Super-morbidly Obese Patients Research Articles

Staple Line Reinforcement Using SEAMGUARD® versus Suture Over Sewing During Laparoscopic Sleeve Gastrectomy for Super Morbidly Obese Patients: A Prospective Randomized Clinical Trial.

A prospective randomized clinical trial included 200 super morbidly obese patients randomized into two groups: Group 1 with reinforcement of the staple line by SEAMGUARD® (Gore Medical, Newark, Delaware) and Group 2 with reinforcement of the staple line using suture over sewing. The mean operative time was significantly shorter in Group 1 than Group 2 (62.6 ± 14.5 vs. 84.7 ±15.8 min, p=0.02). Intraoperative blood loss was significantly lower in Group 1 than Group 2 (17.1± 19.1 vs. 56.8 ± 27.9ml, p=0.00). Staple line hematomas were significantly higher in Group 2. There was no difference in postoperative bleeding between the two groups. No leak was reported in both groups. The cost was higher in Group 1. Reinforcing the staple line in laparoscopic sleeve gastrectomy using suturing is equal to SEAMGUARD® in all aspects except shorter operative time and lower intraoperative blood loss with SEAMGUARD®.

One Year Follow-up of Laparoscopic Single Anastomosis Sleeve Ileal Bypass in Super-morbidly Obese Patients

One Year Follow-up of Laparoscopic Single Anastomosis Sleeve Ileal Bypass in Super-morbidly Obese Patients

Underweight patients are an often under looked “At risk” population after undergoing posterior cervical spine surgery

BackgroundBody Mass Index (BMI) is a weight-for-height metric that is used to quantify tissue mass and weight levels. Past studies have mainly focused on the association of high BMI on spine surgery outcomes and shown variable conclusions. Prior results may have varied due to insufficient power or inconsistent categorical separation of BMI groups (e.g. underweight, overweight, or obese). Additionally, few studies have considered outcomes of patients with low BMI. The aim of the current study was to analyze patients along the entirety of the BMI spectrum and to establish specific granular BMI categories for which patients become at risk for complication and mortality following posterior cervical spine surgery. MethodsPatients undergoing elective posterior cervical spine surgery were abstracted from the 2005–2016 National Surgical Quality Improvement Program (NSQIP) databases. Patients were aggregated into pre-established WHO BMI categories and adverse outcomes were normalized to average risk of normal-weight subjects (BMI 18.5–24.9 kg/m2). Risk-adjusted multivariate regressions were performed controlling for patient demographics and overall health. ResultsA total of 16,806 patients met inclusion criteria. Odds for adverse events for underweight patients (BMI < 18.5 kg/m2) were the highest among any category of patients along the BMI spectrum. These patients experienced increased odds of any adverse event (Odds Ratio (OR) = 1.67, p = 0.008, major adverse events (OR=2.08, p = 0.001), post-operative infection (OR = 1.95, p = 0.002), and reoperation (OR = 1.84, p = 0.020). Interestingly, none of the overweight or obese categories were found to be correlated with increased risk of adverse event categories other than super-morbidly obese patients (BMI>50.0 kg/m2) for post-operative infection (OR = 1.54, p = 0.041). ConclusionsThe current study found underweight patients to have the highest risk of adverse events after posterior cervical spine surgery. Increased pre-surgical planning and resource allocation for this population should be considered by physicians and healthcare systems, as is often already done for patients on the other end of the BMI spectrum.

Bracing a prudent anesthetic challenge: a super-morbidly obese patient posted for an emergency laparotomy: a case report

Bracing a prudent anesthetic challenge: a super-morbidly obese patient posted for an emergency laparotomy: a case report

Improvement in Obstructive Sleep Apnea (OSA) in Super Morbidly Obese Patients After Bariatric Surgery

