Bariatric Surgery an Anaesthetist’s Perspective: Where are we Now?

In the first part of this series (published in Defence Update Winter 2014), a GP and a Physician provided their perspectives on bariatric surgery. In this final part, we have asked a Bariatric Surgeon and an Anaesthetist to discuss their views on this topic.

 An Anaesthetist’s Perspective

When I started in consultant practice in the mid-1990s, I was involved in some of the early cases of adjustable gastric banding (AGB) in both public and private settings. As the idea was unheralded in our facilities, the first few cases (in the 200kg plus range) got sent back from the pre-anaesthesia clinic to the Endocrinologist with my suggestion that the patient lose some weight before the procedure was re-booked. Since then, we have all seen many great successes and some prolonged ICU stays, and sadly even some mortality. Many practices have sprung up with very well-trained Surgeons and back-up teams along with sophisticated marketing online.

Like all Anaesthetists, I now commonly see post-bariatric surgery patients coming in for other procedures. Recently I saw a patient who was around 75kg who had an AGB in place. When I asked her how much weight she had lost in the two years since the band, she told me she had been 87kg before the band, but “I had to eat to get there”. She had been denied surgery at 83kg because that Surgeon had a minimum 85kg rule. This type of patient will be recognised by clinicians who are used to dealing with human motivations for “lifestyle” procedures – not everyone acts reasonably all the time.

As an Anaesthetist you may ask, so what? We don’t select the patients, and there should be a GP and perhaps also a Physician and others involved in a multidisciplinary team. It is a relevant issue for us because these patients have an increased risk of Anaesthetic mortality and morbidity compared to the general population, and the surgery is elective. We are part of a team and equally responsible for the wellbeing of this vulnerable group of people. The patients have high expectations and there are often also high costs because access to public treatment options can be difficult, further increasing the medico-legal risk.¹

General anaesthetic concerns are well known and well managed by Anaesthetists who deal with these patients frequently. Obesity creates extra challenges including:²

• moving and positioning patients
• intravenous and arterial line access
• weight-based drug dosage
• airway management³ – ventilation, intubation and dental damage
• fluid balance
• high intra-abdominal pressures with laparoscopic surgery
• management of major haemorrhage or other critical events such as anaphylaxis that require resuscitation
• comorbidities including sleep apnoea, complicated by opiate pain relief and compromised ventilation
• post-operative atelectasis and venous thromboembolism

I would like to highlight other very specific risks from my MDA National experience and the anecdotal claims of others:

• Anaesthetist participation in the surgery by way of introduction of large bougies into the oesophagus and stomach to facilitate surgery.⁴ Though rare, cases of perforation are potentially catastrophic, and proper training should be undertaken before the Anaesthetist is expected to agree to participate – if he or she agrees at all. In my opinion, the Anaesthetist must remain protective of the patient and should also be comfortable that this approach will not put their employment at risk, as professional autonomy is also important.
• The “occasional” bariatric list where someone who is not familiar with the Surgeon and their work is thrust into what can be a very complex case on a very challenging patient.

Dr Andrew Miller, Anaesthetist
MDA National Mutual Board Member

References
1. Hickson GB, et al. Patient Complaints and Malpractice Risk. JAMA 2002;287(22):2951-2957.
2. Babatunde O, et al. Anesthetic Considerations for Bariatric Surgery. Anesthesia & Analgesia 2002;95(6):1793-1805.
3. Brodsky JB, et al. Morbid Obesity and Tracheal Intubation. Anesthesia & Analgesia 2002;94(3):732-736.
4. Soto FC, et al. Esophageal Perforation During Laparoscopic Gastric Band Placement. Obes Surg 2004;14(3):422-5.