“Morbid Obesity-Perioperative Management”
“A well researched and referenced book that has proved invaluable. The detailed analysis of the pathophysiological changes of morbid obesity will stop any reader from eating a biscuit with their morning coffee!.”...
Prof. Adrian Alvarez Prof. Jay Brodsky
Dear Professors Alvarez and Brodsky,
It is a pleasure and an honor to be able to speak with you about my favorite Obesity Book. Interviewing its authors brings back the early days of bariatric anaesthesia - information was scarce, and this book was the real eye-opener for me.
Ed. Prof. Alvarez, may we start with you explaining how you got the idea to write this book, actually the first comprehensive book about the perioperative management of the morbidly obese ?
AA. Many years ago, I was asked by a surgeon to provide anesthesia for a morbidly obese patient. At that time I have never had the experience before of facing a morbidly obese patient for surgery. For that reason I tried to look for information…and you can imagine what happened. There was almost nothing written. Only a few old case reports, a 20 years old booklet. That was almost it. I realized that there was an absolute need to get some information to guide anesthesiologist on how taking care of these patients for surgery. Some years on from that first experience, I started to look for other colleagues interested in the topic, and that was the beginning of the many interesting and necessary works that have been done in this field.
Ed. You involved an international group of renowned contributors with different specialist areas of interest and the result was a very logical and readable book. Could you tell us a little bit about the story behind these collaborations?
AA. When I first started to work with morbidly obese patients, I thought that as very little was available in the medical literature (about anesthesia and perioperative care), I needed to base my management on physiological basic concepts and extrapolation from other surgical populations to this scenario. Also, that I would need to get in contact with others going through the same experience. So, I get in close contact with many bariatric teams from all over the world. May be due to the fact that I am also a surgeon, my communication with other surgeons was very easy and productive. I started to give lectures in surgical meetings, and during these I was always looking for contacting other anesthesiologists. It was mainly though this route that I started to know many anesthesiologists working in the field. Also, when there was a topic that I considered extremely important to be included in the book and nothing was written for morbidly obese patients. I contacted world opinion leaders in the field, and convinced them to get interested in this “new challenge”. They were very collaborative and that was how I got that great team for the first edition of the book.
Ed. Morbid obesity is nowadays seen in so many patients presenting for anaesthesia, so your book “Morbid Obesity” is very helpful in understanding how obesity changes normal physiology, and how to improve our management of these patients. Prof. Brodsky, when you decided on this book, did you think the aim was to create a guide for obesity anaesthesia or to focus on particulars of anaesthesia in bariatric surgery ?
JB. The goal of our book “Morbid Obesity – Perioperative Management” was to address the entire perioperative management of all obese surgical patients. Because most studies and clinical experience with obese patients concerned bariatric procedures, many of the chapters deal with problems specific to bariatrics, with application to other procedures. However, a soft-cover version of the book was distributed to critical care physicians. That edition contained five key chapters – Pulmonary Physiology and Sleep Disordered Breathing, Ventilatory Strategies, Airway Management, Effects of Obesity on Anesthetic Agents, and Monitoring – clearly these topics (and many others in the book) were appropriate for all morbidly obese patients not just for those undergoing bariatric procedures.
Ed. A great poet once said “ All is old and all is new”….
The first edition of “Morbid Obesity”, published in 2004, followed obese patients from their preoperative assessment and preparation, to their intraoperative surgical and anaesthetic management, and then onto their postoperative care.
How much of what was written then remains, and what has changed in the interim?
JB. The first edition set the blue-print for the subsequent second edition – pre-, intra- and post-operative management. In the 5 years between editions, the published experience with managing obese patients grew exponentially. Many practices considered appropriate in 2004 had changed by 2010, and I think many of the practices in the second edition are now becoming out of date. For instance, the fasting protocols for surgical patients have markedly changed – we no longer insist on “NPO after midnight” but allow clear liquids up to 2 hours before surgery. In 2004 we knew little about “protective lung ventilation” – a standard practice now. I could list many other practices that have changed in 10 years. Again, the anesthetic and surgical management of any patient always follows the same organization – pre-, intra- and post-op - but the specific practices change.
