Anesthetic considerations for bariatric surgery

Structured Routine Use of Styletubation for Oro-Tracheal Intubation in Obese Patients Undergoing Bariatric Surgeries-A Case Series Report

The aim of this case series report is to provide a new topical view of styletubation (video intubating stylet technique) in obese patients undergoing bariatric surgeries. In contrast to various conventional direct laryngoscopes (DLs), videolaryngoscopes (VLs) have been applied in such obese populations with potentially difficult airway complications. The safety and effectiveness of VLs have been repeatedly studied, and the superiority of VLs has then been observed in and advocated for routine use. In this article, among our vast use experiences with styletubation (more than 54,998 patients since 2016) for first-line routine tracheal intubation, we present the unique experience to apply the styletubation technique in obese patients undergoing bariatric surgery. Consistent with the experiences applied in other patient populations, we found the styletubation technique itself to be swift (the time to intubate from 5 s to 24 s), smooth (first-attempt success rate: 100%), safe (no airway complications), and easy (high subjective satisfaction). The learning curve is steep, but competency can be enhanced if technical pitfalls can be avoided. We, therefore, propose that the styletubation technique can be feasibly and routinely applied as a first-line airway modality in obese patients undergoing bariatric surgery.

Effect of Intraoperative Infusion of Esketamine on Quality of Postoperative Recovery in Patients Undergoing Laparoscopic Bariatric Surgery: A Randomized Controlled Trial

INTRODUCTION

This study aims to evaluate the efficacy of esketamine on postoperative recovery quality after laparoscopic bariatric surgery.

METHODS

Patients (n = 74) scheduled for laparoscopic bariatric surgery were randomly divided into two groups: the esketamine group (group E: 0.5 mg/kg/h infusion, i.e., 0.2 mL/kg/h) or the control group (group C: 0.2 mL/kg/h normal saline infusion). The infusions were stopped 20 min before the end of the procedure. The primary outcome was the Quality of Recovery-40 (QoR-40) score on postoperative day 1 (POD 1). The secondary outcomes included QoR-40 scores on PODs 2 and 7, Numeric Rating Scale (NRS) on PODs 1, 2, and 7, time to extubation, additional postoperative analgesic use, length of hospital stay, and time to first exhaust. Additonally, the safety indices were also recorded, including hemodynamic profile, perioperative anesthesia index (Ai), utilization of vasoactive drugs or urapidil, and side effects.

RESULTS

All in all, 70 of the 74 patients completed the study, 35 in each group. The difference of QoR-40 scores on POD 1 was both statistically and clinically significant [difference 7.21, 95% confidence interval (CI) 5.17, 9.25, p < 0.001]. The difference of QoR-40 on POD 2 was statistically significant but clinically insignificant (difference 4.81, 95% CI 2.69, 6.92, p < 0.001). The difference of NRS scores on POD 1 was statistically significant (difference -1.23, 95% CI -2.36, -0.10, p = 0.033). Compared with group C, group E had a lower utilization rate of phenylephrine and higher Ai values (p < 0.05). There was no statistical difference between the two groups on other measures.

CONCLUSION

Continuous ketamine infusion seems to be safe and well tolerated in laparoscopic bariatric surgery. It improved the quality of postoperative recovery and reduced pain on POD 1. In spite of the increased Ai value during the surgery, it also provided better hemodynamics with less usage of phenylephrine.

Postoperative Recovery Outcomes for Obese Patients Undergoing General Anesthesia: A Meta-Analysis of Randomized Controlled Trials

Purpose

This study was performed to assess the postoperative recovery outcomes in obese patients undergoing general anesthesia.

Methods

The eligible studies were identified from PubMed, EmBase, and the Cochrane library until December 2020. The standard mean differences (SMDs) with 95% confidence intervals (CIs) were used to calculate the role of desflurane, sevoflurane, and propofol on recovery outcomes, and the analyses using the random-effects model.

Results

Eleven randomized controlled trials involving 713 obese patients undergoing general anesthesia were selected for final meta-analysis. We noted desflurane was associated with a shorter time to eye-opening than sevoflurane (SMD: −0.86; 95% CI, −1.43 to −0.28; P = 0.003). The use of desflurane with shorter time to extubation as compared with propofol (SMD: −1.13; 95% CI, −1.52 to −0.73; P < 0.001) or sevoflurane (SMD: −1.19; 95% CI, −2.15 to −0.22; P = 0.016), while sevoflurane was associated with longer time to extubation as compared with propofol (SMD: 1.47; 95% CI, 1.03 to 1.91; P < 0.001). Desflurane were associated with shorter time to stating name as compared with propofol (SMD: −1.40; 95% CI, −2.32 to −0.48; P = 0.003) or sevoflurane (SMD: −2.09; 95% CI, −3.33 to −0.85; P = 0.001). In addition, desflurane was associated with a longer time for orientation to place as compared with propofol (SMD: 0.65; 95% CI, 0.22 to 1.07; P = 0.003), while desflurane with shorter time for orientation to place as compared with sevoflurane (SMD: −0.88; 95% CI, −1.46 to −0.30; P = 0.003).

Conclusions

The use of desflurane could provide better recovery outcomes in obese patients undergoing general anesthesia. Further large-scale trials should be comparison the long-term effectiveness of various anesthetics.

A review on the anesthetic management of obese patients undergoing surgery

There has been an observed increase in theprevalence of obesity over the past few decades. The prevalence of anesthesiology related complications is also observed more frequently in obese patients as compared to patients that are not obese. Due to the increased complications that accompany obesity, obese patients are now more often requiring surgical interventions. Therefore, it is important that anesthesiologists be aware of this development and is equipped to manage these patients effectively and appropriately. As a result, this review highlights the effective management of obese patients undergoing surgery focusing on the preoperative, perioperative and postoperative care of these patients.

Anesthesia and Enhanced Recovery After Surgery in Bariatric Surgery

The Enhanced Recovery After Surgery Society published guidelines for bariatric surgery reviewing the evidence and providing specific care recommendations. These guidelines emphasize preoperative nutrition, multimodal analgesia, postoperative nausea and vomiting prophylaxis, anesthetic technique, nutrition, and mobilization. Several studies have since evaluated these pathways, showing them to be safe and effective at decreasing hospital length of stay and postoperative nausea and vomiting. This article emphasizes anesthetic management in the perioperative period and outlines future directions, including the application of Enhanced Recovery After Surgery principles in patients with extreme obesity, diabetes, and metabolic disease and standardization of the pathways to decrease heterogeneity.

