Maternal super obesity is increasing and is associated with an increased risk of pregnancy complications-a call for concern.

OBJECTIVE: This study aimed to assess the relationship of increased body mass index (BMI) with pregnancy complications. STUDY DESIGN: We obtained data for a retrospective cohort of singleton live births using an electronic birth certificate database from 2010 to 2022. Institutional review board exemption was obtained. BMI was assessed as a continuous variable and a categorical variable with groups of BMI 18.5-29.9 kg/m2, 40-49.9 kg/m2, and ≥50 kg/m2 compared to patients with BMI 30-39.9 kg/m2. Primary outcomes were pregnancy and maternal outcomes. Secondary outcomes were neonatal outcomes. ANOVA and χ2 were used to compare continuous and categorical variables respectively, and logistic regression was used to obtain adjusted odds ratios for primary and secondary outcomes. RESULTS: There were 223,837 patients with singleton live births with mean BMI 27.86 kg/m2. 54,385 (24.3%) had BMI 30-39.9 kg/m2, 13,299 (5.9%) had BMI 40-49.9 kg/m2, and 1,958 (0.87%) had BMI ≥50 kg/m2. Patients with BMI > 50 kg/m2 have a higher likelihood of APGAR scores <7 (aOR 1.38, 95% CI 1.05-1.83), and NICU admission or transfer out of facility (aOR 1.17, 95% CI 1.02-1.34). In the nulliparous subgroup analysis, For patients with BMI >50 kg/m2, there was a higher odds of preterm birth <37 weeks (aOR 1.57, 95% CI 1.23-2.00) and preterm birth <34 weeks (aOR 1.51 95% CI 1.00-2.30. There is also an increased odds of cesarean section in both of these BMI groups (aOR 1.68 95% CI 1.57-1.79 and aOR 2.30 95% CI 1.94-2.72). CONCLUSION: BMI ≥ 50 kg/m2 was significantly associated with increased pregnancy complications.

Patients with BMI > 50 kg/m² have a higher likelihood of having pregestational diabetes, gestational diabetes, chronic hypertension, gestational hypertension, and preterm birth < 37 weeks.Increasing obesity in Central New York is leading to worsened pregnancy outcomes.

Early safety of endoscopic sleeve gastroplasty in super obesity (body mass index > 50).

BACKGROUND: The prevalence of super obesity (body mass index [BMI] > 50) continues to rise. However, the adoption of bariatric surgery in this population remains very low. There are limited studies evaluating the utility of endoscopic sleeve gastroplasty (ESG) in super obesity. OBJECTIVES: The purpose of this study is to evaluate the short-term safety profile of ESG in patients with super obesity using data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. SETTING: United States. METHODS: We retrospectively analyzed patients who underwent ESG and sleeve gastrectomy (SG) from 2016 to 2021. Patients with BMI >50 who underwent ESG were compared to ESG patients with BMI <50 and also SG patients with BMI >50. Primary outcomes included the incidence of severe adverse events (AEs), hospital readmission, reintervention, and reoperation within 30 days of the primary procedure. Secondary outcomes included procedure time, hospital length of stay, and total body weight loss at 30 days. RESULTS: There were no significant differences in AE, reoperations, hospital readmissions, or reinterventions for patients with super obesity undergoing ESG, compared to patients with BMI below 50. Mean total body weight loss was greater in patients with super obesity. There were no significant differences in AEs for patients with super obesity who underwent ESG versus SG, although ESG patients had more hospital readmissions, reinterventions, and reoperations. CONCLUSIONS: ESG may be performed safely, with comparable safety to SG, in patients with BMI as high as 70. However, further studies are needed to validate the feasibility and long-term efficacy prior to clinical implementation.

Super-Obesity is Associated With an Increased Risk of Complications Following Primary Total Knee Arthroplasty.

