 39% had hyperlipidemia. 58% had one or more prior invasive cardiac procedures. In the CHF group, 50% had diabetes, 71% had hypertension and 44% had hyperlipidemia. The average length of stay was 3.7 days for CAD patients and 3.3 days for CHF compared to 3.0 days for controls. All co-morbid conditions were improved, and no patient died from cardiac disease. However, one patient died as a complication of GI bleeding, one patient subsequently underwent revascularization and another underwent stenting. Other complications up to 5 years postoperatively were frequent but seldom life-threatening. Conclusion: RYGBP surgery in patients with existing cardiac disease appears to have acceptable risk and is effective in reducing the co-morbid conditions of diabetes, hypertension, hyperlipidemia, sleep apnea and arthritis, but longer term data are needed.     

Histological Behavior of Hepatic Steatosis in Morbidly Obese Patients after Weight Loss Induced by Bariatric Surgery

Background: Hepatic steatosis has a high prevalence among morbidly obese patients. Its relation to steatohepatitis and cirrhosis has been extensively studied among these patients. The aim of this study was to evaluate the behavior of hepatic steatosis with weight loss 1 year after bariatric surgery. Methods: This study is a historical cohort that compared liver biopsies obtained from morbidly obese patients during the bariatric operation, with percutaneous biopsies taken from the same patient 1 year after surgery. The results were compared with weight loss, patients' profile (gender, age, body mass index (BMI) and waist/hip ratio), and with the presence of co-morbidities such as diabetes, hypertension, and dyslipidemia. Results: 90 patients who had liver biopsies taken at the operation and postoperative period for bariatric surgery were included. The prevalence of hepatic steatosis was 87.6%. The average percent of excess weight loss was 81.4%. On the second biopsy, 16 patients (17.8%) of the total had the same degree of steatosis, 25 (27.8%) improved their steatosis pattern and 49 (54.4%) had normal hepatic tissue. There was no statistical difference regarding age, BMI, waist/hip ratio, and co-morbidities (P>0.05), but there was a difference in gender (P=0.044). Conclusion: Significant improvement in the hepatic histology of steatosis was observed after weight loss induced by bariatric surgery in most patients. There was no patient with a worsening in the histology.     

Total Intravenous Anesthesia with Midazolam, Remifentanil, Propofol and Cisatracurium in Morbid Obesity

Background: According to physical impairments of massive obesity, cardiac, respiratory and gastrointestinal physiology must be considered as much as pharmacokinetic behavior. Anesthetic management of morbidly obese patients has to be carefully planned, in order to minimize the increased risks of aspirative pneumonitis, hemodynamic instability and delay in recovery.The ideal anesthesia should provide a smooth and quick induction, allowing rapid airway control, prominent hemodynamic stability, and rapid emergence from anesthesia.To approach these ideal conditions,aTotal Intravenous Anesthesia (TIVA) with midazolam, remifentanil, propofol and cisatracurium was designed and analyzed. Methods: 10 consenting morbidly obese patients scheduled for elective Laparoscopic Adjustable Gastric Banding participated in the study.TIVA with midazolam, remifentanil, propofol and cisatracurium was used in all cases.Time to loss of consciousness, tracheal intubation, perianesthetic physiological parameters and complications, incidence of awareness with recall, recovery times, postoperative analgesia and costs of drugs were evaluated. Results:The analyzed data showed adequate time and physiological conditions for induction and tracheal intubation, stable maintenance with easy handling of deepness, low incidence of perianesthetic complications, excellent recovery performance and institutional efficiency. Conclusions: TIVA with midazolam, remifentanil, propofol and cisatracurium was found to be effective, secure, predictable and economic for the anesthetic management of morbidly obese patients.     

