Lung physiology and obesity: anesthetic implications for thoracic procedures

Clinical Considerations and Outcomes of Robotic Urologic Surgery in Obese Patients

Obesity is associated with many significant physiological changes. These considerations are important to surgery, especially in urological procedures. Obese patients often undergo surgical procedures and are at higher risk of complications. This investigation reviews physiological and anaesthesia considerations for obese and morbidly obese patients. In addition, urological surgeries and procedures should be considered for these higher risk patients. Clinical anaesthesiologists must use detailed assessment and, when appropriate, consultation in developing safe anaesthesia plans for these patients. Newer technologies have improved safety related to airway management, advanced airway devices, and regional anaesthesia with ultrasound-guided nerve blocks, which can reduce the need for opioids postoperatively. Recent developments in drug and monitoring technologies have also been developed and can be effective for obese and morbidly obese patients undergoing urological procedures and perioperative surgery, thus improving the likelihood of safety in this higher risk population.

Multimodal approach utilising a weight management programme prior to bariatric surgery in patients with BMI ≥50 kg/m2: A propensity score matching retrospective cohort study

We evaluated preoperative weight loss and days from initial consult to surgery in patients with BMI ≥50 kg/m2 who were and were not enrolled in medical weight management (MWM) prior to laparoscopic sleeve gastrectomy. We retrospectively identified patients with BMI ≥50 kg/m2 who had primary sleeve gastrectomy between 2014 and 2019 at two bariatric surgery centres in our healthcare system. Patients presenting after 2017 that received preoperative MWM (n = 28) were compared to a historical cohort of non-MWM patients (n = 118) presenting prior to programme initiation in 2017 on preoperative percent total body weight loss (%TBWL) and days from initial consult to surgery. A total of 151 patients (MWM, 33; non-MWM, 118) met inclusion criteria. BMI was significantly greater in MWM versus non-MWM (p = .018). After propensity score matching, median BMI at initial consult in non-MWM versus MWM no longer differed (p = .922) neither were differences observed on the basis of weight, age, sex, race or ethnicity. After PSM, MWM had significantly lower BMI at surgery (p = .018), lost significantly more weight from consult to surgery (p < .001) and achieved significantly greater median %TBWL from consult to surgery (p < .001). We noted no difference between groups on 6-month weight loss (p = .533). Days from initial consult to surgery did not differ between groups (p < .863). A preoperative MWM programme integrated into multimodal treatment for obesity in patients with a BMI ≥50 kg/m2 resulted in clinically significant weight loss without prolonging time to surgery.

General Anesthetic Care of Obese Patients Undergoing Surgery: A Review of Current Anesthetic Considerations and Recent Advances

Obesity has long been linked to adverse health effects over time. As the prevalence of obesity continues to rise, it is important to anticipate and minimize the complications that obesity brings in the anesthesia setting during surgery. Anesthetic departments must recognize the innumerable risks when managing patients with obesity undergoing surgery, including anatomical and physiological changes as well as comorbidities such as diabetes, cardiovascular diseases, and malignancies. Therefore, the purpose of this review is to analyze the current literature and evaluate the current and recent advances in anesthetic care of obese patients undergoing surgery, to better understand the specific challenges this patient population faces. A greater understanding of the differences between anesthetic care for obese patients can help to improve patient care and the specificity of treatment. The examination of the literature will focus on differing patient outcomes and safety precautions in obese patients as compared to the general population. Specifically highlighting the differences in pre-operative, intra-operative, and post-operative care, with the aim to identify issues and present possible solutions.

Does morbid obesity influence perioperative outcomes after video-assisted thoracic surgery (VATS) lobectomy for non-small cell lung cancer? Analysis of the Italian VATS group registry

OBJECTIVES

Obesity in Europe, and worldwide, has been an increasing epidemic during the past decades. Moreover, obesity has important implications regarding technical issues and the risks associated with surgical interventions. Nevertheless, there is a lack of evidence assessing the influence of obesity on video-assisted thoracic surgery (VATS) lobectomy results. Our study aimed to assess the impact of morbid obesity on perioperative clinical and oncological outcomes after VATS lobectomy using a prospectively maintained nationwide registry.

METHODS

The Italian VATS lobectomy Registry was used to collect all consecutive cases from 55 Institutions. Explored outcome parameters were conversion to thoracotomy rates, complication rates, intra-operative blood loss, surgical time, hospital postoperative length of stay, chest tube duration, number of harvested lymph-node, and surgical margin positivity.

