Cost effectiveness of bariatric surgery in patients with obesity related comorbidities: A retrospective study.

Background and Aim: Bariatric surgery has been reported to be an effective but expensive method for obesity management. This study aimed to determine the economic benefit for patients who underwent bariatric surgery. Methodology: We conducted a retrospective chart review of patients who underwent bariatric surgery and was on medications for obesity-related comorbidities at the Obesity Research Center in King Khalid University Hospital, Riyadh, Saudi Arabia. Data on the use and cost of medications before and after bariatric surgery were collected. Results: A total of 266 patients, 107 males (40.23%), and 159 Females (59.77%) with a mean age of 41.06 years were included in the study. There was a reduction in the mean number of medications used by patients before and 1-year post-op (before: 1.84, after: 0.52), with a significant reduction in the cost of medications (SAR5152.24 before, and SAR1695.36 after, 67% reduction, P < 0.001). Patients < 32 years old had the most reduction in medications cost (76.64% reduction). No significant difference in the cost reduction after surgery between genders (P = 0.971). There were significant reductions in numbers of out-patient clinic visits (2.26 ± 2.43 to 1.57 ± 1.42) and in-patient hospitalizations (0.31 ± 0.57 to 0.10 ± 0.36) after surgery (P < 0.001 and P < 0.001, respectively). Conclusion: Bariatric surgery can be considered as a cost-effective treatment for patients with obesity-related comorbidities. A significant reduction has been found in post-operative medications cost, out-patient clinic visits and in-patient hospitalizations after bariatric surgery.

Haemostatic changes in laparoscopic cholecystectomy: a comparison between upper and lower limb measurements.

BACKGROUND: The use of pnuemoperitonium to create the working environment for laproscopic cholecystectomy results in an increase in intraabdominal pressure, which exceeds the pressure of the venous-return from the legs. The resulting venous stasis may increase the risk of thrombosis formation and deep vein thrombosis in the lower limbs. However, there is no information as to whether the venous stasis will also exacerbate the coagulabililty of blood flowing out of the lower limbs. AIM: The aim of the study is to find evidence of haemostatic activation in the blood draining the lower limbs, which experience venous stasis as a result of the laparoscopic cholecystectomy (LC) procedure. MATERIALS AND METHODS: In this study, we prospectively studied 25 patients who underwent LC for uncomplicated cholelithiasis; 20 were female and 5 were male, aged between 17 to 65 years. LC was carried out according to a standard procedure. After general anesthesia, the patients were laid in a 30 degrees anti-Trendelenburg position, and pnuemoperitonium was maintained during the procedure with abdominal pressure of 12 mm Hg. The mean operating time was 55 minutes (range 25 to 118 min).Blood samples were collected simultaneously from the antecubetal fossa (the upper limb) and the dorsum of the foot (the lower limb), on 4 different occasions: i. preoperative; ii. after the induction of anesthesia, and before the inflation of the abdomen; iii. at the end of surgery, before deflation of the abdomen, and iv. 24 hours after surgery. LABORATORY ASSAYS: Prothrombin time, activated partial thromboplastin time, thrombin time, and plasma fibrinogen, Plasma Protein S (total and free), Protein C, Antithrombin, tissue plasminogen activator, and plasminogen activator inhibitor (PAI-I). Platelet function was assessed by the platelet function analyser (PFA100). RESULTS: No significant differences were noted in all measured haemostatic parameters, including PFA100 closure times, when comparing the measurements that were taken simultaneously in the upper and lower limbs' blood. Plasma fibrinogen increased significantly 24 hours after surgery, and antithrombin levels dropped slightly, immediately after surgery, but recovered preoperative levels 24 hours after surgery. Coagulation inhibitors (total and free protein S and protein C), and fibrinolytic parameters did not show any significant fluctuations throughout the study intervals. CONCLUSION: The finding of this study is of no significant activation of coagulation in the blood flowing out of the lower limbs at the time of venous stasis, adds to the criteria of safety of the current surgical procedure used in LC, including reverse Trendelenburg position and pneumoperitoneum that unavoidably produce significant stasis in the lower limbs.

Effect of bispectral index (BIS) monitoring on postoperative recovery and sevoflurane consumption among morbidly obese patients undergoing laparoscopic gastric banding.