BACKGROUND: Obesity, defined as a body mass index (BMI) ≥ 30, is an ever-growing epidemic, with > 35% of adults in the United States currently classified as obese. Super-obese individuals, defined as those who have a BMI ≥ 50, are the fastest-growing portion of this group. This study sought to quantify the infection risk as well as the incidence of surgical, medical, and thromboembolic complications among super-obese patients undergoing total knee arthroplasty (TKA). METHODS: An all-payer claims database was used to identify patients who underwent elective, primary TKA between 2016 and 2021. Patients who had a BMI ≥ 50 were compared to those who had a normal BMI of 18 to 25. Demographics and the incidence of 90-days postoperative complications were compared between the 2 groups. Univariate analysis and multivariable regression were used to assess differences between groups. RESULTS: In total, 3,376 super-obese TKA patients were identified and compared to 17,659 patients who had a normal BMI. Multivariable analysis indicated that the super-obese cohort was at an increased postoperative risk of periprosthetic joint infection (adjusted odds ratio [aOR] 3.7, 95% confidence interval [CI]: 2.1 to 6.4, P < .001), pulmonary embolism (aOR 2.2, 95%-CI: 1.0 to 5.0, P = .047), acute respiratory failure (aOR 4.1, 95%-CI: 2.7 to 6.1, P < .001), myocardial infarction (aOR 2.5, 95%-CI: 1.1 to 5.8, P = .026), wound dehiscence (aOR 2.3, 95%-CI: 1.4 to 3.8, P = .001), and acute renal failure (aOR 3.2, 95%-CI: 2.4 to 4.2, P < .001) relative to patients who have normal BMI. CONCLUSIONS: Super-obese TKA patients are at an elevated risk of postoperative infectious, surgical, medical, and thromboembolic complications. As such, risk stratification, as well as appropriate medical management and optimization, is of utmost importance for this high-risk group.

Analysis of the 1-year efficacy of four different surgical methods for treating Chinese super obese (BMI ≥ 50 kg/m2) patients.

This study aimed to retrospectively analyze the perioperative and postoperative follow-up data of patients with super obesity who had undergone RYGB, SG, BPD/DS, and SADI-S. A retrospective observational study was conducted to analyze the perioperative and postoperative follow-up data of 60 patients with super obesity who had undergone bariatric surgery. A total of 34 men and 26 women were included in this study. The participants had an average preoperative BMI of 53.81 ± 3.25 kg/m2. The body weight and BMI of all four patient groups decreased significantly at 3, 6, and 12 months postoperatively compared with the preoperative values. Additionally, the TWL (%) and EWL (%) of all four groups increased gradually over the same period. Compared with the preoperative values, the systolic and diastolic blood pressure, glycosylated hemoglobin, uric acid, triglycerides, and total cholesterol decreased to varying degrees in the four groups 1 year postoperatively. RYGB, SG, BPD/DS, and SADI-S are all safe and effective in treating super obese patients and improving their metabolic diseases to a certain extent.

Bariatric Surgery Outcomes in Patients with Severe Obesity Compared to Patients with Non-Severe Obesity at A New Institution in The United Arab Emirates.

Background: Bariatric surgery is an effective treatment for weight loss, but a higher body mass index (BMI) may lead to higher postoperative complication rates. This study aims to compare perioperative and postoperative outcomes between UAE patients with severe obesity (SO) [BMI ≥ 50 kg/m2] and non-severe obesity (NSO) [BMI < 50 kg/m2] undergoing primary bariatric surgery. Methods: From September 2015 to July 2019, 542 patients, 94 SO (56.5 ± 6.2 kg/m2) and 448 NSO (41.8 ± 4.1 kg/m2), were retrospectively reviewed. Results: Patients with SO were younger (33.8 ± 13.4 vs. 37.0 ± 11.5 years, p = 0.02) but otherwise had similar demographic characteristics. Their rates of Roux-en-Y gastric bypass (39.4% SO vs. 44.4% NSO, p = 0.37) and sleeve gastrectomy (60.6% vs. 55.6%, p = 0.37) were similar. There were no differences between perioperative complications (6.4% SO vs. 5.8% NSO, p = 0.83), major postoperative complications (5.3% vs. 3.5%, p = 0.42), readmissions (5.3% vs. 3.3%, p = 0.36), or reoperations (3.2% vs. 2.7%, p = 0.78). There were no mortalities. Their total body weight loss was comparable at 12 months (28.1 ± 10.2% vs. 29.0 ± 7.7%, p = 0.58). Conclusions: Although a higher BMI may pose operative challenges, UAE patients with SO do not have worsened outcomes in bariatric surgery, demonstrating similarly low morbidity to patients with NSO, and similar rates of improvement in their BMI.

The 90% effective dose of intrathecal hyperbaric bupivacaine for Cesarean delivery under combined spinal-epidural anesthesia in parturients with super obesity: an up-down sequential allocation study.

