Obesidad, cirugía, anestesia/Obesity, Surgery, Anesthesia

Banda gástrica ajustable y ¨bypass¨ en Y-Roux laparoscópicos como procedimientos primarios para los súper-súper obesos (IMC > 60 kg/m²).  Laparoscopic adjustable banded roux-en-y gastric bypass as a primary procedure for the super-super-obese (body mass index > 60 kg/m²). Dillemans B, Van Cauwenberge S, Agrawal S, Van Dessel E, Mulier JP. Department of General Surgery, AZ Sint-Jan Hospital AV, Brugge, Belgium. bruno.dillemans@azbrugge.be BMC Surg. 2010 Nov 14;10:33. doi: 10.1186/1471-2482-10-33. Abstract BACKGROUND: Currently, there is no consensus opinion regarding the optimal procedure of choice in super-super-morbid obesity (Body mass index, BMI > 60 kg/m²). Roux-en-Y gastric bypass (RYGB) is associated with failure to achieve or maintain 50% excess weight loss (EWL) or BMI < 35 in approximately 15% of patients. Also, percent EWL is significantly less after 1-year in the super-super-obese group as compared with the less obese group and many patients are still technically considered to be obese (lowest post-surgical BMI > 35) following RYGB surgery in this group. The addition of adjustable gastric band (AGB) to RYGB has been reported as a revisional procedure but this combined bariatric procedure has not been explored as a primary operation. METHODS: In a primary laparoscopic RYGB, an AGB is drawn around the gastric pouch through a small opening between the blood vessels on the lesser curve and the gastric pouch. The band is then fixed by suturing the gastric remnant to the gastric pouch both above and below the band to prevent slippage. RESULTS: Between November 2009 and March 2010, 6 consecutive super-super-obese patients underwent a primary laparoscopic adjustable banded Roux-en-Y gastric bypass procedure at our institution. One male patient (21 years, BMI 70 kg/m²) developed a pneumonia postoperatively. No other postoperative complications were observed. CONCLUSION: To the best of our knowledge, this is the first series of patients that underwent a laparoscopic adjustable banded RYGB as a primary operation for the super-super obese in the indexed literature. With the combined procedure, a sequential action mechanism for weight loss is to be expected. The restrictive, malabsorptive and hormonal working mechanism of the RYGB will induce weight loss from the start reaching a stabilised plateau of weight after 12 - 18 months. At that time, filling of the band can be started resulting in further gastric pouch restriction and increased weight loss. Moreover, besides improving the results of total weight loss, a gradual filling of the band can as well prevent the RYGB patient from weight regain if restriction would fade away with time. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2992483/pdf/1471-2482-10-33.pdf     Impacto de la posición corporal de los pacientes sobre el espacio intrabdominal de trabajo durante cirugía laparoscópica  Impact of the patient's body position on the intraabdominal workspace during laparoscopic surgery. Mulier JP, Dillemans B, Van Cauwenberge S. Department of Anaesthesiology, AZ Sint Jan Brugge-Oostende AV, Ruddershove 10, 8000 Brugge, Belgium. Jan.Mulier@azbrugge.be Surg Endosc. 2010 Jun;24(6):1398-402. doi: 10.1007/s00464-009-0785-8. Epub 2010 Jan 7. Abstract BACKGROUND: The effects of the patient's body position on the intraabdominal workspace in laparoscopic surgery were analyzed. METHODS: The inflated volume of carbon dioxide was measured after insufflation to a preset pressure of 15 mmHg for 20 patients with a body mass index (BMI) greater than 35 kg/m(2). The patients were anesthetized with full muscle relaxation. The five positions were (1) table horizontal with the legs flat (supine position), (2) table in 20 degrees reverse Trendelenburg with the legs flat, (3) table in 20 degrees reverse Trendelenburg with the legs flexed 45 degrees upward at the hips (beach chair position), (4) table horizontal with the legs flexed 45 degrees upward at the hips, and (5) table in 20 degrees Trendelenburg with the legs flat. The positions were performed in a random order, and the first position was repeated after the last measurement. Repeated measure analysis of variance was used to compare inflated volumes among the five positions. RESULTS: A significant difference in inflated volume was found between the five body positions (P = 0.042). Compared with the mean inflated volume for the supine position (3.22 +/- 0.78 l), the mean inflated volume increased by 900 ml for the Trendelenburg position or when the legs were flexed at the hips, and decreased by 230 ml for the reverse Trendelenburg position. CONCLUSIONS: The Trendelenburg position for lower abdominal surgery and reverse Trendelenburg with flexing of the legs at the hips for upper abdominal surgery effectively improved the workspace in obese patients, even with full muscle relaxation. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2869437/pdf/464_2009_ Article_785.pdf    Obesidad, anestesia y cirugía bariátrica  L. A. Fernandez Merea, M. Alvarez Blanco Servicio de Anestesiología, Reanimación y Terapéutica del Dolor. Servicio de Cirugía General. Hospital Universitario Central de Asturias (HUCA) - Centro Residencia Covadonga. Oviedo. Rev. Esp. Anestesiol. Reanim. 2004; 51: 80-94 Resumen La obesidad se ha convertido en una patología en constante aumento, constituyendo un grave problema de salud pública con la consiguiente repercusión sobre el gasto sanitario, sobre todo en los países desarrollados. Su principal rasgo es la asociación con numerosas patologías (respiratorias, cardiovasculares, endocrino-metabólicas), que hace que tenga una elevada morbimortalidad, afectando tanto a la calidad como a la duración de la vida. Un gran avance en el tratamiento de los obesos es la cirugía bariátrica. Es aplicable cuando han fallado otras medidas y está obteniendo resultados muy favorables, por lo que se trata de un arma terapéutica en constante auge. Desde el punto de vista anestésico, los obesos se sitúan en desventaja con respecto a la población no obesa, ya que los procedimientos están dificultados y se aumenta la peligrosidad. Esto hace que sea de primordial relevancia conocer los cambios fisiopatológicos que la obesidad produce, así como las implicaciones anestésicas dentro del marco de la cirugía bariátrica, para lograr que los resultados quirúrgicos sean lo más favorables posibles. https://www.sedar.es/vieja/restringido/2004/n2_2004/80-94.pdf  Atentamente Anestesiología y Medicina del Dolor www.anestesia-dolor.org