UNLABELLED: Early and uneventful postoperative recovery of morbidly obese patients remains a challenge for anesthesiologists. It could be valuable to titrate the administration of inhaled anesthetic, such as sevoflurane, in morbid obese patients, in order to shorten emergence using bispectral index (BIS) monitoring. It would be a great advantage if BIS permitted a more rapid recovery and less consumption in morbidly obese patients with a high cost inhaled agent. The aim of the study is to show whether the titration of sevoflurane based on the BIS monitoring would allow shortening of recovery time in morbidly obese patients and to evaluate whether BIS monitoring would contribute to reduce the amount of sevoflurane administered while providing an adequate anesthesia. PATIENTS AND METHODS: Thirty morbidly obese ASA I & II patients undergoing laparoscopic gastric banding (LAGB) procedures were studied. In the first group (15 patients), patients were anesthetized without the use of BIS (non BIS or control group), and sevoflurane being administered according to standard clinical practice (control group). In the second group (15 patients), sevoflurane was titrated to maintain a BIS value between 40 and 60 during surgery, and then 60-70 during 15 min prior to the end of surgery (BIS group). Recovery times were recorded. Time to extubation was also noted, as well as the time to achieve a modified Aldrete score of 9 were evaluated subsequently at 10-min intervals until 3 h after surgery by nurses who had no knowledge of the study. Sevoflurane consumption was calculated using the vaporizer weighing method. RESULTS: Awakening and extubation times were significantly shorter in the BIS group (P < 0.05). In the BIS (vs. non BIS) group, there were no significant differences observed in the time to obtain an Aldrete score of 9. The sevoflurane consumption and cost in the BIS group were lower than in the non BIS group (P < 0.05). CONCLUSION: Bispectral index monitoring during anesthesia for morbidly obese patients provides statistically significant reduction in recovery times. It also has the added advantage in decreasing sevoflurane consumption.

Impedance cardiography: noninvasive assessment of hemodynamics and thoracic fluid content during bariatric surgery.

BACKGROUND: The effects of pneumoperitoneum (ppm) on hemodynamic parameters during bariatric surgery were investigated using the impedance cardiography monitor. METHODS: 11 patients with BMI 46.5+/-10 kg/m2 (range 38.9-60.8 kg/m2) underwent laparoscopic adjustable gastric banding under general anesthesia. Besides routine monitoring, the impedance cardiography (ICG) monitor was used to monitor cardiac output (CO), cardiac index (CI), systemic vascular resistance (SVR), and thoracic fluid content (TFC). Data were recorded at three stages: A) before ppm, B) during ppm, and C) after gas deflation. One-way analysis of variance (ANOVA) was used to analyze differences of the data before, during and after ppm, and post-hoc (Bonferoni test) for multiple comparisons of the data obtained. For all comparisons, P<0.05 was considered significant. RESULTS: There were significant low mean values of heart rate (HR), CO and CI at stage B compared to stage A (P<0.05). The mean values of TFC at stages A, B, and C were 30.48 +/- 4.69, 29.74 +/- 2.86 and 31.72 +/- 4.93 k/Ohm respectively, with a non-significant relationship (P>0.05). The mean values of SVR during the same stages A, B and C were 1299.18 +/- 374.40, 1873.64 +/- 276.26 and 1669.36 +/- 537.92 dynes sec cm(-5) respectively, with significant high mean values at stages B and C compared to mean value at stage A (P<0.05). CONCLUSIONS: Morbid obesity and pneumoperitoneum have significant effects on hemodynamics. However, it appears that these changes were of marginal clinical significance.

The effects of pneumoperitoneum on respiratory mechanics during general anesthesia for bariatric surgery.

BACKGROUND: The effects of pneumoperitoneum (PPM) on respiratory mechanics during bariatric surgery were investigated. PATIENTS AND METHODS: 10 patients with BMI 50.5+/-8 kg/m(2) (range 40.9- 66.8) who underwent laparoscopic adjustable gastric banding with the Swedish band under general anesthesia were studied. Besides routine monitoring of vital signs and lung volumes, respiratory mechanics (compliance and resistance) were measured during positive pressure ventilation using an anesthesia delivery unit (Datex Ohmeda type A_Elec). Data were recorded at the following stages: 1). before PPM, 2). during PPM, and 3). after gas deflation. One-way analysis of variance was used for analysis of data. P <0.05 was considered significant. RESULTS: The airway, peak inspiratory and plateau pressures increased significantly during PPM. Dynamic lung compliances were 44.6+/-7.8 SD, 31.8+/-5.5 and 44.5+/-8.3 cm/H(2)O before, during and after PPM respectively with significant differences (P <0.05). CONCLUSIONS: Although significant decrease in lung mechanics was found in the present study,these variations were well tolerated in morbidly obese patients with PPM pressure of 15 mmHg.