Preoperative preparation and premedication of bariatric surgical patient

The prevalence of obesity has tripled worldwide over the past four decades. The United States has the highest rates of obesity, with 88% of the population being overweight and 36% obese. The UK has the sixth highest prevalence of obesity. The problem of obesity is not isolated to the developed world and has increasingly become an issue in the developing world as well. Obesity carries an increased risk of many serious diseases and health conditions, including type 2 diabetes, heart disease, stroke, sleep apnea, and certain cancers. Our ability to take care of this population safely throughout the perioperative period begins with a thorough and in-depth preoperative assessment and meticulous preparation. The preoperative assessment begins with being able to identify patients who suffer from obesity by using diagnostic criteria and, furthermore, being able to identify patients whose obesity is causing pathologic and physiologic changes. A detailed and thorough anesthesia assessment should be performed, and the anesthesia plan individualized and tailored to the specific patient's risk factors and comorbidities. The important components of the preoperative anesthesia assessment and patient preparation in the patient suffering from obesity include history and physical examination, airway assessment, medical comorbidities evaluation, functional status determination, risk assessment, preoperative testing, current weight loss medication, and review of any prior weight loss surgeries and their implications on the upcoming anesthetic. The preoperative evaluation of this population should occur with sufficient time before the planned operation to allow for modifications of the preoperative management without needing to delay surgery as the perioperative management of patients suffering from obesity presents significant practical and organizational challenges.

Metabolic surgery in treatment of obese Japanese patients with type 2 diabetes: a joint consensus statement from the Japanese Society for Treatment of Obesity, the Japan Diabetes Society, and the Japan Society for the Study of Obesity

Bariatric surgery has been shown to have a variety of metabolically beneficial effects for patients with type 2 diabetes (T2D), and is now also called metabolic surgery. At the 2nd Diabetes Surgery Summit held in 2015 in London, the indication for bariatric and metabolic surgery was included in the “algorithm for patients with type T2D”. With this background, the Japanese Society for Treatment of Obesity (JSTO), the Japan Diabetes Society (JDS) and the Japan Society for the Study of Obesity (JASSO) have formed a joint committee to develop a consensus statement regarding bariatric and metabolic surgery for the treatment of Japanese patients with T2D. Eventually, the consensus statement was announced at the joint meeting of the 38th Annual Meeting of JSTO and the 41st Annual Meeting of JASSO convened in Toyama on March 21, 2021. In preparing the consensus statement, we used Japanese data as much as possible as scientific evidence to consider the indication criteria, and set two types of recommendation grades, “recommendation” and “consideration”, for items for which recommendations are possible. We hope that this statement will be helpful in providing evidence-based high-quality care through bariatric and metabolic surgery for the treatment of obese Japanese patients with T2D.

Efficacy and safety of sugammadex doses calculated on the basis of corrected body weight and total body weight for the reversal of deep neuromuscular blockade in morbidly obese patients

OBJECTIVE

We investigated the efficacy and safety of sugammadex doses calculated using corrected body weight (CBW) for reversing deep rocuronium-induced neuromuscular blockade (NMB) in morbidly obese patients undergoing laparoscopic bariatric surgery.

METHODS

One hundred and twenty-five morbidly obese patients were randomly assigned to three groups: (1) a CBW group, n = 50; (2) a total body weight (TBW) group, n = 50; and (3) a control group, n = 25. Deep NMB was maintained using a continuous infusion of rocuronium. At the reappearance of 1 to 2 post-tetanic counts (PTCs), 4 mg/kg sugammadex, calculated using CBW or TBW, were administered.

RESULTS

All the participants in the CBW and TBW groups recovered to a train-of-four (TOF) ratio of 0.9 within 5 minutes. The recovery times from the start of sugammadex administration to a TOF ratio of 0.9 were 2.2 ± 0.7 and 2.0 ± 0.7 minutes in the CBW and TBW groups, respectively. Thus, a sugammadex dose calculated using CBW was not inferior to that calculated using TBW for the reversal of rocuronium-induced deep NMB in morbidly obese patients.

CONCLUSION

A dose of 4 mg/kg of sugammadex calculated using CBW is efficient and safe for the reversal of deep NMB after a continuous infusion of rocuronium in morbidly obese patients.

CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR1900028652 (Chinese Clinical Trial Registry, www.chictr.org.cn).

Does the Implementation of Enhanced Recovery After Surgery (ERAS) Guidelines Improve Outcomes of Bariatric Surgery? A Propensity Score Analysis in 464 Patients

BACKGROUND

The aim of this study was to investigate whether the implementation of enhanced recovery after surgery (ERAS) guidelines according to Thorell and co. in our tertiary referral bariatric center might improve post-operative outcomes.

METHODS

ERAS program was introduced in our center since January 1, 2017. Retrospective review of a prospectively collected database identified patients who underwent laparoscopic primary and revisional bariatric surgeries from October 2005 to January 2018. Patients exposed to ERAS program ("ERAS group") were matched in a 1:1 ratio with patients exposed to conventional care (control group) using a propensity score based on age, gender, preoperative body mass index (BMI), diabetes mellitus, and the type of procedures. The primary outcome was total hospital length of stay (LOS) and the secondary outcomes included the post-operative complications and readmission rates.

RESULTS

During the study period, 464 patients were included, 232 in each group. Implementation of the ERAS protocol was significantly associated with a reduction of LOS (2.47 ± 1.7 vs 5.39 ± 1.9 days, p < 0.00001). One-third of patients was discharged (77/232, 33%) on the first postoperative day (POD) and more than three quarter of patients on POD 2 (182/232, 77%). At the opposite, no patients of the control group were discharged on POD 2. Overall 30-day and 90-day morbidity and readmission rates were the same in both groups. There was no death in each group.

CONCLUSIONS

This large case-matched study using a propensity score analysis suggests that implementation of ERAS program significantly reduced length of hospital stay without significant increases on overall morbidity, and readmission rates.

Perioperative care of the obese patient

Background

Obesity has become an increasing problem worldwide during the past few decades. Hence, surgeons and anaesthetists will care for an increasing number of obese patients in the foreseeable future, and should be prepared to provide optimal management for these individuals. This review provides an update of recent evidence regarding perioperative strategies for obese patients.