Background: Lifestyle modification is the mainstay therapy for obese patients with obstructive sleep apnea (OSA). However, most of these patients are unable to lose the necessary weight, and bariatric surgery (BS) has been proven to be an effective modality in selected cases. Objective: To provide objective evidence that BS can improve OSA severity. Materials and Methods: A prospective study was conducted in super morbidly obese patients (body mass index [BMI] greater than 40 kg/m² or BMI greater than 35 kg/m² with uncontrolled comorbidities) scheduled for BS. Polysomnography (PSG) was performed for preoperative assessment and OSA was treated accordingly. After successful surgery, patients were invited to perform follow-up PSG at 3, 6, and 12 months. Results: Twenty-four patients with a mean age of 35.0±14.0 years were enrolled. After a mean follow-up period of 7.8±3.4 months, the mean BMI, Epworth sleepiness scale (ESS), and apnea-hypopnea index (AHI) significantly decreased from 51.6±8.7 to 38.2±6.8 kg/m² (p&lt;0.001), from 8.7±5.9 to 4.7±3.5 (p=0.003), and from 87.6±38.9 to 28.5±21.5 events/hour (p&lt;0.001), respectively. Conclusion: BS was shown to dramatically improve clinical and sleep parameters in super morbidly obese patients. Keywords: Morbid obesity, Bariatric surgery, Obstructive sleep apnea (OSA)

Preoperative Evaluation, Anesthesia and Outcome of a Super Morbidly Obese Patient.

Background; Nowadays anesthesia and outcome of morbidly obese patients became not only challenges but and an obligation in abdominal surgery. Sometimes morbidly obese patients postponed from all the kinds of surgery till it is life-threatening. The ward of anesthetists is obligate for a very careful preoperative evaluation, anesthesia, and outcome of morbidity obese patients. These include the preoperative evaluation of obesity, particularly on cardiac, respiratory, and metabolic systems; airway management; perioperative management (i.e., hemodynamic, respiratory, and hyperglycemic) and postoperative care.&#x0D; Case description: A 62 years old female with BMI=63.7 kg/m² with severe hypertension treatment came to a surgery ward for the plastic abdomen. After a careful preoperative preparation for the respiratory system and prophylaxis for thrombosis home, we started preoperative care 72 hours before surgery done in our hospital. We used general anesthesia for operation, the surgery lasts 190 minutes, and the patient was extubated according to weaning criteria only 16 hours after surgery. The patient stayed 2 days in intensive care and left a safe hospital on her ten days of recovery.&#x0D; Discussion: Super obese surgical patients represent numerous challenges to the anesthetist.&#x0D; Conclusion: A better understanding of the pathophysiology and complications that accompany obesity may improve their care and outcome.

Combined Oocyte Retrieval and Robot-assisted Hysterectomy in a Super Morbidly Obese Patient with Endometrial Carcinoma

To report on the unique, innovative management of a super morbidly obese patient presenting for fertility preservation in the setting of Grade 2 endometrioid endometrial adenocarcinoma. A back-to-back oocyte retrieval and robot-assisted total laparoscopic hysterectomy (RA-TLH) with bilateral salpingo-oophorectomy (BSO) was performed in a 37-year-old nulligravid woman with super morbid obesity (BMI 63 kg/m2) with endometrial cancer. the successful retrieval of oocytes for fertility preservation and oncologic intervention via RA-TLH with BSO in the same operative and anesthetic episode. This combined procedure strategy was successful in our case and is a feasible option for similar high-risk patients in the future. Identifying safe and effective approaches for oocyte retrieval in morbidly obese patients represents a pressing need as obesity rates rise among reproductive-aged women. Back-to-back oocyte retrieval and RA-TLH with BSO are not only feasible, but could also decrease significant anesthetic risks for morbidly obese patients.

Endoscopic Biological Glue Injection for Treating Multiple Staple-Line Leaks and Dehiscence Following Laparoscopic Sleeve Gastrectomy – A Case Report and Review of the Literature

In the past decade laparoscopic sleeve gastrectomy (LSG) has become the primary restrictive procedure in bariatric surgery. LSG offers an excellent outcome with regards to weight loss and comorbidity reduction. LSG is a restrictive procedure without the mal-absorptive component present in other bariatric procedures. It involves resection of two-thirds of the stomach to provide increased satiety and decreased appetite. Sleeve gastrectomy for weight loss was first described by Marceau in 1993 as a component of biliopancreatic diversion. Laparoscopic sleeve gastrectomy (LSG) was performed as a component of biliopancreatic diversion with duodenal switch (BPD-DS) in 2000 by Ren et al. and subsequently used as the initial stage of a two-staged approach for super-morbidly obese patients. Here, we describe a case of a an 18-year-old male presented to the emergency department complaining of a 3-day lasting abdominal pain, a week after undergoing LSG with an otherwise uneventful post-operative period.