Ed. In your capacity as the preface writer, to whom do you think this book should most appeal?
JB .“Morbid Obesity – Perioperative Management” covers all aspects of the perioperative management of obese patients – I think its main audience are anesthesiologists and surgeons; but certainly internists, sleep-medicine physicians, nutritionists, psychologists, surgical ward nurses, and any one else involved in the clinical management of obese patients will find the book useful. Several years ago our book was considered for a book prize in the UK – not as an anesthetic text but as a medical textbook – one that appealed to a wide readership; again, anyone involved in the management of morbidly obese patients.
Ed. The foreword of the book, written by prof. Mervyn Deitel, bariatric surgeon, co- founder of IFSO and founder of Obesity Surgery, underlines the challenges of morbidly obese and the need for the multidisciplinary team especially the importance of close relationship between surgeons and anaesthesiologists.
Prof. Alvarez as you have the both experiences, I have a question of a more philosophical nature: What is the key of the anaesthesiologist-surgeon relationship and why is so important when dealing with morbidly obese?
AA. As I said before, being a surgeon helped me in many ways. For example, I got a whole lot of collaboration from the surgical world. I also had a great platform to share my experiences with other colleagues from all over the planet and to learn from others.
When you have to deal with challenging perioperative situations, good communication and collaboration is essential.
Going back to 20 years ago, the situation was challenging. Bariatric surgery was a very new surgical subspecialty. It was something absolutely new in the majority of the countries in the globe. It was challenging for the surgeons because they had to create new operations (laparoscopic gastric by-pass, Scopinaro technique, duodenal switch, adjustable gastric banding etc.), develop new instruments…
Also, during the very first years of training in bariatric surgery the learning curve can be really stressful.
Complications after surgery in morbidly obese patients are more frequent than in lean individuals. And this is something that almost every bariatric team had experienced. When, as a surgeon you have to face many complications (and many times, very severe and life threatening ones), much more than those in your previous practice, you ask to yourself: what am I doing wrong?. Those surgeons who were pioneers in bariatrics earlier on realized that in order to achieve good outcomes there was an absolute need to have a multidisciplinary approach. A peri-operative, multidisciplinary team was the most important element to start working in this field.
In my country, 2 decades ago I was directing an Institute devoted to bariatric surgery, and I used to have a team with more than 10 different specialties working altogether to take good care of these patients.
Finally, the key of the anesthesiologist-surgeon relationship is honest, clear and strong communication. This is true in bariatric surgery, but also, in any type of complex surgical procedure. If you are a surgeon, and you are operating on an extremely difficult case (technically speaking) and you ask your anesthesiologist how the patient is doing… you want an honest answer, and you have to trust in the people that is taking care of your patient.
Now, seeing the same situation from the anesthesiologist point of view, you also need to trust in your surgeon. Frequently you will need to take decisions together, for example to reduce intra-abdominal pressure to convert to an open procedure etc.
Strong, honest communication and teamwork is crucial in taking care of surgical morbidly obese patients.
Ed. What were the first edition sales?
AA.I have never asked.
Ed. Has the book been translated into any languages other than English ? If so, do you find the translations are different from the original version?
AA.As far as I know, it is only written in English.
Ed. Prof. Alvarez-The changes in anaesthesia techniques are obvious . Your interest in TIVA/TCI and use of remifentanil are related to the correlation between the pharmacokinetic and dynamic of this drug and the known sensitivity to opioids of morbidly obese. Regarding opioids in the morbidly obese, what do you think are the major debates or points of contention in this area, and what are the main learning points?
AA.It seems that opioid analgesia is not the best option for morbidly obese patients. There is evidence that opioid analgesia is not the best option for any patient.
Nowadays there is much interest in optimizing postoperative recovery. Going deeper in the analysis it could be said that the interest is in optimizing perioperative physiology. Immune function, nausea and vomiting, gastrointestinal propulsive activity, early ambulation etc. are key points to achieve the fastest and best quality recovery. All that I mentioned in the previous paragraph might be affected negatively by the use of opioids in any surgical population. But if morbidly obese are considered the situation is even worse due to the association of OSAS.
