Consultant anesthesiologist

Anaesthesia department

Security Force Hospital, Riyadh, KSA.

Adnan B. Mofti MB. ChB. FRCS(Eng) FRCS(Glas)

Consultant Surgeon

Department of Surgery

Security Forces Hospital, Riyadh, K.S.A.

Adel Al-Zourkany MB.ChB.

Anaesthesia Registrar

Anaesthesia department

Security Force Hospital (SFH), Riyadh, KSA

Nader M. Hussein MB. ChB, FRCS(Ed)

Senior Registrar.

Department of Surgery

Security Forces Hospital, Riyadh, K.S.A

Mohammad S.M. Takrouri MB. ChB. FFARCSI.

Locum Consultant Intensive Care, Department of Anaesthesia SFH

Professor of Anaesthesia

King Khalid University Hospital (KKUH), Medical college, King Saud University, Riyadh, K.S.A.

Address for correspondence: Safwan T Jandali,

Department of Anaesthesia, Security Forces Hospital,

P.O.box 3643, Riyadh 11481, Kingdom of Saudi Arabia.

Tel 009661 4774480

Fax 009661 4764747

BACKGROUND: Laparoscopic surgery has become a widely practiced procedures, especially in the gynecological day surgery and branches of general surgery. Now more procedures are done using this technique, Laparoscopic Gastroplasty for morbid obesity is one of these new applications, The anaesthesia implications are special, due to the association of morbid obesity with restrictive -obstructive lung diseases, cerebro- cardio-vascular diseases and the possibility of occurrence of sudden death in this group of patients. The creation of pneumoperitoneum adds more burden on the respiratory and cardiovascular systems in the perioperative period..

OBJECTIVES: Description of the first case of gastroplasty at SFH (Riyadh) using laparoscopic technique and the implication of morbid obesity on choice of anaesthesia.

SETTING: Tertiary care Security Forces Hospital in Riyadh.

PATIENT: A 26 years old female developed morbid obesity (after the birth of her second child) which was a social and psychological embarrassment, which lead her to request surgical interference.

INTERVENTIONS: After preoperative evaluation, General anesthesia was given , which included planned operative and post operative epidural analgesia and selective SICU admission for monitoring and pain relief.

MEASUREMENT AND THE MAIN RESULTS: Preoperative lung function tests, intraoperative cardiovascular pressure measurements, which continues during the immediate post-operative Anaesthesia. Epidural narcotics and low concentration of local analgesics were used to control pain, blood gases urea and electrolytes were monitored. Capnography and pulse oximetry were used as well.

CONCLUSION: Anaesthesia for laparoscopic gastroplasty has special issue to solve. Though monitoring, ventilation and proper analgesia will reduce the hospital stay, morbidity and mortality.

KEY WARDS:

Major MeSH: Anaesthesia, general; Gastrointestinal tract, intestine; Surgery gastrointestinal Gastroplasty [methods]; Laparoscopy;.

Minor MeSH: Adult; Female; Middle age; Pain relief; Monitoring; Investigation

Check Tag: Case Report, Human.

Banded gastroplasty combines the best that has been learned about gastric reduction operations with another feature: a window through both walls of the stomach just above the craw’s foot and next to the outlet along the lesser curvature. This window allows the application of staples up to create a small pouch (less than 50 mL)[1].Operation is the only effective measure for the morbidly obese patient. It is associated with long term weight loss which will correct or improve related conditions , including sleep apnea syndrome. obesity hypoventilation syndrome, hypercholesterolaemia and hypertension [2]. Mortality and morbidity rate were coated as 1.2, 0.1, 0.5.% and 7.3, 10.3, 15% respectively. [3,4,5]

Laparoscopic surgery has become a widely practiced procedures. The wealth of experience in laparoscopy proved that this new technique is safe, less expensive with reduced incidence of severe pain and the patient resume his normal life in short time. [6] Also it presented new special problems including the complications of insufflation of carbon dioxide and its resorption to the blood [7], embolization, and the cardiovascular effects which occur due to the increased intra-abdominal pressure. The anaesthesia implications of morbid obesity are special since the patient may have respiratory and cardiovascular function limitation. The use of pneumoperitoneum during the procedure may inflict more problems regarding the carbon dioxide absorption, the diaphragmatic dysfunction and the cardiovascular sequelae of the raised intra-abdominal pressure. In this paper we are reporting the first experience in laparoscopic gastroplasty in the Security Forces Hospital. . A review of literature revealed no published anaesthetic experience of bariatric surgery. from the Kingdom of Saudi Arabia.