Abstract PR207

Background & Objectives: We conducted a service evaluation of anaesthesia in morbidly obese parturients in our unit. Our aims were to quantify the extent of the issue locally, identify the level of anaesthetist involved and make recommendations. Materials & Methods: Following hospital governance approval, cases were identified from the Anaesthesia Obstetric Database. Women with a Body Mass Index (BMI) more than 40 kg/m2 who required an anaesthetic intervention between 1st of January 2014 to 31st of December 2014 were included. Two hundred and fourteen individual cases were identified out of 5,848 deliveries. We obtained 151 case notes. Seventeen cases were excluded due to missing data or discrepancies, leaving 134 cases for analysis. Data was collected for demographics, mode of delivery, analgesia technique, anaesthesia, complications (resites, bloody taps, dural punctures), grade of anaesthetist and outcomes. Results: BMI ranged between 40 to 65 kg/m2 at term. Sixty-one women were seen in our dedicated antenatal high BMI clinic. Seventy-three women underwent a Lower Segment Caesarean Section (LSCS). There were six category 1 Caesarean sections with five general anaesthesia cases and one epidural top-up. A Decision to Delivery Interval time (DDI) of less than 30 minutes was achieved in all cases. Seven women had assisted vaginal delivery and fifty-four a normal vaginal delivery. Our rate of labour epidural/CSE in morbidly obese patients was 69.81%, with a failure rate of 17.15%. We found a poor correlation between the antenatally ultrasound estimated depth of epidural space and the actual depth found in labour. The following complications were identified: eight cases of multiple attempts (one being impossible), three cases of accidental dural punctures and three bloody taps. Our super-morbidly obese patients (BMI more than 50 kg/m2) were managed by senior anaesthetists (seventeen cases) and three cases were by juniors. Conclusion: Our data is similar to internationally published studies of morbidly obese parturients in terms LSCS incidence (54.47%), rate of labour epidural and regional anaesthesia failure.1 We recommended threading more length of epidural catheter in the space to account for its movement with position related tissue expansion.2 There should be senior anaesthetic involvement with all super-morbidly obese patients. The demographic data from this audit was used to inform a successful bid for equipment funding from the Department of Health.

Robotic surgery in supermorbidly obese patients with endometrial cancer

Morbid obesity is a known risk factor for the development of endometrial cancer. Several studies have demonstrated the overall feasibility of robotic-assisted surgical staging for endometrial cancer as well as the benefits of robotics compared with laparotomy. However, there have been few reports that have evaluated robotic surgery for endometrial cancer in the supermorbidly obese population (body mass index [BMI], ≥50 kg/m(2)). We sought to evaluate safety, feasibility, and outcomes for supermorbidly obese patients who undergo robotic surgery for endometrial cancer, compared with patients with lower body mass indices. We performed a retrospective chart review of 168 patients with suspected early-stage endometrial adenocarcinoma who underwent robotic surgery for the management of their disease. Analysis of variance and univariate logistic regression were used to compare patient characteristics and surgical variables across all body weights. Cox proportional hazard regression was used to determine the impact of body weight on recurrence-free and overall survival. The mean BMI of our cohort was 40.9 kg/m(2). Median follow up was 31 months. Fifty-six patients, 30% of which had grade 2 or 3 tumors, were supermorbidly obese with a BMI of ≥50 kg/m(2) (mean, 56.3 kg/m(2)). A comparison between the supermorbidly obese and lower-weight patients demonstrated no differences in terms of length of hospital stay, blood loss, complication rates, numbers of pelvic and paraaortic lymph nodes retrieved, or recurrence and survival. There was a correlation between BMI and conversion to an open procedure, in which the odds of conversion increased with increasing BMI (P = .02). Offering robotic surgery to supermorbidly obese patients with endometrial cancer is a safe and feasible surgical management option. When compared with patients with a lower BMI, the supermorbidly obese patient had a similar outcome, length of hospital stay, blood loss, complications, and numbers of lymph nodes retrieved.

Robotic surgery in super-morbidly obese patients with endometrial cancer

Robotic surgery in super-morbidly obese patients with endometrial cancer

Anaesthetic challenges in a super-morbidly obese patient undergoing laparoscopic sleeve gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is an effective method of treating patients suffering from morbid obesity. The perioperative care of these patients can be complicated by physiological derangement, comorbidities, problems with the patient's airway and alterations in pharmacokinetics and pharmacodynamics of some drugs. We report a case of a 45-year-old man with body weight of 252 kg and body mass index (BMI) of 77 kg/m2 who underwent LSG. This case investigates possibly the most overweight patient to undergo general anaesthesia in the United Arab Emirates (UAE). Specific protocols in anaesthetic management and perioperative care should be implemented to allow effective and safer treatment in obese patients.

