Obesity surgery
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Venous thromboembolic (VTE) disease is a much-feared complication of bariatric surgery. The most common unexpected cause of death in the morbidly obese patient is pulmonary embolism (PE). Recent data supports the expanded use of systemic thrombolytics in hemodynamically stable patients with PE and echocardiographic evidence of right ventricular (RV) dysfunction. ⋯ To our knowledge, this is the first report of systemic thrombolysis for a submassive PE after bariatric surgery in a hemodynamically stable patient with RV dysfunction. Given the high incidence and morbidity of VTE disease in this population, and the expanding indications for thrombolytic therapy, successful cases such as these should be documented.
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Obesity is a well known risk factor for obstructive sleep apnea (OSA). Medical therapy is not effective for morbid obesity. Bariatric surgery is therefore a reasonable option for weight reduction for patients with clinically severe obesity. Unrecognized OSA, especially in those patients receiving abdominal surgery, has influenced perioperative morbidity and morality. The incidence of OSA for patients being evaluated for bariatric surgery has not been previously defined. ⋯ This population of clinically severe obese patients being evaluated for bariatric surgery had an 88% incidence of an OSRBD, 71% with OSA. Appropriate therapy with CPAP perioperatively would theoretically prevent hypoxic complications associated with OSRBD. Providers should have a low threshold for ordering a PSG as part of the preoperative evaluation for bariatric surgery. Empiric CPAP at 10 cm H2O should be considered for those patients who cannot complete a PSG before surgery.
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Comparative Study
Helium pneumoperitoneum ameliorates hypercarbia and acidosis associated with carbon dioxide insufflation during laparoscopic gastric bypass in pigs.
In the morbidly obese patient undergoing laparoscopic gastric bypass (LGBP), insufflation with carbon dioxide to 20 mmHg for prolonged periods may induce significant hypercarbia and acidosis with attendant sequelae. We hypothesize that the use of helium as an insufflating agent results in less hypercarbia and acidosis. ⋯ Helium pneumoperitoneum in LGBP is associated with less intraoperative hypercarbia and acidosis than is the use of CO2. In addition, pCO2 returns to normal more rapidly postoperatively with the use of helium insufflation. Study of helium insufflation in humans undergoing LGBP is needed to prove its benefits in the clinical setting.
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Anesthetized morbidly obese patients often exhibit impaired pulmonary gas exchanges, mostly because of a reduction in functional residual capacity. At present, several approaches are suggested to ventilate these patients. ⋯ RTP and PEEP can be considered adequate ventilatory settings for morbidly obese patients, without any significant difference with regard to gas exchange improvement. However, the decrease in CO may partially counteract the beneficial effects on oxygenation of these ventilatory settings.
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Case Reports
Gastric perforation in an obese patient with an intragastric balloon, following previous fundoplication.
The Bioenterics Intragastric Balloon (BIB) has been a safe and effective method used in treatment of moderate obesity. Gastric perforation is a rare complication, and its possible sequelae are dangerous. ⋯ According to our experience, fundoplication represents an absolute contraindication to positioning of a BIB.