A 26 year old woman, married and have two children, was scheduled for laparoscopic gastroplasty.

The patient was interviewed by the respiratory therapist and a selection of exercises breathing, and calf movements were adopted. the patient was put on prophylactic low molecular weight heparin heparin commencing the morning of surgery and cephalosporins antibiotic. On the day of surgery she received premedication of oral lorazepam and metoclopromide (plasil).

In the theater two anesthesiologists administered anaesthesia. and two principal surgeons performed the procedure. An epidural was performed in the interspinous space T10-11 using 18g Tohey needle and an epidural catheter was inserted. Monitoring of the patient included ECG, pulse oximetry, capnography, central venous pressure from a catheter inserted in the right internal jugular vein, and direct arterial pressure from cannula inserted in the left radial artery. The patient was induced on the operating table. Anaesthesia was induced by using midazolam and fentanyl injected intravenously in a peripheral small cannula in the left hand, Intubation of the trachea was facilitated by atracurium 40 mg. cricoid pressure was applied till inflation of the tracheal cuff. Pneumatic cast compression was applied to both legs. After induction a special nasogastric tube with balloon was inserted in order to empty the stomach and to facilitate the surgery, and replaced at the end of surgery with smaller nasogastric tube. Maintenance of anaesthesia was achieved by incremental dosage of fentanyl 0.05 mg atracurium infusion, nitrous oxide:oxygen 50:50 % and isoflurane supplement. The tidal volume of 1 liter was used. The patient was positioned in reverse Trendelenburg position with foot rest and pneumatic intermittent inflation on both legs. The peak respiratory pressure was in the region of 25-30 cm H2O. The patient arms were placed on arm rests. A total of 200 ug fentanyl intravenously was used during the length of the surgery, in intermittent doses. 100 ug of fentanyl was injected epidurally. Muscle relaxation was maintained by infusion of atracurium 10 ug/kg/min. The course of the anaesthesia was uneventful.

The surgical procedure: After draping of the abdomen, a small incision was done through the umbilicus. Veress needle was introduced and pneumoperitoneum was created, and laparoscope was inserted. After retracting the left lobe of the liver, the stomach was pulled down using Endo-clench to stretch the area in the gastroesophageal junction. Then, dissecting at the upper part of the lesser curvature, using the microdissector and blunt dissection, a window was created in that area dissecting posteriorly. The reticular was introduced through the 10-mm port and passed around the cardia. The nasogastric tube with a balloon was introduced and filled with 10 cc of saline and pulled until it hinged at the gastroesophageal junction and then the gastroplasty band was introduced through the 12-mm port and passed through the window created around the upper part of the fundus of the stomach and closed around that angle below the nasogastric balloon. The special occluding machine is utilized to close the ring. Then fundoplication was done to bury the band using the endoscopic suturing device. About four interrupted vicryl stitches were done for this fundoplication. The tail of the gastroplasty band was brought out through the 5-mm port in the left side and connected to the reservoir which was fixed deep in the fascia of the rectus muscle using vicryl stitches. Minimal blood loss was noticed. Calibration was done by the gastrometer. The band would receive 5 cc saline if needed and pressure inside it would rise to 3 Torr. The wounds were sutured.

Post operative intensive care management:

At the end of the procedure, antagonism of the residual muscle relaxation was reversed by 2.5 mg neostigminee, the patient was awake and extubated and transferred to the SICU in a semirecumbent position. During the next five hours in the post operative period, analgesia was achieved by injecting preservative free morphine epidurally. CVP readings were reflecting good filling and at no time hypotension occurred. The urine output was at rate of 100 ml/h and that continue for 18 hours post operatively. The nursing management included oxygen therapy, early mobilization, incentive spirometry and chest physiotherapy. These were repeated at 2 hour interval. The patient needed minimal epidural narcotics consisted of 3 mg of morphine in 10 ml saline /12 h, she maintained good blood gases all through. On the morning of the second post operative day the patient was mobile, pain free, and starting soft diet. She was transferred to the surgical ward and was discharged home next day.