RESULTS

From 2016 to 2019, a total of 4412 patients were collected. 74 patients present morbid obesity (1.7%). Multivariable-adjusted analysis showed that morbid obesity was associated with a higher rate of complications (32.8% vs 20.3%), but it was not associated with a higher rate of conversion, and surgical margin positivity rates. Moreover, morbid obesity patients benefit from an equivalent surgical time, lymph-node retrieval, intraoperative blood loss, hospital postoperative length of stay, and chest tube duration than non-morbid obese patients. The most frequent postoperative complications in morbidly obese patients were pulmonary-related (35%).

CONCLUSION

Our results showed that VATS lobectomy could be safely and satisfactorily conducted even in morbidly obese patients, without an increase in conversion rate, blood loss, surgical time, hospital postoperative length of stay, and chest tube duration. Moreover, short-term oncological outcomes were preserved.

Obesity Surgery and Anesthesiology Risks: a Review of Key Concepts and Related Physiology

The obesity epidemic is swelling to epic proportions. Obese patients often suffer from a combination of hypertension, dyslipidemia, and type 2 diabetes mellitus (T2DM), also known as the "metabolic syndrome." The metabolic syndrome is an independent predictor of cardiac dysfunction and cardiovascular disease and a risk factor for perioperative morbidity and mortality. In this paper, we discuss the perioperative risk factors and the need for advanced care of obese patients needing general anesthesia for (bariatric) surgical procedures based on physiological principles.

Atelectasis in Bariatric Surgery: Review Analysis and Key Practical Recommendations

Obesity is a condition that affects multiple organ systems, particularly the cardiovascular and respiratory system. In recent years, bariatric surgery has been reported to be the gold standard in the treatment of morbid obesity. Body mass index alone is insufficient to predict risks related to anaesthesia and surgery. Obesity contributes to significant postoperative atelectasis and is considered an independent risk factor for postoperative atelectasis owing to decreased functional residual capacity. The treatment and reversibility of atelectasis developed in obese patients undergoing bariatric surgery are challenging. Therefore, an optimisation of pulmonary functions before surgery, lung-sparing ventilation during the perioperative period, awareness of potential postoperative complications and knowledge about preventive measures and therapeutic approaches have become increasingly important in bariatric surgery. The aim of this review was to aid clinicians in the management of atelectasis in patients undergoing bariatric surgery during the perioperative and postoperative period.

Comparison of Arndt-endobronchial blocker plus laryngeal mask airway with left-sided double-lumen endobronchial tube in one-lung ventilation in thoracic surgery in the morbidly obese

This study aimed to evaluate the feasibility and performance of Arndt-endobronchial blocker (Arndt) combined with laryngeal mask airway (LMA) compared with left-sided double-lumen endobronchial tube (L-DLT) in morbidly obese patients in one-lung ventilation (OLV). In a prospective, randomized double-blind controlled clinical trial, 80 morbidly obese patients (ASA I-III, aged 20-70) undergoing general anesthesia for elective thoracic surgeries were randomly allocated into groups Arndt (n=40) and L-DLT (n=40). In group Arndt, a LMA™ Proseal was placed followed by an Arndt-endobronchial blocker. In group L-DLT, patients were intubated with a left-sided double-lumen endotracheal tube. Primary endpoints were the airway establishment, ease of insertion, oxygenation, lung collapse and surgical field exposure. Results showed similar ease of airway establishment and tube/device insertion between the two groups. Oxygen arterial pressure (PaO2) of patients in the Arndt group was significantly higher than L-DLT (154±46 vs 105±52 mmHg; P<0.05). Quality of lung collapse and surgical field exposure in the Arndt group was significantly better than L-DLT (effective rate 100 vs 90%; P<0.05). Duration of surgery and anesthesia were significantly shorter in the Arndt group (2.4±1.7 vs 3.1±1.8 and 2.8±1.9 vs 3.8±1.8 h, respectively; P<0.05). Incidence of hoarseness of voice and incidence and severity of throat pain at the post-anesthesia care unit and 12, 24, 48, and 72 h after surgery were significantly lower in the Arndt group (P<0.05). Findings suggested that Arndt-endobronchial blocker combined with LMA can serve as a promising alternative for morbidly obese patients in OLV in thoracic surgery.