Methods

A search for papers on the perioperative care of obese patients (English language only) was performed in July 2019 using the PubMed, Scopus, Web of Science and Cochrane Library electronic databases. The review focused on the results of RCTs, although observational studies, meta-analyses, reviews, guidelines and other reports discussing the perioperative care of obese patients were also considered. When data from obese patients were not available, relevant data from non-obese populations were used.

Results and conclusion

Obese patients require comprehensive preoperative evaluation. Experienced medical teams, appropriate equipment and monitoring, careful anaesthetic management, and an adequate perioperative ventilation strategy may improve postoperative outcomes. Additional perioperative precautions are necessary in patients with severe morbid obesity, metabolic syndrome, untreated or severe obstructive sleep apnoea syndrome, or obesity hypoventilation syndrome; patients receiving home ventilatory support or postoperative opioid therapy; and obese patients undergoing open operations, long procedures or revisional surgery.

[Comparison of volume-controlled and pressure-controlled ventilation on respiratory mechanics in laparoscopic bariatric surgery: randomized clinical trial]

BACKGROUND

It is not clear which mechanical ventilation mode should be used in bariatric surgery, one of the treatment options for patients with obesity.

OBJECTIVES

To compare volume-controlled ventilation and pressure-controlled ventilation in terms of respiratory mechanics and arterial blood gas values in patients undergoing laparoscopic bariatric surgery.

METHODS

Sixty-two patients with morbid obesity scheduled for gastric bypass were included in this study. Their ideal body weights were calculated during preoperative visits, and patients were divided into two groups, volume-controlled ventilation and pressure-controlled ventilation. The patients were ventilated in accordance with a previously determined algorithm. Mechanical ventilation parameters and arterial blood gas analysis were recorded 5 minutes after induction, 30 minutes after pneumoperitoneum, and at the end of surgery. Also, the dynamic compliance, inspired O₂ pressure/fractional O₂ ratio, and alveolar-arterial oxygen gradient pressure were calculated.

RESULTS

Peak airway pressures were lower in patients ventilated in pressure-controlled ventilation mode at the end of surgery (p = 0.011). Otherwise, there was no difference between groups in terms of intraoperative respiratory parameters and arterial blood gas analyses.

CONCLUSIONS

Pressure-controlled ventilation mode is not superior to volume-controlled ventilation mode in patients with laparoscopic bariatric surgery.

Comparison of volume-controlled and pressure-controlled ventilation on respiratory mechanics in laparoscopic bariatric surgery: randomized clinical trial

Background

It is not clear which mechanical ventilation mode should be used in bariatric surgery, one of the treatment options for patients with obesity.

Objectives

To compare volume-controlled ventilation and pressure-controlled ventilation in terms of respiratory mechanics and arterial blood gas values in patients undergoing laparoscopic bariatric surgery.

Methods

Sixty-two patients with morbid obesity scheduled for gastric bypass were included in this study. Their ideal body weights were calculated during preoperative visits, and patients were divided into two groups, volume-controlled ventilation and pressure-controlled ventilation. The patients were ventilated in accordance with a previously determined algorithm. Mechanical ventilation parameters and arterial blood gas analysis were recorded 5minutes after induction, 30minutes after pneumoperitoneum, and at the end of surgery. Also, the dynamic compliance, inspired O₂ pressure/fractional O₂ ratio, and alveolar-arterial oxygen gradient pressure were calculated.

Results

Peak airway pressures were lower in patients ventilated in pressure-controlled ventilation mode at the end of surgery (p = 0.011). Otherwise, there was no difference between groups in terms of intraoperative respiratory parameters and arterial blood gas analyses.

Conclusions

Pressure-controlled ventilation mode is not superior to volume-controlled ventilation mode in patients with laparoscopic bariatric surgery.

A Randomized, Double-Blind, Placebo-Controlled Trial of Intravenous Acetaminophen on Hospital Length of Stay in Obese Individuals Undergoing Sleeve Gastrectomy

BACKGROUND

Retrospective studies indicate that acetaminophen iv administration reduces hospital length of stay (LoS) and opiate consumption in patients undergoing bariatric surgery.

OBJECTIVE

This study sought to determine whether using acetaminophen iv in morbidly obese subjects undergoing sleeve gastrectomy decreased LoS and total hospital charges as compared to patients receiving saline placebo.

SETTING

Single-center university hospital METHODS: Using a randomized, double-blind, placebo-controlled design, subjects were assigned to receive either acetaminophen iv (group A) or saline placebo iv (group P). Data were collected between Jan 1 and Dec 31, 2016. Group A received acetaminophen every 6 h for a total of four doses. The first dose was administered following the induction of general anesthesia; group P received saline iv on the same schedule. Anesthetic management and prophylactic antiemetic regimen were standardized in all subjects. Postoperative pain management consisted of hydromorphone via patient-controlled infusion pump. Primary outcomes include hospital LoS and associated hospital costs. Secondary outcomes include patient satisfaction and postoperative nausea and pain scores.

RESULTS

Subject demographics (n = 127) and intraoperative management were similar in the two groups. Across all subjects, median hospital LoS in group A (n = 63) was 1.87 vs. 1.97 days in group P (n = 64) (p = 0.03, Wilcoxon rank-sum test). Postoperatively, daily quality-of-recovery (QoR-15) scores, narcotic consumption, and the use of rescue antiemetics were not significantly different between groups. Median hospital costs were as follows: group A, $12,885 vs. group P, $12,977 (n = 64).

CONCLUSIONS

Acetaminophen iv may reduce hospital LoS in subjects undergoing sleeve gastrectomy.

Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea

The purpose of the Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommendations based on current scientific evidence. This guideline seeks to address questions regarding the intraoperative care of patients with OSA, including airway management, anesthetic drug and agent effects, and choice of anesthesia type. Given the paucity of high-quality studies with regard to study design and execution in this perioperative field, recommendations were to a large part developed by subject-matter experts through consensus processes, taking into account the current scientific knowledge base and quality of evidence. This guideline may not be suitable for all clinical settings and patients and is not intended to define standards of care or absolute requirements for patient care; thus, assessment of appropriateness should be made on an individualized basis. Adherence to this guideline cannot guarantee successful outcomes, but recommendations should rather aid health care professionals and institutions to formulate plans and develop protocols for the improvement of the perioperative care of patients with OSA, considering patient-related factors, interventions, and resource availability. Given the groundwork of a comprehensive systematic literature review, these recommendations reflect the current state of knowledge and its interpretation by a group of experts at the time of publication. While periodic reevaluations of literature are needed, novel scientific evidence between updates should be taken into account. Deviations in practice from the guideline may be justifiable and should not be interpreted as a basis for claims of negligence.