PURPOSE: To determine the 90% effective dose (ED90) of intrathecal hyperbaric bupivacaine for Cesarean delivery under combined spinal-epidural anesthesia (CSE) in parturients with super obesity (body mass index [BMI] ≥ 50 kg·m-2). METHODS: We enrolled parturients with BMI ≥ 50 kg·m-2 with term, singleton vertex pregnancies undergoing elective Cesarean delivery under CSE. An independent statistician generated the 0.75% hyperbaric bupivacaine dosing regimen in increments of 0.75 mg using a biased-coin up-down sequential allocation technique. This was combined with 15 µg fentanyl, 150 µg morphine, and normal saline to a volume of 2.05 mL. The initial and maximum doses were 9.75 mg and 12 mg, respectively. Participants, clinical team, and outcome assessors were blinded to the dose. The primary outcome was block success, defined as T6 block to pinprick within ten minutes and no intraoperative analgesic supplementation within 90 min of spinal injection. We determined the ED90 using logistic regression. RESULTS: We enrolled 45 parturients and included 42 in the analysis. All doses achieved a T6 level within ten minutes, and the primary outcome occurred in 0/1 (0%) of the 9.75-mg doses, 2/3 (67%) of the 10.5-mg doses, 21/27 (78%) of the 11.25-mg doses, and 11/11 (100%) of the 12-mg doses. The ED90 of hyperbaric bupivacaine was 11.56 mg (95% confidence interval, 11.16 to 11.99). Four parturients (9.5%) had sensory level higher than T2, but none was symptomatic or required general anesthesia. CONCLUSION: The estimated ED90 of hyperbaric bupivacaine with fentanyl and morphine in parturients with super obesity undergoing Cesarean delivery under CSE was approximately 11.5 mg. STUDY REGISTRATION: ClinicalTrials.gov (NCT03781388); first submitted 18 December 2018.

RéSUMé: OBJECTIF: Notre objectif était de déterminer la dose efficace à 90 % (DE90) de bupivacaïne hyperbare intrathécale pour l'accouchement par césarienne sous péri-rachianesthésie combinée (PRC) chez les personnes parturientes atteintes de super obésité (indice de masse corporelle [IMC] ≥ 50 kg·m−2). MéTHODE: Nous avons recruté des personnes parturientes ayant un IMC ≥ 50 kg·m−2 présentant des grossesses uniques à terme, en présentation céphalique et bénéficiant d'un accouchement par césarienne programmée sous PRC. Un·e statisticien·ne indépendant·e a généré le schéma posologique de bupivacaïne hyperbare à 0,75 % par incréments de 0,75 mg à l'aide d'une technique d'allocation séquentielle en escalier. La bupivacaïne a été combinée à 15 µg de fentanyl, 150 µg de morphine et à une solution physiologique salée jusqu'à un volume de 2,05 mL. Les doses initiale et maximale étaient respectivement de 9,75 mg et 12 mg. Les participant·es, l'équipe clinique et les personnes évaluant les résultats n'avaient pas connaissance de la dose. Le critère d'évaluation principal était la réussite du bloc, définie comme un bloc à T6 à la piqûre dans les dix minutes et aucune supplémentation analgésique peropératoire dans les 90 minutes suivant l'injection rachidienne. Nous avons déterminé la DE90 à l'aide d'une méthode de régression logistique. RéSULTATS: Nous avons recruté 45 personnes parturientes et en avons inclus 42 dans l'analyse. Toutes les doses ont atteint le niveau T6 en dix minutes, et le critère d'évaluation principal a été obtenu pour 0/1 (0 %) des doses de 9,75 mg, 2/3 (67 %) des doses de 10,5 mg, 21/27 (78 %) des doses de 11,25 mg et 11/11 (100 %) des doses de 12 mg. La DE90 de bupivacaïne hyperbare était de 11,56 mg (intervalle de confiance à 95 %, 11,16 à 11,99). Quatre personnes parturientes (9,5 %) ont affiché un niveau sensoriel supérieur à T2, mais aucune n'était symptomatique ni n'a nécessité d'anesthésie générale. CONCLUSION: La DE90 estimée de bupivacaïne hyperbare avec fentanyl et morphine chez les personnes parturientes hyperobèses bénéficiant d'une césarienne sous PRC était d'environ 11,5 mg. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT03781388); soumis pour la première fois le 18 décembre 2018.

Super super obesity with a BMI of 98 kg/m2: a case report.