Propofol infusion syndrome in a super morbidly obese patient (BMI = 75)

Propofol infusion syndrome (PRIS) is a rare but often fatal complication as a result of large doses of propofol infusion (4–5 mg/kg/hr) for a prolonged period (>48 h). It has been reported in both children and adults. Besides large doses of propofol infusion, the risk factors include young age, acute neurological injury, low carbohydrate and high fat intake, exogenous administration of corticosteroid and catecholamine, critical illness, and inborn errors of mitochondrial fatty acid oxidation. PRIS manifestation include presence of metabolic acidosis with a base deficit of more than 10 mmol/l at least on one occasion, rhabdomyolysis or myoglobinuria, acute renal failure, sudden onset of bradycardia resistant to treatment, myocardial failure, and lipemic plasma. The pathophysiology of PRIS may be either direct mitochondrial respiratory chain inhibition or impaired mitochondrial fatty acid metabolism mediated by propofol. We report a case of supermorbidly obese patient who received propofol infusion by total body weight instead of actual body weight and developed PRIS.

M1668 Laproscopic Adjustable Gastric Banding (LAGB) in Super Morbidly Obese Patients (BMI>50) in Ambulatory Surgery Center is Safe

M1668 Laproscopic Adjustable Gastric Banding (LAGB) in Super Morbidly Obese Patients (BMI>50) in Ambulatory Surgery Center is Safe

Is biliopancreatic diversion with duodenal switch indicated for patients with body mass index

Background Biliopancreatic diversion with duodenal switch (DS) has been the standard surgical approach for the treatment of morbidly obese patients at our institution since the early 1990s. The published data, however, have shown the use of the DS to be limited to the treatment of super-morbidly obese patients (body mass index [BMI] ≥50 kg/m 2). The aim of the present study was to present our long-term results with the DS in patients with an initial BMI of <50 kg/m 2. Methods This was a retrospective study of all patients with a BMI <50 kg/m 2 who had undergone DS from June 1992 to May 2005. The data are reported as the mean ± standard deviation. Results The data from 810 consecutive patients, with a mean initial BMI of 44.2 ± 3.6 kg/m 2, were reviewed. The mean follow-up was 103 ± 49 months. Major perioperative complications occurred in 5.8% of patients, including 5 deaths (.6%). The initial excess weight loss was 76% ± 22%, and the excess weight loss was >50% in 89% of patients. Malnutrition required readmission in 4.3% and surgical revision in 1.5%. The prevalence of severe albumin deficiency (<30 g/L) was 1.1%, hemoglobin deficiency (<100 g/L), 1.6%, iron deficiency (<4 mmol/L) 2.1%, and calcium deficiency (<2 g/L) 3%. The percentage of patients “very satisfied” with the global result was 91%, and 37% would have preferred to lose more weight. Conclusion These results showed that in non super-obese patients, DS was very efficient in terms of weight loss and patient satisfaction. This was associated with a 1.5% risk of revision for malnutrition. However, nutritional deficiencies required frequent readjustment of supplements, particularly for calcium, vitamin A, and vitamin D.

A new and standardized approach for trocar placement in laparoscopic Roux-en-Y gastric bypass

Super-morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) present unique technical challenges. In our experience the ease of the operation and the operative time seem to be more dependent on body habitus than body mass index (BMI). We hypothesized that the distance between the xyphoid process and the umbilicus (the XU distance) correlated with surgical difficulty and described an original modification of trocar placement based on this measurement to improve the ease of the operation. Seven hundred and seventy-four patients underwent LRYGB, and the XU distance was measured in a subset of 38 patients midway through the experience. The need for additional trocars was assessed intraoperatively and the relationship between the XU distance and the need for extra trocars was subsequently analyzed. A standardized approach for trocar placement was implemented in the second half of our series. The operative time was compared between the standardized and nonstandardized groups. Fifty percent of the patients required a five-trocar technique. Median XU distance in this group was 21.4 cm (range 17-25 cm). In the remaining 19 patients additional trocars were added; median XU distance was 27.3 cm (range 24-33 cm). From the 774 patients included in the study period, the operative time for the first 322 patients who were completed with a nonstandardized trocar approach was significantly longer than the subsequent 452 cases in which the standardized trocar approach was used (210 versus 173 min, p < 0.001). We define XU distance as the key element in determining the choice of trocar placement. When XU distance is less then 25 cm, the basic approach should be used and if it is greater than 25 cm, the advanced trocar approach is recommended. This standardized technique leads to decreased operative time and improved ease of operation.