Retrospective Evaluation of Patients who Underwent Laparoscopic Bariatric Surgery

OBJECTIVE

In the present study, we aimed to retrospectively evaluate the preoperative characteristics, intraoperative and postoperative results of patients who underwent laparoscopic obesity surgeries.

METHODS

After obtaining the approval of the Ethics Committee, records of patients who underwent laparoscopic obesity surgery from January 2013 to December 2016 were reviewed. Demographic characteristics, medications used in anaesthesia and analgesia, the duration of recovery unit/hospital stay, intensive care unit/mechanical ventilation requirements and complications were recorded.

RESULTS

A total of 329 ASA II-III patients over a 3-year period were operated. Thiopental and propofol were administered at induction, sevoflurane, isoflurane and desflurane were administered for the maintenance, and vecuronium and rocuronium were administered to aid in neuromuscular blockage. The mean durations of recovery unit and hospital stays were 30.80±6.01 minutes and 4.27±1.68 days, respectively. The hypnotic agent, muscle relaxant or inhalation anaesthetics used did not have a significant effect on the duration of recovery unit and hospital stay. Mask ventilation and intubation were noted to be difficult in 5.5% and 8.5% of the cases, respectively. The presence of obstructive sleep apnoea syndrome and high body mass index and Mallampati scores significantly increased difficult mask ventilation and difficult intubation rates. Four patients were transferred to intensive care unit for close monitoring. Two patients were re-operated on, two patients had rhabdomyolysis, one patient had Wernicke's encephalopathy and two patients had peripheral neuropathy. Perioperative mortality did not occur in any patient.

CONCLUSION

We believe that appropriate patient selection, the use of well-designed anaesthesia and surgical protocols play important roles in increasing the success rate of patient outcomes and early and late complications in laparoscopic obesity surgery.

The Impact of Obesity on Orthopedic Upper Extremity Surgery

Obese patients have increased rates of upper extremity injury, carpal tunnel syndrome, and upper extremity osteoarthritis. Preoperative considerations include cardiovascular disease, pulmonary disease, and diabetes mellitus. Intraoperative and anesthetic considerations include specialized equipment, patient positioning, and the physiology of obese patients. Postoperative considerations should include increased risk of cardiovascular complications as well as surgical site infections and malunion. Surgery of the hand and upper extremity may be less prone to the postoperative complications seen in other regions of the body. There are currently no direct contraindications for obese patients to undergo orthopedic procedures if the appropriate considerations have been made.

Dexmedetomidine metabolic clearance is not affected by fat mass in obese patients

BACKGROUND

Obesity has been associated with reduced dexmedetomidine clearance, suggesting impaired hepatic function or reduced hepatic blood flow. The aim of this study was to clarify the effect of obesity in dexmedetomidine metabolic clearance.

METHODS

Forty patients, ASA I-III, 18-60 yr old, weighing 47-126 kg, scheduled for abdominal laparoscopic surgery, were enrolled. Anaesthetic agents (propofol, remifentanil, and dexmedetomidine) were dosed based on lean body weight measured by dual X-ray absorptiometry. Serial venous samples were drawn during and after dexmedetomidine infusion. A pharmacokinetic analysis was undertaken using non-linear mixed-effect models. In the modelling approach, the total body weight, lean body weight, and adjusted body weight were first tested as size descriptors for volumes and clearances. Hepatic blood flow, liver histopathology, liver enzymes, and gene expression of metabolic enzymes (UGT2B10 and UGT1A4) were tested as covariates of dexmedetomidine metabolic clearance. A decrease in NONMEM objective function value (ΔOFV) of 3.84 points, for an added parameter, was considered significant at the 0.05 level.

RESULTS

A total of 637 dexmedetomidine serum samples were obtained. A two-compartmental model scaled to measured lean weight adequately described the dexmedetomidine pharmacokinetics. Liver blood flow was a covariate for dexmedetomidine clearance (ΔOFV=-5.878). Other factors, including fat mass, histopathological damage, and differential expression of enzymes, did not affect the dexmedetomidine clearance in the population studied (ΔOFV<3.84).

CONCLUSIONS

We did not find a negative influence of obesity in dexmedetomidine clearance when doses were adjusted to lean body weight. Liver blood flow showed a significant effect on dexmedetomidine clearance.

CLINICAL TRIAL REGISTRATION

NCT02557867.

Can We Predict the Perioperative Pulmonary Complications Before Laparoscopic Sleeve Gastrectomy: Original Research

BACKGROUND

The increasing prevalence of obesity in worldwide is one of the most serious chronic public health problems and is considered to be a global epidemic. Bariatric surgical procedures have also been applied more often with increased prevalence of obesity. As a result, the incidence of surgical complications has increased. Preoperative evaluation is quite important for these patients.

AIMS

The aim of our study is to determine the predictors of perioperative pulmonary complications of laparoscopic sleeve gastrectomy.

STUDY DESIGN

The study is a cross-sectional study.

METHODS

One hundred eighty-three consecutive patients who received laparoscopic bariatric surgery were followed up during 3 months. Patients were divided into two groups A and B. Group A being the patients who had perioperative pulmonary complications (n = 28) and group B being patients who had not (n = 155). Pulmonary function test (PFT), body mass index (BMI), preoperative oxygen saturation, age, gender, comorbid diseases, and smoking history were compared between these groups.

RESULTS

Mean age, size, weight, BMI, PFT parameters of groups A and B were close to each other. The strongest predictors of perioperative pulmonary complications were duration of smoking in current smokers and low baseline oxygen saturation.

CONCLUSIONS

Preoperative oxygen saturation and smoking history may help to predict perioperative complications of laparoscopic sleeve gastrectomy.

Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations

BACKGROUND

During the last two decades, an increasing number of bariatric surgical procedures have been performed worldwide. There is no consensus regarding optimal perioperative care in bariatric surgery. This review aims to present such a consensus and to provide graded recommendations for elements in an evidence-based "enhanced" perioperative protocol.