When the first edition of the book was published I was very much interested in remifentanil due to the fact of the rapid off set of opioid respiratory depression. The problem was to find and adequate method to provide safe and effective postoperative analgesia once remifentanil was discontinued.
Many years have passed and I have being trying different analgesic regimes. At this moment (and for more than 10 years) I have been using thoracic epidural analgesia, opioid free of course. In other perioperative scenarios, thoracic epidural anesthesia/analgesia has been demonstrated to promote better outcomes (less nausea and vomiting, better respiratory performance, faster recovery of intestinal function, etc.) all of them related to enhanced recovery and to reduce the length of stay. For that reason (I am very much prone to that kind of perioperative approaches) I have been doing this in morbidly obese patients. I strongly believe this is a field (regional anesthesia/analgesia, and enhanced recovery) that needs to be investigated in our population.
Ed. When I think about obese airway management the name that pops up in my mind is - Prof Jay Brodsky. Even if you didn’t tackle this issue in the book I know your experience is extremely vast in this dynamic field that develops continually.
In your opinion, what are there real grounds for anaesthesiologists’ concern when dealing with morbidly obese airway and what are the skills they need to master accordingly?
JB . Thank you. I have been an anesthesiologist for over 40 years. When I started, extremely obese patients were rare – very unique. A mystique grew about the “dangers and challenges” of their airway management. This was before pulse oximetry, end-tidal carbon dioxide monitoring, even fiberoptic bronchoscopy. I remember “blind, awake intubations” in some patients. Now we can monitor what is happening. We can differentiate between the obese patient who may have airway problems (OSA, large neck) and the obese patient with normal anatomy. We have learned that correct positioning (Reverse Trendelenburg, Head Elevated Laryngoscopy Position) can increase safe-apnea time and improve view during laryngoscopy. All these advances over the past 2 decades have now made the airway management of the great majority of obese patients “routine” and safe. Of course, there is a subset of obese patients (like every size patient) who may be difficult – and for these patients we must be prepared. To manage the obese patients we all must be familiar with additional airway tools (bougies, fiber optic bronchoscopes, video-laryngoscopes), position the patient correctly, and always have an additional pair of experienced hands nearby to help if needed. Most of us now realize that effective face mask ventilation of extremely obese patients is much more difficult than the intubation of their trachea.
Ed. The other recognized area of your expertise is in lung isolation during thoracic surgery –do you think the application of these techniques to morbidly obese justifies and requires a free standing chapter?
JB. Each type of surgery has its own unique challenges when dealing with the extreme obese patient. The book “Morbid Obesity – Perioperative Management” was an intended as an overview concerning general problems. Another of our co-editors on that book, Dr Harry Lemmens, and I have published a companion textbook, “Anesthetic Management of the Obese Surgical Patient” in which individual chapters consider the special challenges for each surgical subspecialty – thoracic, orthopedics, gynecology, etc.
Ed. Moving to a broader perspective I might have a few questions:
On the ESPCOP website the key points for obese anaesthesia are published - the teamwork of international experts who presented lectures at the this year Euroanaesthesia in Stockholm.
Do you have suggestions for further key points regarding the perioperative management of morbidly obese?
AA. At this point in the evolution of perioperative medicine, I believe that ERAS and morbid obesity should be emphasized. Also, considering all the potential advantages that regional (neuraxial included obviously) anesthesia have shown in other patients populations, I strongly believe that regional anesthesia is one of the most important fields to develop in this population.
Summarizing: ERAS and regional anesthesia.
JB.The lessons we learn continue to change and evolve. We all benefit from ongoing education – journal articles, reviews, web sites, discussion groups, medical meetings – since all are needed to keep abreast on the management of obese patients.
Ed. Prof. Alvarez together with Prof. Brodsky you are the founders of the ISPCOP the sister Society with the same interest and mission as ESPCOP.
Just wondering what thoughts you might have on the future of the development and progress of these Societies as well as their relationship?
AA. Strong and honest collaboration.
ISPCOP was created to spread the knowledge in this field and to encourage research. ESPCOP seeks for the same goals. Working together and helping each other is the only logical way to go.