Has Laparoscopic Bariatric Surgery been Accepted in Japan? The Experience of a Single Surgeon

Obesity is steadily increasing in Asia due to factors such as a lack of exercise, adoption of a more Western diet, changing lifestyles, environments, or stresses. Even in Japan, this tendency is notable, and metabolic syndrome has become widely recognized. However, bariatric surgery is still uncommon in Japan. There are no adequate data regarding the experience and outcome of bariatric surgery in Asia. Here, we report on the current status of morbid obesity and the outcomes of bariatric surgery by a single surgeon in Japan. Between February 2002 and January 2008, we have performed laparoscopic bariatric surgery for morbid obesity in 178 cases. They consisted of laparoscopic Roux-en-Y gastric bypass (LRYGBP) in 105 cases, laparoscopic sleeve gastrectomy (LSG) in 26 cases, laparoscopic sleeve gastrectomy with duodenal jejunal bypass (LSG/DJB) in 14 cases, laparoscopic adjustable gastric banding (LAGB) in 13 cases, and laparoscopic biliopancreatic diversion with duodenal switch in one case under the same protocol of follow up. The first author of this paper performed all procedures. One hundred and thirty-eight patients with a follow-up of over 3 months after surgery were enrolled. LRYGBP accounted for 72% of all bariatric procedures. The reduction of weight and body mass index (BMI) in LRYGBP and LSG showed similar results. These outcomes were superior to those of LAGB. Percentage of excess BMI loss (%EBMIL) of LRYGBP showed greater reductions at follow-ups 6, 9, 12, and 18 months after surgery compared to that of LRYGBP and LAGB. All procedures resulted in over 50% of %EBMIL after 18 months of follow-up. There was no postoperative mortality within 30 days after surgery. Preoperative comorbidity including diabetes mellitus, hypertension, and hyperlipidemia were resolved or improved after surgery in most patients. In bariatric surgery, LRYGBP is the most effective treatment for morbid obesity, while LAGB has a low risk of postoperative complications. LSG is also a safe procedure for supermorbidly obese patients. We expect that bariatric surgery will be a common procedure for patients with morbid obesity in Japan.

Transfer device for supermorbidly obese patients

Transfer device for supermorbidly obese patients

A reply

Although we do not disagree with Drs Thomas and Cook about the inherent benefits of using the LMA ProSeal (PLMA) over the LMA Classic (cLMA), we do not share their enthusiasm for its use in the ICU setting. We would be unlikely to use any laryngeal mask airway device routinely for bronchoscope-guided percutaneous tracheostomy or as a planned bridge to extubation during problematic weaning because we fail to see any proven benefit. The use of such devices has a financial cost, as well. We used the cLMA in ICU as a short-term emergency measure to break a cycle of repeated tracheal intubations in a postsurgical, semiconscious, super-morbidly obese patient in whom we were desperate to avoid prolonged ventilation for obvious reasons. We were not concerned about aspiration or gas leak around the laryngeal mask airway seal or into what remained of the stomach following gastric bypass surgery, as we knew this to be empty and we were only delivering a maximum 20 cmH2O of continuous positive airway pressure to a spontaneously breathing patient. Our main concern was keeping the patient's airway patent, for which the cLMA proved perfectly adequate. In fact, given a choice (which we don't have at present) we would have probably still have opted for cLMA as this is familiar and should be easier to insert, particularly in an un-anaesthetised patient. We will, however, take on board their comments and if the situation arises where we require the additional performance of the PLMA, we will endeavour to use it.

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

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 > or =50 kg/m(2)), including super-super-obese (BMI > or =60) derives from experience with morbidly obese (MO) patients (BMI 40-49.9 kg/m(2)). We compared anesthetic and perioperative data of SO patients and MO patients undergoing weight loss operations to evaluate if anesthetic management influenced outcome. 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. 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). 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.