METHODS

The English-language literature between January 1966 and January 2015 was searched, with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded. After critical appraisal of these studies, the group of authors reached a consensus recommendation.

RESULTS

Although for some elements, recommendations are extrapolated from non-bariatric settings (mainly colorectal), most recommendations are based on good-quality trials or meta-analyses of good-quality trials.

CONCLUSIONS

A comprehensive evidence-based consensus was reached and is presented in this review by the enhanced recovery after surgery (ERAS) Society. The guidelines were endorsed by the International Association for Surgical Metabolism and Nutrition (IASMEN) and based on the evidence available in the literature for each of the elements of the multimodal perioperative care pathway for patients undergoing bariatric surgery.

The Effect of Aromatherapy with the Essential Oil of Orange on Pain and Vital Signs of Patients with Fractured Limbs Admitted to the Emergency Ward: A Randomized Clinical Trial

BACKGROUND AND OBJECTIVE

Pain is an emotional and unpleasant experience associated with actual or potential tissue damage. The literature shows no study on the effect of aromatherapy with the essential oil of orange on unpleasant feelings of patients with fractured limbs. In this regard, this paper aims at studying the effect of aromatherapy with the essential oil of orange on patients with fractured limbs admitted to the emergency ward.

METHODS

Sixty patients admitted to the emergency ward of Vali-e-Asr Hospital were selected by purposive sampling method and then were divided into two groups of control and experiment by block method. This study was done in one shift work (morning or afternoon). Four drops of the orange oil were poured on a pad and were pinned with a plastic pin to the patient's collar, about 20 cm distant from head. The old pad was replaced by the new one every 1 h. The patients' pain and vital signs were checked every 1 h for at last 6 h. The data were analyzed by SPSS Version 21.

RESULTS

Forty (66.7%) patients were male and twenty (33.3%) were female. Their age average was 37.93 ± 18.19 years old. The most fractured cases were in the scapular (11 patients [18.3%]). Friedman test showed that pain in the experiment group (P = 0.0001) decreased significantly rather than the control group (0.339). However, in vital signs, there could be found that no significant change between the two groups was seen.

CONCLUSION

Aromatherapy with orange oil can relieve pain in patients with fractured limbs but has no effect on their vital signs. Therefore, aromatherapy with orange oil can be used as a complementary medicine in these patients.

Perioperative care in bariatric surgery in the context of the ACERTO project: reality versus surgeons assumptions in a Cuiabá hospital

Objective:

to assess the level of knowledge among bariatric surgeons, about the recommendations of the ACERTO Project, correlating their assumptions on their perioperative prescriptions and the reality, according to the patients charts.

Method:

we conducted a prospective, longitudinal, observational study comparing the assumptions of bariatric surgeons obtained through responses on a specific questionnaire with the reality found in clinical data from the hospital records. We analyzed the following variables: preoperative fasting, early postoperative feeding, intravenous hydration, perioperative antibiotic prophylaxis, use of abdominal drains, type of analgesia, and prophylaxis of nausea and vomiting. We confronted the responses of seven surgeons with data from 200 records of patients undergoing gastroplasty for morbid obesity.

Results:

all interviewed surgeons knew the ACERTO Project. Five (72%) responded that they followed the protocol thoroughly. The median time of preoperative fasting found in the records was higher than the reported by the surgeons (p<0.05). Early postoperative feeding was prescribed for 96.5% of cases. The median volume of intravenous fluids prescribed in the first 24 hours was 4000ml, which was consistent with the interviews. There were no differences between the response in the questionnaire and the findings in the hospital records in relation to antibiotic prophylaxis, use of catheters and drains, analgesia and prophylaxis of nausea and vomiting.

Conclusion:

the ACERTO Project was well practiced among the surveyed surgeons. There was a good correlation between their assumptions and the reality in perioperative care of patients undergoing bariatric surgery. However, there was a significant difference in preoperative fasting time.

Anesthetic Considerations in Patients Undergoing Bariatric Surgery: A Review Article

Context

This article discusses the anesthetic considerations in patients undergoing bariatric surgery in the preoperative, intraoperative, and postoperative phases of surgery.

Evidence Acquisition

This review includes studies involving obese patients undergoing bariatric surgery. Searches have been conducted in PubMed, MEDLINE, EMBASE, Google Scholar, Scopus, and Cochrane Database of Systematic Review using the terms obese, obesity, bariatric, anesthesia, perioperative, preoperative, perioperative, postoperative, and their combinations.

Results

Obesity is a major worldwide health problem associated with many comorbidities. Bariatric surgery has been proposed as the best alternative treatment for extreme obese patients when all other therapeutic options have failed.

Conclusions

Anesthetists must completely assess the patients before the surgery to identify anesthesia- related potential risk factors and prepare for management during the surgery.

Bariatric Surgery Provides a "Bridge to Transplant" for Morbidly Obese Patients with Advanced Heart Failure and May Obviate the Need for Transplantation

BACKGROUND

In patients with advanced heart failure, morbid obesity is a relative contraindication to heart transplantation due to higher morbidity and mortality in these patients.

METHODS

We performed a retrospective analysis of consecutive morbidly obese patients with advanced heart failure who underwent bariatric surgery for durable weight loss in order to meet eligibility criteria for cardiac transplantation.

RESULTS

Seven patients (4 M/3 F, age range 31-56 years) with left ventricular ejection fraction (LVEF) ≤ 25 % underwent laparoscopic bariatric surgery. Median preoperative body mass index (BMI) was 42.8 kg/m(2) (range 37.5-50.8). There were no major perioperative complications in six of seven patients. Median length of hospital stay was 5 days. There was no mortality recorded during complete patient follow-up. At a median follow-up of 406 days, median BMI reduction was 12.9 kg/m(2) (p = 0.017). Postoperative LVEF improved to a median of 30 % (interquartile range (IQR) 25-53 %; p = 0.039). Two patients underwent successful cardiac transplantation. Two patients reported symptomatic improvement with little change in LV function and now successfully meet listing criteria. Three patients showed marked improvement of their LVEF and functional status, thus removing the requirement for transplantation.

CONCLUSIONS

Bariatric surgery can achieve successful weight loss in morbidly obese patients with advanced cardiac failure, enabling successful heart transplantation. In some patients, cardiac transplantation can be avoided through surgical weight loss.