Variations in dynamic lung compliance during endoscopic thoracic sympathectomy with CO2 insufflation.

Endoscopic thoracic sympathectomy (ETS) is the preferred surgery for treatment of intractable palmar hyperhidrosis (PH). General anesthesia with onelung collapsed ventilation (OLCV) using single-lumen tracheal tube (SLT), is our preferred anesthetic technique for ETS. Intrapleural CO(2) insufflation (capnothorax) was used to ensure lung collapse. The current study examined the effects of capnothorax on dynamic lung compliance (DLC) of the ventilated lung during ETS. After obtaining written informed consent, 10 adult male patients ASA I&II undergoing ETS were studied. Their average age and weight were 25 +/- 7 yr and 67 +/- 8 kg. General anesthesia with SLT and OLCV technique was used. Capnothorax with intrapleural pressure (IPP) of 10 mmHg was initially used, then it was reduced and maintained at 5 mmHg throughout the operation. Anesthesia delivery unit (Datex Ohmeda type A_Elec, Promma, Sweden) was used where airway pressures and DLC were displayed during OLCV. A computer program (SPSS 9.0 for Windows; SPSS Inc., Chicago, IL) was used for statistical analysis of the data obtained. One way analysis of variance (ANOVA) was used for analysis of data before, during and after OLCV. P<0.05 was considered significant. The mean values of the DLC were 52 +/- 6, 30 +/- 3, 39 +/- 5 and 53 +/- 9 ml/cmH(2)O before, during (at 10 and 5 mmHg IPP) and after OLCV respectively with significant differences before and at 10 and 5mmHg IPP. In conclusions, during OLCV and capnothorax for ETS, DLC tends to decrease with increasing of intrapleural CO(2) insufflation pressure. However, in short procedures it has no deleterious postoperative effect. To the best of our knowledge this is the first study performed to investigate DLC changes during OLCV with capnothorax.

Thoracoscopic sympathectomy: endobronchial anesthesia vs endotracheal anesthesia with intrathoracic CO2 insufflation.

PURPOSE: To compare clinical advantages and hemodynamic and respiratory changes during one lung-collapsed ventilation (OLCV) using a double-lumen tube (DLT) or a single-lumen tube (SLT) with intrathoracic CO(2) insufflation, in patients undergoing thoracic sympathectomy (TS) under general anesthesia. METHODS: One hundred and twenty-five patients (94 men and 31 women) undergoing TS for the treatment of palmar hyperhidrosis (PH) were randomly allocated to two groups: group A (68 patients; age, 29 +/- 6 years) in whom DLT was used, and group B (57 patients; age, 32 +/- 3 years) in whom SLT with intrathoracic CO(2) insufflation at a rate of 0.5-1 l.min(-1) and sustained intrathoracic pressure at 6 mmHg insufflation were used. Anesthesia was maintained with 1 minimum alveolar concentration (MAC) isoflurane in 50% nitrous oxide in oxygen with incremental doses of sufentanil and atracurium when required. Arterial blood gases were measured in 10 patients in group B. Hemodynamic and respiratory parameters were obtained perioperatively. RESULTS: There were no significant differences in hemodynamic and respiratory parameters between the two groups during the study phases, except for the arterial oxygen saturation (SpO(2)). The times required for anesthesia and surgery were significantly shorter in the SLT group than in the DLT group. SpO(2) during OLCV was 95 +/- 1% with DLT and 98 +/- 1% with SLT, with a significant difference. Three patients had an SpO(2) of less than 90% in the recovery room, where the chest tube position was readjusted, with no further sequelae. CONCLUSION: General anesthesia with SLT and intrathoracic CO(2) insufflation provides optimal operating conditions, adequate oxygenation, and perfect hemodynamic stability during TS.