Standards of care in regards to super-super obese patients are yet to be evolving due to the sparsity of this weight category along with the high morbidity and mortality rates attributed to it. We report a successful case of laparoscopic sleeve gastrectomy for a 35 years old lady with a body mass index (BMI) of 98 kg/m2.

Outcomes of Laparoscopic Sleeve Gastrectomy (LSG) vs One-Anastomosis Gastric Bypass (OAGB) in Patients with Super-Super Obesity (BMI ≥ 60 kg/m2).

INTRODUCTION: The data comparing laparoscopic sleeve gastrectomy (LSG) and one-anastomosis gastric bypass (OAGB) in patients with BMI ≥ 60 kg/m2 is scarce. METHODS: Prospectively collected data of patients with BMI ≥ 60 kg/m2 undergoing LSG or OAGB from January 2008 until June 2022 was analyzed retrospectively. Weight loss outcomes, impact on comorbidities, and complications were compared in both groups. RESULTS: Fifty-six patients underwent LSG and 13 patients underwent OAGB. The median age and BMI were 37 (34-44) years and 63 (61.3-64.6) kg/m2 respectively. Both the groups had similar baseline demographic parameters. The percentage excess BMI loss (%EBMIL) was statistically similar in LSG and OAGB groups at 1 year (46.2% vs 46.1%), 3 years (52.9% vs 56.7%), and 5 years (51.1% vs 62.3%). The percentage excess BMI regain was lower (although statistically similar) following OAGB at 3 years (5.3% vs 0.1%) and 5 years (12.9% vs 4.4%). OAGB was found to correlate positively with weight loss and negatively with weight regain (p > 0.05). There was one 30-day mortality due to postoperative lower respiratory infection in the LSG group. CONCLUSION: OAGB has a trend towards better weight loss outcomes as compared to LSG in patients with a BMI ≥ 60 kg/m2 with lesser complication rates and might be a preferred option. LSG also has acceptable weight loss and should be considered a standalone procedure if OAGB is not feasible technically.

Outcomes of totally robotic Roux-en-Y gastric bypass in patients with BMI ≥ 50 kg/m2: can the robot level out "traditional" risk factors?

Roux-en-Y gastric bypass (RYGB) in patients with body mass index (BMI) ≥ 50 kg/m2 is a challenging procedure and BMI ≥ 50 kg/m2 has been identified as independent risk factor for postoperative complications and increased morbidity in previous studies. The objective of the present study was to assess whether a BMI ≥ 50 kg/m2 and various established risk factors maintain their significance in patients undergoing fully robotic RYGB (rRYGB). A single-center analysis of prospectively collected data of 113 consecutive patients undergoing standardized rRYGB with robotic stapling technique and hand-sewn gastrojejunostomy using the daVinci Xi system. Surgical outcomes were analyzed considering a number of individual perioperative risk factors including BMI ≥ 50 kg/m2. The mean BMI of the total cohort was 50.6 ± 5.5 kg/m2 and 63.7% of patients had a BMI ≥ 50 kg/m2. There were no major surgical and perioperative complications in patients with BMI ≥ 50 kg/m2 as well as in those with BMI < 50 kg/m2 after rRYGB. We identified female sex and surgeon experience but neither body weight, BMI, metabolic disorders, ASA nor EOSS scores as independent factors for shorter operation times (OT) in multivariate analyses. Complication rates and length of hospital stay (LOS) did not significantly differ between patients with potential risk factors and those without. rRYGB is a safe procedure in both, patients with BMI ≥ 50 kg/m2 and with BMI < 50 kg/m2. Higher body weight and BMI did affect neither OT nor LOS. A fully robotic approach for RYGB might help to overcome "traditional" risk factors identified in conventional laparoscopic bariatric surgery. However, larger and prospective studies are necessary to confirm these results.

Styletubation in Bariatric Surgery: A Case Report.

Direct laryngoscopes and videolaryngoscopes are the dominant endotracheal intubation tools. The styletubation technique (using a video-assisted intubating stylet) has shown its advantages in terms of short intubation time, high success rate, less required stimulation, and operator satisfaction. The learning curve can be steep but is easily overcome if technical pitfalls are avoided. Conditions that make styletubation challenging include secretions/blood, short/stiff neck, restricted mouth opening and cervical spine mobility, anatomical abnormalities over head and neck regions, obesity, etc. In this clinical report, we present the effectiveness and efficiency of the routine use of the styletubation for tracheal intubation in a super-super-obese patient (BMI 103 kg/m2) undergoing bariatric surgery with laparoscopic sleeve gastrectomy.