A review of important medical and surgical considerations for obese patients undergoing arthroscopic surgery

Obesity represents a unique challenge in orthopaedic surgery, the impact of which is seen through all phases of injury: in the development of disease, during the operative procedure, and throughout the rehabilitation period. Given the high prevalence of obesity in the United States and around the world, this patient population represents a substantial proportion of patients in need of orthopedic care. The effects of this disease constrain both medical and financial resources. For obese patients undergoing orthopedic procedures, adequate steps must be taken to minimize the risks that occur before, during, and after surgical intervention. This literature review discusses the impact of obesity on arthroscopic procedures, with a focus on procedures involving the shoulder, hip, and knee. The management of obese patients during the perioperative period should address the specific concerns relating to these patients. Obesity is a risk factor for numerous comorbidities, is associated with surgical complications, and is a predictor of poor functional outcomes following arthroscopy. Efforts to minimize the negative impact of obesity on arthroscopic procedures are crucial.

Subcutaneous perfusion before and during surgery in obese and nonobese patients

Hypoxia at the surgical site impairs wound healing and oxidative killing of microbes. Surgical site infections are more common in obese patients. We hypothesized that subcutaneous oxygen tension (Psq O2) would decrease substantially in both obese and non-obese patients following induction of anesthesia and after surgical incision. We performed a prospective observational study that enrolled obese and non-obese surgical patients and measured serial Psq O2 before and during surgery. Seven morbidly obese and seven non-obese patients were enrolled. At baseline breathing room air, Psq O2 values were not significantly different (p = 0.66) between obese (6.8 kPa) and non-obese (6.5 kPa) patients. The targeted arterial oxygen tension (40 kPa) was successfully achieved in both groups with an expected significant increase in Psq O2 (obese 16.1 kPa and non-obese 13.4 kPa; p = 0.001). After induction of anesthesia and endotracheal intubation, Psq O2 did not change significantly in either cohort in comparison to levels right before induction (obese 15.5, non-obese 13.5 kPa; p = 0.95), but decreased significantly during surgery (obese 10.1, non-obese 9.3 kPa; p = 0.01). In both morbidly obese and non-obese patients, Psq O2 does not decrease appreciably following induction of anesthesia, but decreases markedly (∼33%) after commencement of surgery. Given the theoretical risks associated with low Psq O2 , future research should investigate how Psq O2 can be maintained after surgical incision.

Perioperative fluid guidance with transthoracic echocardiography and pulse-contour device in morbidly obese patients

BACKGROUND

In bariatric surgery, non- or mini-invasive modalities for cardiovascular monitoring are addressed to meet individual variability in hydration needs. The aim of the study was to compare conventional monitoring to an individualized goal-directed therapy (IGDT) regarding the need of perioperative fluids and cardiovascular stability.

METHODS

Fifty morbidly obese patients were consecutively scheduled for laparoscopic bariatric surgery (ClinicalTrials.gov Identifier: NCT01873183). The intervention group (IG, n=30) was investigated preoperatively with transthoracic echocardiography (TTE) and rehydrated with colloid fluids if a low level of venous return was detected. During surgery, IGDT was continued with a pulse-contour device (FloTrac™). In the control group (CG, n=20), conventional monitoring was conducted. The type and amount of perioperative fluids infused, vasoactive/inotropic drugs administered, and blood pressure levels were registered.

RESULTS

In the IG, 213 ± 204 mL colloid fluids were administered as preoperative rehydration vs. no preoperative fluids in the CG (p<0.001). During surgery, there was no difference in the fluids administered between the groups. Mean arterial blood pressures were higher in the IG vs. the CG both after induction of anesthesia and during surgery (p=0.001 and p=0.001).

CONCLUSIONS

In morbidly obese patients suspected of being hypovolemic, increased cardiovascular stability may be reached by preoperative rehydration. The management of rehydration should be individualized. Additional invasive monitoring does not appear to have any effect on outcomes in obesity surgery.

Postoperative recovery after anesthesia in morbidly obese patients: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Obese patients present a challenge to safe general anesthesia because of impaired cardiopulmonary physiology and increased risks of aspiration and acute upper airway obstruction. Since studies are lacking regarding the postoperative effects on recovery from general anesthesia in morbidly obese patients, we conducted a systematic review and meta-analysis of recovery outcomes in morbidly obese patients who had undergone general anesthesia.

SOURCE

We systematically searched the PubMed, EMBASE™, Cochrane, and Scopus™ databases for randomized controlled trials that evaluated the outcome of anesthesia with desflurane, sevoflurane, isoflurane, or propofol in morbidly obese patients. Using a random effects model, we conducted meta-analyses to assess recovery times (eye opening, hand squeezing, tracheal extubation, and stating name or birth date), time to discharge from the postanesthesia care unit (PACU), and the incidence and severity of postoperative nausea and vomiting (PONV).

PRINCIPAL FINDINGS

We reviewed results for 11 trials and found that patients given desflurane took less time: to respond to commands to open their eyes (weighted mean difference [WMD] -3.10 min; 95% confidence interval (CI): -5.13 to -1.08), to squeeze the investigator's hand (WMD -7.83 min; 95% CI: -8.81 to -6.84), to be prepared for tracheal extubation (WMD -3.88 min; 95% CI: -7.42 to -0.34), and to state their name (WMD -7.15 min; 95% CI: -11.00 to -3.30). We did not find significant differences in PACU discharge times, PONV, or the PACU analgesic requirement.

CONCLUSION

Postoperative recovery was significantly faster after desflurane than after sevoflurane, isoflurane, or propofol anesthesia in obese patients. No clinically relevant differences were observed regarding PACU discharge time, incidence of PONV, or postoperative pain scores. The systematic review was registered with PROSPERO (CRD42014009480).

Comparison of recovery criteria in morbidly obese patients undergoing laparoscopic gastric sleeve resection following use of sevoflurane and isoflurane

Context:

The favorable kinetic properties of sevoflurane could be advantageous in obese patients undergoing bariatric surgery, improving recovery from general anesthesia (GA).

Aims:

To compare the recovery criteria following anesthesia with sevoflurane and isoflurane in morbidly obese patients undergoing laparoscopic gastric sleeve resection.

Settings and Design:

This was a prospective randomized controlled study conducted in 50 patients undergoing laparoscopic sleeve gastrectomy.