Obesity is common metabolic disease. It is prevailing in KSA, recent study [8] indicated that high prevalence of overweight and obesity especially among females. Overweight and obesity were defined as 25 kg/m2 < BMI < 30Kg/m2 and BMI > 30 kg/m2 respectively, using this definition in a sample of 1485 patients (685 males and 800 females) was found to be 31.5% and 40.5% for females and 40.20% and 21.0% for male respectively. These values were lower when BMI greater than 85th and 95th percentile of the American population of age group 20-29 years, was used to define overweight and obesity. There were sex differential and patients with chronic diseases such as diabetes mellitus, hypertension and gall stone have a significantly higher proportion of obesity. This Saudi study confirm the findings of similar previous studies.. Usually body mass index is calculated in order to indicate clinically the presence of obesity (BMI = weight (kg)/height (m)2). Obesity is defined as a BMI greater than 30 Kg m-2 and morbid obesity as BMI greater than 39 kg m-2 [9]. In the Saudi studies females shown higher tendencies for morbid obesity due to hormonal, life style and eating habits of the Saudi women. In a Meta-analysis study it was concluded That all large, and several smaller prospective studies have found that morbid obesity (body mass index (BMI) greater or equal to 35 kg/m2) is associated with an approximately two-fold increase in total mortality and seven-fold increase in mortality from diabetes, cerebrovascular, cardiovascular disease, and certain forms of cancer. The incidence of sudden death unexplained at autopsy is up to 40 times greater than in general population [10]. Weight reducing or bariatric surgery is a well defined surgical subspecialty in the west. Earlier treatment of obesity by bypass surgery was complicated by dumping, vitamin B12, folate and iron deficiencies [11].

laparoscopy on the other hand, employs highly technical equipment, and the surgeon should have formal training in the technique. it is essential to have in-depth knowledge of the use of optics, electrical principles, gas under pressure, and the physiologic changes that occur when carbon dioxide is placed in the abdominal cavity. Above all, the surgeon must adhere rigidly to guidelines for appropriate technique. deviation will most assuredly result in complications and even death [12]. General surgery application of laparoscopy followed a wealth of medical experience from gynecological laparoscopies, which declared the technique as safe, reduce hospital stay with little pain and disfigurement and laparoscopic cholecystectomy started to enjoy ever increasing popularity. It retained the advantages of shorter hospital stay, more rapid return to normal activities, less pain, small incisions and less postoperative ileus compared with the traditional open cholecystectomy. Soon many procedures were done using this new technique in adult and children, Hernia repair, diaphragmatic repair, fundoplications gastroplasty.

Anaesthesia for laparoscopy has been established with a broad usage of agents an techniques. General anaesthesia using balanced anaesthesia technique including intravenous induction agents like: Thiopentone, propofol, etomidate, and inhalational agents like: Nitrous oxide, isoflurane[13,14],

Desflurane[13] has been reported. variety of muscle relaxants including succinyl choline, mivacurium,[15] atracurium, vecuronium aiming at rapid recovery and cardiovascular stability. [16] Total intravenous anaesthesia using agents propofol, midazolam and ketamine, alfentanil and vecuronium has been reported also for outpatient laparoscopy [17]. Epidural anaesthesia was considered as safe alternative to general anaesthesia for outpatient laparoscopy without associated respiratory depression. [18]. In the case presented a model case of anaesthesia and surgical management was intended, since it was the first to be performed using laparoscopy. A combination of balanced anaesthesia using muscle relaxant, intravenous and epidural narcotics and artificial ventilation to combat the effect of surgical insult and the effects of pneumoperitoneum, namely the resorption of carbon dioxide, diaphragmatic movement impairment and the reduction in lung volumes. The direct arterial pressure monitoring helped in given continuos records of blood pressure and the blood gases estimation when is needed. the CVP helped in assessing the preload status. While the ECG demonstrated the rhythm status continuously. The recommended prophylactic heparin use is in accordance with prevention of deep venous thrombosis and subsequent pulmonary embolism. the use of intermittent inflated pneumatic cast compression helped in maintaining circulation in the legs during the operation. The admission to SICU was intended in order to have closer monitoring, administration of oxygen therapy, epidural narcotics and to have vigorous physiotherapy. Since over weight, obesity and morbid obesity has in general a high prevalence in Saudi population, we expect that more morbidly obese patient will seek the surgical help. There is no specialist center for this type of surgery and it is practiced as side line of the general anaesthetist and general surgeon practice. the special implication of the disease and the safe outcome needed for this type of surgery would necessitate that the anaesthesiologist should administer his skill in this most sophisticated set up of laparoscopic and highly demanding cases. The method adopted in anaesthetizing this patient is the result of literature revision and following the common sense in making the choice of agents and technique.

