Intraoperative ventilatory strategies for prevention of pulmonary atelectasis in obese patients undergoing laparoscopic bariatric surgery.

BACKGROUND: Atelectasis occurs regularly after induction of general anesthesia, persists postoperatively, and may contribute to significant postoperative morbidity and additional health care costs. Laparoscopic surgery has been reported to be associated with an increased incidence of postoperative atelectasis. It has been shown that during general anesthesia, obese patients have a greater risk of atelectasis than nonobese patients. Preventing atelectasis is important for all patients but is especially important when caring for obese patients. METHODS: We randomly allocated 66 adult obese patients with a body mass index between 30 and 50 kg/m(2) scheduled to undergo laparoscopic bariatric surgery into 3 groups. According to the recruitment maneuver used, the zero end-expiratory pressure (ZEEP) group (n = 22) received the vital capacity maneuver (VCM) maintained for 7-8 s applied immediately after intubation plus ZEEP; the positive end-expiratory pressure (PEEP) 5 group (n = 22) received the VCM maintained for 7-8 s applied immediately after intubation plus 5 cm H(2)O of PEEP; and the PEEP 10 group (n = 22) received the VCM maintained for 7-8 s applied immediately after intubation plus 10 cm H(2)O of PEEP. All other variables (e.g., anesthetic and surgical techniques) were the same for all patients. Heart rate, noninvasive mean arterial blood pressure, arterial oxygen saturation, and alveolar-arterial Pao(2) gradient (A-a Pao(2)) were measured intraoperatively and postoperatively in the postanesthesia care unit (PACU). Length of stay in the PACU and the use of a nonrebreathing O(2) mask (100% Fio(2)) or reintubation were also recorded. A computed tomographic scan of the chest was performed preoperatively and postoperatively after discharge from the PACU to evaluate lung atelectasis. RESULTS: Patients in the PEEP 10 group had better oxygenation both intraoperatively and postoperatively in the PACU, lower atelectasis score on chest computed tomographic scan, and less postoperative pulmonary complications than the ZEEP and PEEP 5 groups. There was no evidence of barotrauma in any patient in the 3 study groups. CONCLUSIONS: Intraoperative alveolar recruitment with a VCM followed by PEEP 10 cm H(2)O is effective at preventing lung atelectasis and is associated with better oxygenation, shorter PACU stay, and fewer pulmonary complications in the postoperative period in obese patients undergoing laparoscopic bariatric surgery.

Role of descending venography and endovenous embolization in treatment of females with lower extremity varicose veins, vulvar and posterior thigh varices.

OBJECTIVE: To evaluate the prevalence of refluxing pelvic veins among female patients with lower extremity varicose veins and the role of embolization treatment in these cases. METHODS: Of 158 female patients suffering from primary varicose veins of the lower extremities presented to the Venous Disease Clinic at Dhahran Health Center between January 2002 and December 2004, 25 patients (15.8%) were noted to have vulvar or postero-medial thigh varices or both. Those were referred for trans-jugular descending pelvic venography with or without subsequent embolization of the contributing refluxing veins. RESULTS: Venous reflux contributing to the vulvoperineal or posterior thigh varices was detected in 23 patients (92%) on catheter venography. Left ovarian venous reflux was responsible for 60% of all cases. Embolization, using multiple coils, was successful in 18 patients with positive reflux (78.3%). One patient had primary vulvar venous malformation that required additional percutaneous sclerotherapy using dehydrated ethanol. Four patients had femoro-saphenous reflux contributing to the varices and required subsequent surgical ligation excision. All treated cases showed significant improvement of their symptoms without any procedure related complications. CONCLUSION: In patients with vulvar or postero-medial thigh varicose veins, radiological study of ovarian and hypogastric venous reflux should be considered. Trans-jugular descending venography and embolization is a feasible, effective and safe diagnostic and therapeutic modality.