Challenges of morbid obesity in gynecological practice.

Obesity is currently a global pandemic, with increasing trends worldwide. Data from the WHO, US CDC, and the UK show an increasing trend, with 50% and 25% of the US population expected to be obese and morbidly obese by 2030. Obesity affects several aspects of health, with increased risks of cardiovascular disease, diabetes, metabolic syndrome, and several malignancies. Morbid obesity significantly impacts several aspects of female life and health, from adolescence, through the reproductive years, to the postmenopausal age group. In gynecology, there is a higher prevalence of menstrual disorders and infertility and reduced success rates of assisted reproduction; increased risk of miscarriage; pelvic organ prolapse; and endometrial, ovarian, and breast cancers. Surgery in the patient with morbid obesity is associated with several logistical challenges as well as increased surgical and peri-operative risks and increased cost. In this review, we provide an overview of the current literature, with a focus on challenges of morbid obesity in gynecological practice.

Long-Term Results After Bariatric Surgery in Super-Super-Obese Patients.

Introduction: Despite addressing to high risk population, we can propose laparoscopic bariatric surgery to super-super-obese (SSO) patients (body mass index [BMI] ≥60 kg/m2). The aim of this study was to report our experience in terms of weight loss and improvement of medical comorbidities after a follow-up of 5 years in the SSO population who underwent different bariatric procedures. Methods: This retrospective study includes all SSO patients who underwent bariatric surgery (sleeve gastrectomy [SG] and/or gastric bypass) between 2006 and 2017. The population was divided in three groups (SG alone; Roux-en-Y gastric bypass [RYGB] alone and SG+RYGB). The rate of complication and the weight-loss results were analyzed. Results: Among 43 patients who underwent surgery, the mean age was 42[31-54]. There were more women (72%) with the mean preoperative BMI of 64.9 kg/m2 [59.6-70.1]. There were 9 SGs, 26 RYGB, and 8 SG revised to gastric bypass (SG+RYGB) after a median delay of 23.5 months [16.5-32]. The perioperative complication rate was 25%, and there was 1 postoperative death. The median follow-up was 69 months [1-128]. The mean percentage of excess weight loss (%EWL) was 39.2% [18.2-60.3] after 5 years. For the SG group, the %EWL was inferior -27.1 [-3.6 to 57.8], but with no significant difference. An improvement of comorbidities' rate was recorded in all groups of patients. Conclusion: Bariatric surgery in SSO patients leads to an improvement of comorbidities even if the weight-loss results, especially in the SG group, are less favorable. The two steps approach should be re-evaluated by shortening the interval between. Other surgical strategies than RYGB are needed to be evaluated to improve long-term weight loss.

Comparison of perioperative outcomes and anesthetic-related complications of morbidly obese and super-obese parturients delivering by cesarean section.

OBJECTIVE: To compare the perioperative outcomes and anesthetic-related complications of morbidly obese and super-obese parturients delivering by cesarean section. METHODS: A retrospective analysis of 6 years of data was performed. Exclusions were cases with gestational ages <24 weeks, placenta accreta spectrum, polyhydramnios, or multiple gestations. RESULTS: The study included 494 patients whose body mass index (BMI) exceeded 40 kg/m2 at delivery. Of these, 469 were morbidly obese (BMI 40-49.9; mean, 42.9 ± 2.4), and 25 were super obese (BMI >50; mean, 54.5 ± 4.2). Twenty-four (5.1%) morbidly obese women received general anesthesia. The other 445 patients (94.9%) in the morbid obesity group underwent cesarean delivery under regional anesthesia; however, some (2.2%; 10/445) received general anesthesia after regional anesthesia failed. In the super-obesity group, 23 patients (92.0%) received regional anesthesia, while two patients (8.0%) received general anesthesia. There were no cases of pulmonary aspiration, maternal deaths, or difficult or failed intubation. There was one episode of cardiac arrest in a patient with a BMI of 47.9. Among the morbidly obese and super-obese women given regional anesthesia, the super-obese patients had significantly greater volumes of ephedrine and norepinephrine consumption (p = 0.027 and 0.030), intravenous fluids (p = 0.006), and bleeding during surgery (p = 0.017). They also had more hypotensive episodes (p = 0.038). The two groups' incidences of neonatal birth asphyxia, postpartum hemorrhage, blood transfusion, and uterine atony did not differ significantly. The lengths of stay in the hospital were also comparable. CONCLUSIONS: Among the women receiving regional anesthesia, the super-obese parturients had greater intraoperative bleeding, a higher proportion of hypotensive episodes, and a greater vasopressor requirement than the morbidly obese parturients. Anesthesiologists must prepare for the adverse perioperative events that such women risk experiencing during a delivery by cesarean section.www.clinicaltrials.gov ID: NCT04657692.