Materials and Methods:

Following awake fiberoptic intubation, GA was induced and maintained with sevoflurane in Group A and isoflurane in Group B. 2% sevoflurane and 1.2% isoflurane were used and concentration varied to maintain a mean arterial pressure (MAP) of >75 mm of Hg, maximum concentration being 3% for sevoflurane and 2% for isoflurane. Inhalational agent was terminated at time of skin suturing and patients were extubated when completely awake. Recovery criteria followed were eye opening on call, voluntary head raising on command for 5 s and orientation assessed by answering name and location.

Statistical Analysis Used:

Student's t-test was used to test statistical significance of difference in mean values between the groups, analysis of covariance was used to test diastolic blood pressure (DBP) changes and Chi-square test to assess association between categorical variables.

Results:

There was no significant variability in heart rate, systolic blood pressure, DBP and MAP between 2 groups up to 210 min. Group A patients had significantly faster eye opening compared to Group B (4.4 ± 1.6 vs. 9.2 ± 2.18 min), were significantly faster in obeying commands (6.08 ± 1.6 vs. 10.08 ± 2.02 min), had a significantly shorter extubation time (7.08 ± 1.6 vs. 11.16 ± 2.18 min) and significantly faster orientation in time as compared to Group B (9.24 ± 1.7 vs. 12.32 ± 2.42 min).

Conclusion:

Sevoflurane has a better recovery profile based on eye opening, obeying commands, time for extubation and orientation, than isoflurane in morbidly obese patients undergoing laparoscopic sleeve gastrectomy.

Anesthetic management of patients undergoing bariatric surgery: two year experience in a single institution in Switzerland

BACKGROUND

In the field of anesthesia for bariatric surgery, a wide variety of recommendations exist, but a general consensus on the perioperative management of such patients is missing. We outline the perioperative experiences that we gained in the first two years after introducing a bariatric program.

METHODS

The perioperative approach was established together with all relevant disciplines. Pertinent topics for the anesthesiologists were; successful airway management, indications for more invasive monitoring, and the planning of the postoperative period and deposition. This retrospective analysis was approved by the local ethics committee. Data are mean [SD].

RESULTS

182 bariatric surgical procedures were performed (147 gastric bypass procedures (GBP; 146 (99.3%) performed laparascopically). GBP patients were 43 [10] years old, 78% female, BMI 45 [7] kg/m(2), 73% ASA physical status of 2. 42 patients (28.6%) presented with obstructive sleep apnea syndrome. 117 GBP (79.6%) patients were intubated conventionally by direct laryngoscopy (one converted to fiber-optic intubation, one aspiration of gastric contents). 32 patients (21.8%) required an arterial line, 10 patients (6.8%) a central venous line. Induction lasted 25 [16] min, the procedure itself 138 [42] min. No blood products were required. Two patients (1.4%) presented with hypothermia (<35 °C) at the end of their case. The emergence period lasted 17 [9] min. Postoperatively, 32 patients (21.8%) were transferred to the ICU (one ventilated). The other patients spent 4.1 [0.7] h in the post anesthesia care unit. 15 patients (10.2%) required take backs for surgical revision (two laparotomies).

CONCLUSIONS

The physiology and anatomy of bariatric patients demand a tailored approach from both the anesthesiologist and the perioperative team. The interaction of a multi-disciplinary team is key to achieving good outcomes and a low rate of complications.

TRIAL REGISTRATION

DRKS00005437 (date of registration 16(th) December 2013).

Role of intraoperative fluids on hospital length of stay in laparoscopic bariatric surgery: a retrospective study in 224 consecutive patients

BACKGROUND

Studies are unclear regarding optimal intraoperative fluid management during laparoscopic bariatric surgery. The purpose of this 1-year study was to investigate the role of intraoperative fluid administration on hospital length of stay (hLOS) and postoperative complications in laparoscopic bariatric surgery.

METHODS

Patient data analyzed included previously reported demographics, comorbidities, and intraoperative fluid administration on the duration of hLOS and incidence of postoperative complications.

RESULTS

Logistic regression analysis of demographic and comorbidity variables revealed that BMI (P = 0.0099) and history of anemia (P = 0.0084) were significantly associated with hLOS (C index statistic, 0.7). Lower rates of intraoperative fluid administration were significantly associated with longer hLOS (P = 0.0005). Recursive partitioning observed that patients who received <1,750 ml of intraoperative fluids resulted in longer hLOS when compared to patients who received ≥ 1,750 ml (LogWorth = 0.5). When intraoperative fluid administration rates were defined by current hydration guidelines for major abdominal surgery, restricted rates (<5 ml/kg/h) were associated with the highest incidence of extended hLOS (>1 postoperative day) at 54.1 % when compared to 22.9 % with standard rates (5-7 ml/kg/h) and were lowest at 14.5 % in patients receiving liberal rates (>7 ml/kg/h) (P < 0.0001). Finally, lower rates of intraoperative fluid administration were significantly associated with delayed wound healing (P = 0.03).

CONCLUSIONS

The amount of intravenous fluids administered during laparoscopic bariatric surgery plays a significant role on hLOS and on the incidence of delayed wound healing.

The expansion of the pulmonary rib cage during breath stacking is influenced by age in obese women

OBJECTIVE

To analyze in obese women the acute effects of the breath stacking technique on thoraco-abdominal expansion.

DESIGN AND METHODS

Nineteen obese women (BMI ≥ 30 kg/m(2)) were evaluated by anthropometry, spirometry and maximal respiratory muscle pressures and successively analyzed by Opto-Electronic Plethysmography and a Wright respirometer during quiet breathing and breath stacking maneuvers and compared with a group of 15 normal-weighted healthy women. The acute effects of the maneuvers were assessed in terms of total and compartmental chest wall volumes at baseline, end of the breath stacking maneuver and after the maneuver. Obese subjects were successively classified into two groups, accordingly to the response during the maneuver, group 1 = prevalent rib cage or group 2 = abdominal expansion.

RESULTS

Age was significantly lower in group 1 than group 2. When considering the two obese groups, FEV1 was lower and minute ventilation was higher only in group 2 compared to controls group. During breath stacking, inspiratory capacity was significant differences in obese subjects with a smaller expansion of the pulmonary rib cage and a greater expansion of the abdomen compared to controls and also between groups 1 and 2. A significant inverse linear relationship was found between age and inspiratory capacity of the pulmonary rib cage but not of the abdomen.