JB. These societies were founded in order to bring physicians and others with an interest in obesity together – again to learn from each other and to help share our experiences with “non-specialists”. I support the continued growth with both professional and friendly interchange between members of ISPCOP, EPSCOP, and the UK’s SOBA.
Ed. “To improve is to change; to be perfect is to change often”- Churchill’s statement says it all..
…to improve first we must undergo change, extrapolating to the extreme that improving to the point of perfection requires frequent change.
How can we best change in our aim to improve the peri-operative management of our morbidly obese patients?
JB. Understanding of physiology and actual clinical practices change and evolve as we learn more about obesity For example, until recently obese patients were specifically excluded from drug studies. Hence, our practice of giving medications based on actual weight were derived from studies of non-obese, normal weight patients. This is not only incorrect but dangerous. Today, people like my colleague Jerry Ingrande at Stanford, specifically study the pharmacology of routine anesthetic agents, but now in morbidly obese patients. Jerry has shown that administering propofol on a straight mg/kg basis (as advocated by some in the past and unfortunately by some currently) is unnecessary and potentially dangerous; and that lean body weight is a better and safer scalar. We have to change our practices as the science and the experience with these patients grow.
AA. In medicine, change has to be guided by evidence. Evidence comes from honest research and scientific communication of results.
I agree, everything is perfectible and perfection comes from permanent change. Our work is not an exception to this rule. In order to change looking for excellence first we must to do research. Maybe, one day, our societies (ISPCOP, ESPCOP SOBA, etc) may help to encourage international research.
Ed. I’ve got one last question, what would the next Obesity book title be?
AA. “ Morbid obesity-Perioperative Optimization”
JB. I think “Morbid Obesity – Perioperative Management” is a great title – why would we change it?
Ed. Thank you for taking time out to participate in this interview .
JB. Thank you
AA. You are very welcome, in fact I feel I am the one to thank you for your kind interview and for the chance to share ideas within our community.
Prof. Adrian Alvarez
ISPCOP Founder President
Conference Organizing Committee (COC).
World Congress of Anesthesiologists (WCA)2012
Hospital Italiano de Buenos Aires. Argentina
Prof. Jay Brodsky
Anesthesiology, Perioperative and Pain Medicine
Stanford University ,USA
Obesity Upcoming meetings
The 5th ESPCOP Meeting
Ghent , Saturday 20th December 2014
Don’t miss the opportunity to meet & learn with other colleagues involved in perioperative care of morbidly obese
On the topic:
How do the morbidly obese patients perform in non-bariatric settings?
The Early bird registration deadline on 1st of November 2014
The ESPCOP and SOBA members benefit of reduced fees
On Friday 19th
Live demonstration in the operation theatre for bariatric patients -limited availability - please book your place now!
We are pleased to inform that is opened Call for abstracts!
Authors are encouraged to submit an abstract related to obesity and anesthesia or ICU presented for the first time within the last year to be presented at the meeting.
Selected abstracts will be presented as posters and the best five will be selected for oral presentation. There will be prizes of 250-500-1000 euro for the three best presentations.
The SOBA Key Issues and Annual Scientific Meeting
London, Friday and Saturday 5th & 6th December 2014
For those unable to attend the excellent scientific programme of the ESPCOP meeting in Ghent on the 20th
of December, all is not lost. Two weeks beforehand, at the Royal College of Physicians in Central London, the UK Society for Obesity and Bariatric Anaesthesia (SOBA) is also running an Obesity Anaesthesia Meeting.
The meeting runs over two days, with a “Key Issues” study day on the Friday the 5th, covering all aspects of obesity anaesthesia and aimed at education, re-licensing and revalidation; followed by a more academic and cutting-edge Annual Scientific Meeting on the Saturday 6th, focussed more upon Bariatric Anaesthesia and Surgery. This second day includes the SOBA abstract prize presentation session, and we welcome abstract submissions of any unpublished bariatric or obesity anaesthesia related study.
Details of the meeting, including accommodation suggestions, can be found at www.sobaconference.com
. The detailed programme for each of the days can be downloaded from here:
The reciprocal arrangement between SOBA and ESPCOP means that any member of ESPCOP is entitled to the same £25 reduction in registration fees as a SOBA member. If you are an ESPCOP or SOBA member booking before the 1st
of November to get the early bird rate, the registration is a total of £225 for the entire meeting – Christmas come early!