Super obesity parturients are at a significantly higher risk of intraoperative bleeding, maternal hypotension, and higher vasopressor requirement compared to parturients with morbid obesity undergoing cesarean delivery.We additionally found a weak positive correlation between patient body weight and intraoperative blood loss in a patient with morbid obesity regardless of anesthetic technique.

Impact on Cardiovascular Health of Using Phentermine/Topiramate in Combination With Laparoscopic Sleeve Gastrectomy in Super Obesity.

INTRODUCTION: Management of patients with BMI≥50 kg/m2 is challenging. In previous work, pre and postoperative pharmacotherapy with phentermine/topiramate plus laparoscopic sleeve gastrectomy (PT + SG) promoted greater weight loss than sleeve gastrectomy (SG) alone at 24 mo postoperatively. This current secondary analysis studied the impact of PT + SG on blood pressure (BP), heart rate, and antihypertensive usage. METHODS: Patients with BMI≥50 kg/m2 planning to have SG (n = 13) were recruited from 2014 to 2016, at an academic medical center in Winston-Salem, North Carolina, for this open-label trial. Participants took phentermine/topiramate (PT; 7.5/46-15/92 mg/d) for ≥3 mo preoperatively and 24 mo postoperatively. The control group (n = 40) underwent SG during the same time frame. We used mixed models for BP and heart rate to compare PT + SG versus SG alone over time, adjusted for age, sex, and initial BP. RESULTS: By 24 mo postoperatively the model adjusted changes in systolic blood pressure/diastolic blood pressure (SBP/DBP) (mm Hg) were -24.44 (-34.46,-14.43)/-28.60 (-40.74,-16.46) in the PT + SG group versus -11.81 (-17.58,-6.05)/-13.89 (-21.32,-6.46) in the control group (SBP P = 0.02; DBP P = 0.03). At baseline 8 (61.5%) participants in the PT + SG arm and 22 (55.0%) in the control group used antihypertensives. Excluding patients lost to follow-up (n = 3), by 24 mo postoperatively, none of the PT + SG participants were on antihypertensives compared to 14 (41.2%) in the control group (P = 0.01). CONCLUSIONS: Patients with BMI≥50 kg/m2 treated with PT + SG had greater improvement in BP with no use of antihypertensive medication at 24 mo postoperatively versus SG alone, where 41% continued medication use. Larger trials are required to evaluate this.

Traqueostomía quirúrgica en un paciente con súper-súper obesidad. Caso clínico y revisión de la literatura / Surgical tracheostomy in a super-super obese patient. Case report and literature review

La obesidad es un problema de salud que ha presentado un aumento preocupante en Chile y el mundo, en las últimas décadas. Esta condición se asocia a múltiples comorbi-lidades, entre ellas, afecciones respiratorias. La traqueostomía es un procedimiento quirúrgico que puede resultar desafiante en este tipo de pacientes, debido a las alteraciones que la obesidad genera en la anatomía cervical, asociándose a mayor morbimortalidad. Requiere una buena planificación preoperatoria. Se presenta el caso de un paciente con antecedente de súper-súper obesidad, con un índice de masa corporal de 78 kg m2, que requirió la realización de una traqueostomía quirúrgica. Se describe el manejo realizado, junto a las consideraciones especiales aplicadas al caso: se realizó lipectomía cervical, se utilizó instrumental quirúrgico de mayor longitud, suturas al plano subcutáneo para facilitar visualización intraoperatoria, suturas de la piel a la tráquea previo a la apertura de la vía aérea, uso de cánula de traqueostomía extra larga. El paciente presentó como complicación postoperatoria un granuloma periostomal que fue tratado y, finalmente, fue decanulado previo su alta hospitalaria. Se presenta una revisión en la literatura pertinente al caso.