A Preliminary Study of the Optimal Anesthesia Positioning for the Morbidly Obese Patient

Background: Hypoxemia during the induction of general anesthesia for the morbidly obese patient is a major concern of anesthesiologists. The etiology of this pathophysiological problem is multifactorial, and patient positioning may be a contributing factor. The present study was designed to identify optimal patient positioning for the induction of general anesthesia that minimizes the risk of hypoxemia in these patients. Methods: 26 morbidly obese patients (body mass index - BMI 56±3) were randomly assigned to one of three positions for induction of anesthesia: 1) 30° Reverse Trendelenburg; 2) Supine-Horizontal; 3) 30° Back Up Fowler. Mask ventilation, full neuromuscular paralysis and direct laryngoscopy were performed. Any airway difficulties were noted. After endotracheal tube placement, subjects were ventilated for 5 minutes with 1% isoflurane in a mixture of 50% oxygen / 50% air and then disconnected from the ventilation circuit.The time required for capillary oxygen saturation (SaO₂), as measured by pulse oximeter, to decline from 100% to 92% was noted and identified as the safe apnea period (SAP). Ventilation was then immediately re-established.The lowest SaO₂ after resuming ventilation and the time from that nadir to an SaO₂ of 97% were also recorded. Results: BMI and hip-waist ratios of patients in groups 1, 2 and 3 did not significantly differ. There were no differences in airway difficulties between the different groups. The SAP in groups 1, 2 and 3 was 178±55, 123±24 and 153±63 seconds, respectively. The SaO₂ of patients in the reverse Trendelenburg position dropped the least and took the shortest time to recover to 97%. Conclusions: In morbidly obese patients, the 30° Reverse Trendelenburg position provided the longest SAP when compared to the 30° Back Up Fowler and Horizontal-Supine positions. Since on induction of general anesthesia morbidly obese patients may be difficult to mask ventilate and/or intubate, this extra time may preclude adverse sequelae resulting from hypoxemia. Therefore, Reverse Trendelenburg is recommended as the optimal position for induction.     

Weight Loss and Postoperative Complications in Morbidly Obese Patients with Binge Eating Disorder Treated by Laparoscopic Adjustable Gastric Banding

Background: The authors investigated the outcome of morbidly obese patients with binge eating disorder (BED) treated surgically with laparoscopic adjustable gastric banding. Methods: The 5-year outcomes of 130 patients with BED and 249 patients without BED are described. The diagnosis of BED was made preoperatively and all patients with BED were supported with psychological therapy. Results: Patients with and without BED had similar BMI levels before surgery. More patients with than without BED had depressive symptoms and associated minor disturbances of eating behavior (night eating and grazing). Percent excess weight loss (%EWL) in the first 5 years after surgery was similar in patients with and without BED. The percentage of BED patients showing %EWL >50% at the 5-year evaluation was 23.1, and 25.7% in non-BED patients. The percentage of patients showing weight regain in the last 4 years of follow-up was similar in binge eaters (20.8%) and in non-binge eaters (22.5%). The 5-year frequency of gastric pouch and esophageal dilatation was significantly higher in binge eaters than in non-binge eaters (25.4 vs 17.7 %, P<0.05 and 10.0 vs 4.8%, P<0.05, respectively). Binge eaters underwent a higher number of postoperative band adjustments than non-binge eaters (3.0±2.1 vs 2.6±1.9, P<0.05) and the maximum band fill after surgery was higher in the BED patients than in non-BED patients (3.2±1.2 vs 2.8±1.3 ml, P<0.01). Conclusion: Morbidly obese patients with BED supported by adequate psychological treatment can have good outcomes after gastric banding.     

Treatment of Urolithiasis in the Morbidly Obese

Background: Morbidly obese patients with urolithiasis present a therapeutic and diagnostic challenge to the Urologist. Management is reported and potential difficulties discussed. Methods: Morbidly obese patients (body mass index ≥ 40kg/m2) with stone disease were identified by retrospective review. Stone load was calculated and treatment modalities noted. Results: 18 renal units (kidneys) were treated in 17 patients. Of these, 2 required no treatment, 2 had open procedures, and 15 were treated with flexible ureteroscopy. Mean stone burden in patients treated with flexible ureteroscopy was 18 mm, but 8 patients had stone loads >15 mm and in these patients mean stone burden was 23 mm. All were successfully treated or rendered asymptomatic. There were no major complications. Conclusion: Obesity is increasingly prevalent and associated with a high incidence of co-morbidity and complications. Imaging can be difficult and treatment options are limited. Flexible ureteroscopy has proven to be the most successful treatment option, and can avoid the need for more invasive procedures. Furthermore, stone loads greater than normally acceptable can be successfully undertaken in these patients, and should be attempted due to problems associated with other techniques.     