Hoping to see as many of you as possible come December, if not in Ghent, then maybe in London.
Nerve stimulators to treat OSA
Implantation of a sleep apnea device called Inspire Upper Airway Stimulation (UAS) therapy can lead to significant improvements for patients with obstructive sleep apnea (OSA), according to a study published in the New England Journal of Medicine
The Stimulation Therapy for Apnea Reduction STAR trial is a multicenter (22 medical centers in the United States and Europe), prospective, single-group, cohort design study that evaluated the clinical safety and effectiveness of upper airway stimulation for sleep apnea. Primary outcomes measured were the apnea–hypopnea index (AHI) and oxygen desaturation index (ODI). The study shows a 68% median reduction in AHI, a 70% median reduction in ODI, and improved quality of life.
Bariatric surgery and CPAP Reduce the Risk of Atrial Fibrillation in morbidly obese patients
The presence of OSA increases the risk to develop AF and also the success of AF ablation. CPAP therapy may well help mitigate these effects, improving the outcomes of Pulmonary Vein Isolationin the OSA patient population.
AF is exceedingly prevalent in patients with obstructive sleep apnea (OSA) Mechanisms by which OSA increases the risk of AF include: 1) intermittent nocturnal hypoxemia and hypercapnia; 2) enhanced sympathetic tone with varies the blood pressure during apneic episodes leading to left atrial stretch and volume overload; 3) increased oxidative stress and inflammatory processes.
CPAP is an important therapy in OSA patients undergoing pulmonary vein isolation (PVI) that improves arrhythmia free survival. PVI offers limited value to OSA patients not treated with CPAP( Journal of the American College of Cardiology Volume 62, Issue 4
, 23 July 2013, Pages 300–305)
Bariatric surgery for patients with severe obesity effectively reduces sleep disorders breathing, especially OSA
A randomized, controlled trial, was designed, conducted, and reported in Sao Paolo, Brazil in accordance with the standards of The CONSORT (Consolidated Standards of Reporting Trials) Statement.
80 patients undergoing bariatric surgery met the criteria for OSA (75%) and 25% of these patients had moderate-to-severe OSA. The findings demonstrate that bariatric surgery for patients with severe obesity effectively reduces neck and waist circumference, improves pulmonary function, improves sleep architecture and reduces respiratory sleep disorders, especially OSA. The patients are currently in follow up for the determination of the results of bariatric surgery after one year.
MD Daniela Godoroja
work in progress…
The UK Society for Obesity and Bariatric Anaesthesia (SOBA) and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) are writing guidelines on managing the obese surgical patient. The working party is led by Dr. Claire Nightingale and the writing started mid 2012!
The first AAGBI guidelines on the peri-operative management of the obese patient were published in 2007. These focussed on organisational and equipment issues for anaesthetic departments (1). In 2012 a consensus statement was published on anaesthesia for patients with morbid obesity, written and endorsed by SOBA(2). The Centre for Maternal and Child Enquiries and the Royal College of Obstetricians and Gynaecologists (CMACE/RCOG) have also published a Joint Guideline on management of women with obesity in pregnancy (3). Our guidelines are an update of the existing ones and include new material on several topics including pharmacology, positioning and sleep disordered breathing, plus the single sheet aide-memoire which is already available from the SOBA website (www.SOBAUK.com). The advent of bariatric (weight treatment) surgery has produced a subgroup of anaesthetists with specific experience in the management of obese patients. SOBA was set up in 2009 to share the knowledge gained from bariatric anaesthesia to improve the anaesthetic care of obese patients in general. This experience forms the basis of these guidelines.
Much of the information is adapted from material presented at SOBA’s one-day courses on how to safely anaesthetise the obese patient. This material is constantly being updated and the emphasis subtly changed as more information comes to light. This of course makes writing guidelines all the more challenging. Some of the areas engendering heated discussion are: where to anaesthetise the patient, who should be doing it, how much anaesthetic do they need and where should they be cared for afterwards?
Currently the guidelines are in the final stages of editing and will hopefully be submitted for peer review in the next few weeks.
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