Obesity is a health problem that has shown a worrisome increase in Chile and the world in recent decades. This condition is associated to multiple comorbidities, including respiratory disorders. A tracheostomy is a surgical procedure that can be challenging in this type of patient due to the variations that obesity generates in the cervical anatomy, which is associated to greater morbidity and mortality. Due to this, it requires good preoperative planning. We present the case of a male patient with a history of super-super obesity, with a body mass index (BMI) of 78 kg m2, who required surgical tracheostomy; the management is described with the special considerations applied to the case: cervical lipectomy was performed, longer surgical instruments were used, sutures to the subcutaneous plane were placed to facilitate intraoperative visualization, skin sutures to the trachea were placed prior to opening the airway, use of extra-large tracheostomy cannula (XL). The patient presented a peristomal granuloma as a postoperative complication which was treated, and he was decannulated prior to hospital discharge. A review of the literature relevant to the case is presented.

The patient with obesity and super-super obesity: Perioperative anesthetic considerations.

Obesity is associated with increased morbidity and mortality related to many complex physiologic changes and the rise worldwide has had far ranging implications in healthcare. According to the World Health Organization, over 2.8 million people die each year from being overweight or obese. Patients who are obese often need surgical procedures or interventional pain procedures and are at higher risk of complications. Patients with super-super obesity are those with body mass index greater than 60 kg/m2 and are at even greater risk for complications. The present investigation reviews epidemiology, pathophysiology, and anesthesia considerations for best practice strategies in managing these higher risk patients. Clinical anesthesiologists must utilize careful assessment and consultation in developing safe anesthesia plans. Improvements in technology have advanced safety with regard to airway management with advanced airway devices and in regional anesthesia with ultrasound-guided nerve blocks that can provide increased flexibility in formulating a safe anesthetic plan. As well, newer drugs and monitors have been developed for perioperative use to enhance safety in patients with obesity.

Impact of preoperative weight loss achieved by gastric balloon on peri- and postoperative outcomes of bariatric surgery in super-obese patients: a retrospective matched-pair analysis.

BACKGROUND: An intragastric balloon is used to cause weight loss in super-obese patients (BMI > 60 kg/m2) prior to bariatric surgery. Whether weight loss from intragastric balloon influences that from bariatric surgery is poorly studied. METHODS: In this retrospective, single-center study, the effects of intragastric balloon in 26 patients (BMI 69.26 ± 6.81) on weight loss after bariatric surgery (primary endpoint), postoperative complications within 30 days, hospital readmission, operation time, and MTL30 (secondary endpoints) were evaluated. Fifty-two matched-pair patients without intragastric balloon prior to bariatric surgery were used as controls. RESULTS: Intragastric balloon resulted in a weight loss of 17.3 ± 14.1 kg (BMI 5.75 ± 4.66 kg/m2) with a nadir after 5 months. Surgical and postoperative outcomes including complications were comparable between both groups. Total weight loss was similar in both groups (29.0% vs. 32.2%, p = 0.362). Direct postoperative weight loss was more pronounced in the control group compared to the gastric balloon group (29.16 ± 7.53% vs 23.78 ± 9.89% after 1 year, p < 0.05 and 32.13 ± 10.5% vs 22.21 ± 10.9% after 2 years, p < 0.05), who experienced an earlier nadir and started to regain weight during the follow-up. CONCLUSION: A multi-stage therapeutic approach with gastric balloon prior to bariatric surgery in super-obese patients may be effective to facilitate safe surgery. However, with the gastric balloon, pre-treated patients experienced an attenuated postoperative weight loss with an earlier nadir and earlier body weight regain. This should be considered when choosing the appropriate therapeutic regime and managing patients' expectations.

Outcome of Sleeve Gastrectomy Versus Roux-en-Y Gastric Bypass for Patients with Super Obesity (Body Mass Index > 50 kg/m2).