Gallstone Formation after Weight Loss following Gastric Banding in Morbidly Obese Dutch Patients

Background: Obesity is a risk factor for the development of gallstones. Rapid weight loss may be an even stronger risk factor. We retrospectively assessed the prevalence and risk factors of gallstone formation after adjustable gastric banding (AGB) in a Dutch population. Methods: All patients who underwent AGB between Jan 1992 and Dec 2000 for morbid obesity were invited to take part in this study. Transabdominal ultrasonography of the gallbladder was performed in those patients without a prior history of cholecystectomy (Group A). Additionally, 45 morbidly obese patients underwent ultrasonography of the gallbladder before weight reduction surgery (Group B). Results: 120 patients were enrolled in the study (Group A). Prior history of cholecystectomy was present in 21 patients: 16 before and 5 after AGB. Ultrasonography was performed in 98 patients: gallstones were present in 26 (26.5%). On multivariate analysis, neither preoperative weight, nor maximum weight loss, nor the interval between operation and the postoperative ultrasonography were determinants of the risk for developing gallstone disease. Prevalence of gallstones was significantly lower in the morbidly obese patients who had not yet undergone weight reduction surgery (Group B). Conclusions: Rapid weight loss induced by AGB, is an important risk factor for the development of gallstones. No additional determinants were found. Every morbidly obese patient undergoing bariatric surgery must be considered at risk for developing gallstone disease.     

Intra-abdominal Pressure in the Morbidly Obese

Background: Recent data suggests that increased intra-abdominal pressure (IAP) is one factor associated with the morbidity of morbidly obese patients, who have a BMI >35 kg/m². IAP has been proposed to be an abdominal compartment syndrome (ACS). This study investigated the characteristics of IAP in morbidly obese patients. Methods: 45 morbidly obese patients (mean BMI 55±2 kg/m²) had IAP measured using urinary bladder pressure. Results: The mean IAP for the morbidly obese group was 12±0.8 cmH₂O, increased when compared to controls (IAP=0±2 cmH₂O). The IAP correlated to the sagittal abdominal diameter, an index of the degree of central obesity (r=+0.83, P<0.02); however, it did not correlate to basal insulin, body weight, or BMI. The end-expiratory IAP did not change when measured after the laparotomy incision was made, but IAP measured in the last 15 patients increased during the first 2 postoperative days. The IAP for patients with pressure-related morbidity (gastroesophageal reflux disease, hernia, stress incontinence, diabetes, hypertension, and venous insufficiency) was 12±1 cmH₂O, while those without these morbidities had an IAP of 9±0.8 cmH₂O. Conclusion: We conclude that IAP is increased in morbid obesity. This increased IAP is a function of central obesity and is associated with increased morbidity. The degree of IAP elevation correlates with increased co-morbidities. We also conclude that elevation in IAP in morbid obesity is not a true ACS but represents a direct mass effect of the visceral obesity.     

Development of Acute Gouty Attack in the Morbidly Obese Population after Bariatric Surgery

Background: Gout is associated with increased body weight. We evaluated the prevalence of gout and acute gouty attacks in the morbidly obese population who underwent bariatric surgery. Methods: The medical records and operative reports of 1,240 patients who underwent bariatric surgery were reviewed retrospectively for weight parameters, BMI, weight loss, medical history of gout, and onset of acute gouty attacks. Results: Of the 1,240 patients, 5 (0.4%) had been previously diagnosed with gout. 2 of these 5 had acute attacks during the postoperative period, and responded succesfully to intravenous colchicine. Conclusion: Although rare, gout must be considered a co-morbid illness in obese and morbidly obese patients. Surgeons should be familiar with the signs and symptoms of attacks in the postoperative period, and be knowledgeable in the management.