85J.G. Brock-Utne, Case Studies of Near Misses in Clinical Anesthesia, DOI 10.1007/978-1-4419-1179-7_30, © Springer Science+Business Media, LLC 2011

You are scheduled to anesthetize a 28 year old woman, 90 kg, 5 ft 7 in. tall, for abdominoplasty. Two years previously she underwent a laparoscopic gastric band-ing for morbidly obesity. Prior to that operation she was 188 kg. She now wishes to have excess abdominal skin removed. At this time she does not complain of gastroesophageal reflux, hypertension, and noninsulin dependent diabetes mellitus. Interestingly, she had these diagnoses prior to her gastric banding.

On the day of surgery she has neither eaten nor drunk anything for 12 h. You see her in the preoperative holding area. On examination you find nothing abnormal and classify her airway as class 2. An IV is easily placed and 2 mg midazolam IV has good effect. In the operating room you place standard noninvasive monitors.

Questions

Would you consider a rapid sequence in this patient? If, yes, why? If, no, why not?

Chapter 30Case 30: Post Bariatric Surgery – Any Concerns?

86 30 Case 30: Post Bariatric Surgery – Any Concerns?

Solution

You should always do a rapid sequence in a patient who has a past history of bariatric surgery. This is because there are detrimental changes in the anatomy and physiology of the gastrointestinal tract, including a decrease in esophageal-gastric peristalsis and impairment of lower esophageal sphincter relaxation [1, 2]. Furthermore, there is an increased risk of bronchial aspiration [3, 4] and increased possibility of aspiration pneumonia and long-term pulmonary complications [5] in these patients. Di Francesco et al. [6] showed that after a vertical banded gastroplasty, a decrease in basal lower esophageal sphincter tone and an increase in acid reflux also occurred.

It is interesting to note that in the study by Jean et al. [4], pulmonary complica-tions were seen only in patients who had no premedication with H2-antagonists.

Recommendation

Patients who have had bariatric surgery are at risk for pulmonary aspiration and should be managed with a rapid sequence technique with cricoids pressure. Antacids, metoclopramide, and H2-antagonists should also be given.

References

1. Presutti RJ, Gorman RS, Swain JM. Primary care perspective on bariatric surgery. Mayo Clin Proc. 2004;79:1158–66.

2. Weiss HG, Nehoda HJ, Labeck B, Peer-Kuhberere MD, Klingler P, Gadenstatter M, et al. Treatment of morbid obesity with laprascopic adjustable gastric banding affects esophageal motility. Am J Surg. 2000;180:479–82.

3. Kocian R, Spahn DR. Bronchial aspiration in patients after weight loss due to gastric banding. Anesth Analg. 2005;100:1856–7.

4. Jean J, Compere V, Fourdrinier V, Marguerite C, Auquit-Auckbur I, Milliez PY, et al. The risk of pulmonary aspiration in patients after weight loss due to bariatric surgery. Anesth Analg. 2008;107:1257–9.

5. Alamoudi OS. Long-term pulmonary complications after laparascopic adjustable gastric banding. Obes Surg. 2006;16:1685–8.

6. Di Francesco V, Baggio E, Mastromauro M, Zoico E, Stefenelli N, Zamboni M, et al. Obesity and gastro-oesphageal acid reflex, physiopathological mechanism and role of gastric bariatric surgery. Obes Surg. 2004;14:1095–102.