PURPOSE: With increasing BMI, the complexity of treating patients with obesity rises. The focus of this study is to investigate the effects of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on perioperative morbidity and remission of comorbidities at 3 years in patients with a BMI > 50 kg/m2. MATERIALS AND METHODS: A retrospective multicenter analysis of a prospectively maintained database was performed to enroll patients with a 3-year follow-up after SG or RYGB between 2005 and 2019 and a BMI of > 50 kg/m2 preoperatively. Patients' BMI and comorbidity status were recorded preoperatively. RESULTS: We analyzed data from 2939 patients who had at least a preoperative BMI > 50 kg/m2. A total of 1278 patients underwent RYGB surgery, and 1661 underwent SG. The distribution of sex, BMI, hypertension, reflux, and sleep apnea was significant between the two groups. Three years after surgery, the percent excess weight loss (%EWL) was 62.21% in RYGB and 55.87% in SG (p < 0.001). The change in hypertension (p < 0.001) and reflux (p < 0.001) was significantly in favor of RYGB. The change in diabetes mellitus was not significant between the two groups (p > 5%). There was a minimal difference in sleep apnea in favor of SG (p < 0.001). Mortality and overall complication rates were not significant in either group. CONCLUSION: Both procedures positively affected comorbidities, BMI, and %EWL in patients with super obesity 3 years after surgery. In some categories, RYGB was better than SG. Nevertheless, the decision between the two methods remains a matter of the surgeon's experience and the patient's general condition.

Safety of Primary Versus Revisional Biliopancreatic Diversion with Duodenal Switch in Patients with Super Obesity Using the MBSAQIP database.

INTRODUCTION: For patients with super obesity (BMI > 50 kg/m2), biliopancreatic diversion/duodenal switch (BPD/DS) can be an effective bariatric operation. Technical challenges and patient safety concerns, however, have limited its use as a primary procedure. This study sought to assess the safety of primary versus revisional BPD/DS. MATERIALS AND METHODS: The MBSAQIP database was queried for primary and revisional BPD/DS (2015-2018). Inclusion criteria were patients ≥ 18 years of age, BMI > 50 kg/m2, and with no concurrent procedures. Preoperative variables were compared using a chi-square test or Wilcoxon two-sample tests. Multivariate logistic or robust linear regression models were used to compare outcomes. RESULTS: There were 3,378 primary BPD/DS and 487 revisional BPD/DS patients. Primary BPD/DS patients had higher BMI (56.5 [IQR4.4] versus 54.8 [IQR4] kg/m2, p < 0.0001) and had more diabetes mellitus type II (29.1% versus 17.2%, p < 0.0001). Intraoperatively, revisional BPD/DS had longer operative time (165 [IQR47] min versus 139 [IQR100] min, p < 0.0001). After adjusting for preoperative characteristics, there was no difference in 30-day readmission or ED visits (primary 12.9% versus revisional 14.6%), reoperation or reintervention (primary 5.7% versus revisional 7.8%), or mortality (primary 0.4% versus revisional 0.6%). In contrast, the revisional BPD/DS patients had higher odds of major morbidity (primary 3.4% versus revisional 5.3%, OR 1.9, CI 1.1-3.2, p = 0.019). CONCLUSIONS: Revisional BPD/DS is associated with higher morbidity than primary BPD/DS in patients with super obesity. These patients should thus be counselled appropriately when choosing a primary or revisional bariatric procedure.

The first survey addressing patients with BMI over 50: a survey of 789 bariatric surgeons.

BACKGROUND: Bariatric surgery in patients with BMI over 50 kg/m2 is a challenging task. The aim of this study was to address main issues regarding perioperative management of these patients by using a worldwide survey. METHODS: An online 48-item questionnaire-based survey on perioperative management of patients with a BMI superior to 50 kg/m2 was ideated by 15 bariatric surgeons from 9 different countries. The questionnaire was emailed to all members of the International Federation of Surgery for Obesity (IFSO). Responses were collected and analyzed by the authors. RESULTS: 789 bariatric surgeons from 73 countries participated in the survey. Most surgeons (89.9%) believed that metabolic/bariatric surgery (MBS) on patients with BMI over 50 kg/m2 should only be performed by expert bariatric surgeons. Half of the participants (55.3%) believed that weight loss must be encouraged before surgery and 42.6% of surgeons recommended an excess weight loss of at least 10%. However, only 3.6% of surgeons recommended the insertion of an Intragastric Balloon as bridge therapy before surgery. Sleeve Gastrectomy (SG) was considered the best choice for patients younger than 18 or older than 65 years old. SG and One Anastomosis Gastric Bypass were the most common procedures for individuals between 18 and 65 years. Half of the surgeons believed that a 2-stage approach should be offered to patients with BMI > 50 kg/m2, with SG being the first step. Postoperative thromboprophylaxis was recommended for 2 and 4 weeks by 37.8% and 37.7% of participants, respectively. CONCLUSION: This survey demonstrated worldwide variations in bariatric surgery practice regarding patients with a BMI superior to 50 kg/m2. Careful analysis of these results is useful for identifying several areas for future research and consensus building.