We would like to thank Mrs. Mary Germaine C. Villavert operating room secretary for secretarial and typing help she gave. Also we would like to thank Mr Aahoor Hussein of Anaesthesia Department KKUH, and Mr Mohammad Akram off Medical Photography at KKUH, for their swift assistance in producing the artwork of figures (1&2).

References

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[2] Sugarman HJ, Kellum JM, Engle KM. Gastric bypass for treating severe obesity. American Journal of clinical Nutrition 1992; 55:560S-566S

[3] Pasulka PS, Bistrian Br, Bebotti PN, BN, Blackburn GL. The risks of surgery in obese patients. Annals of internal Medicine 1986; 104:540-456.

[4] Mason EE, Renquist KE, Jiang D. perioperative risks and safety of surgery for severe obesity. American Journal of clinical Nutrition 1992; 55:573S-576S.

[5] Goulding ST, Hovell BC. Anaesthetic experience of vertical banded gastroplasty BJA 1995:75:3:301.

[6] Cali R.W. Laparascopy: Symposium on modern techniques in surgery. Surg Clin North Am 1980;60(20:407-24.

[7] Waldvogel H.H., Schneck H.J., Felber A., Von Hundelshausen B.

Anesthesia relevant features of laparoscopy- the value of capnograohy (German text)Anaesthesiol Reanim 1994;1914-10.

[8] Ogbeide DO, Bamgboye EA, KarimA, Al-Khalifa I. The prevaleence of overweight and obesity and its correlation with chronic diseases in Al-Kharj adult outpatients, Saudi Arabia. Saudi Medical Journal 1996;17(3):327-332.

[9] Bary GA Definition, measurements, and classification of the syndrome of obesity. International Journal of Obesity 1978;2:99 -114.

[10] Sjostrom LV. Mortality of severely obese subjects. American journal of clinical Nutrition 1992;55:516s-523s.

[11] Fobi MAL, Fleming AW, Vertical banded gastroplasty versus gastric bypass in the treatment of obesity. Journal of the National medical Association 1986;78:1091-1098.

[12] Cali R.W. Laparascopy: Symposium on modern techniques in surgery. Surg Clin North Am 1980;60:20:407-24.

[13] Van Hemelrijck J., Smith I., White P.F. Use of desflurane for outpatient anesthesia. a comparison with propofol and nitrous oxide. Anesthesiology 1991;75(2):197-203.

[14] de Grood P.M., Harberts J.B., van Egmond J., Crul J.F. Anaesthesia for laparoscopy. A comparison of five techniques including propofol, etomidate, thiopentone and isoflurane. Anaesthesia 1987 42(8):815-23.

[15] Ding Y., Fredman B., White.,

use of mivacurium during laparoscopic surgery: effect of reversal drugs on post operative recovery.

Anesth Analg 1994;78(3):450-4.

[16] Ding Y., Fredman B., White.,

use of mivacurium during laparoscopic surgery: effect of reversal drugs on post operative recovery.

anesth Analg 1994;78(3):450-4.

[17] Bailie R., Craig G., Restall J. Total intravenous anaesthesia for laparoscopy. Anaesthesia 1987;44(1):60-3.

[18] Ciofolo M.J., Clergue F., Seebacher J., Lefebvre G., Viares P. Ventilatory effects of laparascopy under epidural anesthesia. Anesth Analg 1990;70(4):357-61.

TABLE (1) The preoperative lung function tests showing restrictive obstructive lung condition. The patient is female, aged 25 y, height 158cm., weight 105.5 kg. The values are at BTPS. Date July 20^th 1997.