CONCLUSIONS

In obese women the maximal expansion of the rib cage and abdomen is influenced by age and breath stacking maneuver could be a possible therapy for preventing respiratory complications.

Aprepitant's prophylactic efficacy in decreasing postoperative nausea and vomiting in morbidly obese patients undergoing bariatric surgery

BACKGROUND

Postoperative nausea and vomiting is a major cause of patient dissatisfaction towards surgery. For bariatric surgery, increased vomiting/retching is detrimental to surgical anastomosis. The present study evaluated the efficacy of aprepitant (neurokinin-1 inhibitor) as a prophylactic antiemetic in morbidly obese patients for laparoscopic bariatric surgery.

METHODS

After institutional review board approval, 125 morbidly obese patients were recruited into this double-blind placebo-controlled trial. On random division, the patients received a tablet of aprepitant (80 mg) in group A, or a similar-appearing placebo in group P, an hour prior to surgery. All patients received intravenous ondansetron (4 mg) intraoperatively. Postoperatively, the patients were evaluated for nausea and vomiting by a blinded evaluator at 30 min, 1, 2, 6, 24, 48, and 72 h.

RESULTS

Both groups were evenly distributed for age, body mass index, type, and length of surgery. Cumulative incidence of vomiting at 72 h was significantly lower in group A (3%) compared to group P (15%; p = 0.021). Odds ratio for vomiting in group P compared to group A was 5.47 times. On Kaplan-Meier plot, time to first vomiting was also significantly delayed in group A (p = 0.019). A higher number of patients showed complete absence of nausea or vomiting in group A compared to group P (42.18 vs. 36.67%). On the other hand, nausea scores were unaffected by aprepitant, and no significant difference between groups was found at any of the measured time points.

CONCLUSIONS

In morbidly obese patients undergoing laparoscopic bariatric surgery, addition of aprepitant to ondansetron can significantly delay vomiting episodes simultaneously lowering the incidence of postoperative vomiting.

Proper Patient Positioning and Complication Prevention in Orthopaedic Surgery

➤ The consequences of improper intraoperative positioning can be profound: it not only may cause substantial morbidity but also may be a major area of litigation, particularly when peripheral nerve injury occurs.➤ The ulnar nerve is most likely to be injured secondary to improper positioning. The elbow should be flexed ≤90° and the forearm placed in a neutral or slightly supinated position intraoperatively to minimize pressure in the cubital tunnel.➤ Pressure-related complications, such as pressure ulcers and alopecia, are best avoided by the use of adequate padding. Cushions on the operating-room table and armrest should be emphasized under osseous prominences.➤ Positioning the head in a non-neutral alignment or arm abduction of ≥90° may result in injury to the brachial plexus.➤ The hemilithotomy position increases intracompartmental pressure in the leg on the uninjured side. The risk of well-leg compartment syndrome can be minimized by avoiding this position if possible.

Morbid obesity and optimization of preoperative fluid therapy

BACKGROUND

Preoperative venous return (VR) optimization and adequate blood volume is essential in management of morbidly obese patients (MO) in order to avoid perioperative circulatory instability. In this study, all subjects underwent a preoperative 3-week preparation by rapid-weight-loss-diet (RWL) as part of their treatment program for bariatric surgery.

METHODS

This is a prospective, observational study of 34 morbidly obese patients consecutively scheduled for bariatric surgery at Sunderby County Hospital, Luleå, Sweden. Preoperative transthoracic echocardiography (TTE) was performed in the awake state before and after intravascular volume challenge (VC) of 6 ml colloids/kg ideal body weight (IBW). Effects of standardized VC were evaluated by TTE. Dynamic and non-dynamic echocardiographic indices for VC were studied. Volume responsiveness and level of VR before and after VC were assessed by TTE. An increase of stroke volume ≥13% was considered as a volume responder.

RESULTS

Twenty-nine out of 34 patients were volume responders. After VC, a majority of patients (23/34) were euvolemic, and only 2/34 were hypovolemic. Post-VC hypervolemia was observed in 9/34 of patients.

CONCLUSIONS

The IBW-based volume challenge regime was found to be suitable for preoperative rehydration of RWL-prepared MO. Most of the patients were volume responders. Preoperative state of VR was not associated with volume responsiveness. IBW estimates and appropriate monitoring avoids potential hyperhydration in MO. For VC assessment, conventional Doppler indices were found to be more suitable compared to tissue Doppler, giving sufficient information on pressure-volume correlation of the left ventricle in morbidly obese.

The use of VivaSight™ single lumen endotracheal tube in morbidly obese patients undergoing laparoscopic sleeve gastrectomy

Background

The population of obese patients is progressively growing and bariatric operations are becoming increasingly common. Morbidly obese patients require special anesthetic care and are often considered to be difficult to ventilate and intubate. The VivaSight™ Single Lumen tube is an endotracheal tube with a camera embedded in its tip. The view from the tip appears continuously on a monitor in the anesthesiologist's vicinity. The aim of this study was to assess the VivaSight™ in comparison with conventional endotracheal tube as an aid in the intubation and surveillance of tube position during surgery of obese patients.

Methods

This is a prospective study of 72 adult obese patients who underwent laparoscopic sleeve gastrectomy. The patients were randomly assigned to be intubated by either the VivaSight™ (40 patients, test group) or a conventional endotracheal tube (32 patients, control group). Data on the patients, the pre-operative airway evaluation, the endotracheal intubation and the post-operative outcome were collected and compared.

Results

The Mallampati scores were significantly higher in the test group than in the control group. Endotracheal intubation took 29 ± 10 and 24 ± 8 seconds using the VivaSight™ and a conventional tube respectively (p = 0.02). Three of the patients in the control group, while none of those in the test group, had soft tissue injury (p < 0.05).

Conclusion

We found the VivaSight™ SL to be helpful in the endotracheal intubation and continuous surveillance of tube position in morbidly obese patients undergoing laparoscopic sleeve gastrectomy.

An unusual cause of hypoglycemia in a middle-aged female after bariatric surgery

Non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS) is a disorder characterized by postprandial hypoglycemia and islet cell hypertrophy. It is an uncommon complication of weight-loss surgery. However, with the rising incidence of gastric bypass surgeries, it is important to be able to recognize the clinical picture of NIPHS and not to incorrectly ascribe the symptoms to late dumping syndrome.