Intragastric balloon positioning and removal: sedation or general anesthesia?

BACKGROUND: Different anesthesiological techniques are currently used for intragastric balloon positioning and removal. The aim of this study is to compare different anesthesiological approaches for balloon positioning and removal in a large multicentric patient population. METHODS: Retrospective multicenter study was conducted. From May 2000 to April 2008, 3,824 patients underwent BIB(®) placement [1,022 male/2,802 female; mean age 39.5 ± 14.7 years, range 12-71 years; mean body mass index (BMI) 44.8 ± 9.7 kg/m(2), range 28.0-79.1 kg/m(2); excess weight (EW) 59.1 ± 29.8 kg, range 16-210 kg; %EW 89.3 ± 31.7, range 21.4-262]. Patients were allocated to three groups according to anesthesiological technique used: conscious sedation (group A), deep sedation (group B), and general anesthesia (group C). Intragastric balloon was placed after diagnostic endoscopy and removed after 6 months. Both positioning and removal were done under different protocols. Conscious sedation was obtained with topical lidocaine spray, adding diazepam (0.05-0.1 mg/kg iv) or midazolam (0.03-0.05 mg/kg iv). Deep sedation was obtained with propofol alone or adding other drugs such as midazolam, meperidine/fentanyl or meperidine/fentanyl + midazolam. General anesthesia was obtained with midazolam premedication (0.01-0.02 mg/kg iv) followed by induction with propofol (1-1.5 mg/kg iv) + Norcuron (80 mcg/kg iv) + fentanyl (0.5-1 mcg/kg iv), and maintenance with propofol (50-150 µg/kg/min) or sevorane. Oxygen saturation, hemodynamic stability, major anesthesiological complications and related mortality, patient satisfaction, time to return to autonomous walking, duration of procedure, and hospital stay were considered. RESULTS: Sedation-related mortality was absent. A significant number of patients with bronchoinhalation during balloon removal was observed with general anesthesia (P < 0.001). CONCLUSIONS: BIB positioning and removal should be performed under conscious sedation for patient safety and comfort, and technical success.

LapBand System in super-superobese patients (>60 kg/m(2)): 4-year results.

BACKGROUND: Bariatric surgery in superobese (BMI > 50 kg/m(2)) and super-superobese (BMI > 60 kg/m(2)) patients can be a formidable technical and therapeutic challenge because these patients often present multiple medical, surgical, and anesthetic risks. Only a few dedicated reports on different surgical options in this kind of patient population are available. The aim of this study is the evaluation of laparoscopic adjustable gastric banding (LAGB) results in an unselected populations of super-superobese patients operated during the last 4 years. METHODS: Super-superobese (BMI > 60 kg/m(2)) patients who underwent LAGB were recruited from the prospective database of our institution. LapBand System (Allergan, Irvine, CA, USA) was positioned in all cases via pars flaccida, 1-2 cm below the gastroesophageal junction and fixed anteriorly with three non-absorbable stitches. The band was not filled at the time of surgery. Operative time, co-morbidities, laparotomic conversion, intra- and postoperative complications, mortality, and weight-loss-related parameters were considered. Data were expressed as mean +/- standard deviation, except as otherwise indicated. RESULTS: From January 2003 to December 2006, 823 patients underwent a bariatric surgical procedure, 95 of whom (11.5%) were BMI > 60 kg/m(2) (59 F/ 36 M; mean BMI, 62.5 +/- 4.2; range, 60.1-77 kg/m(2); mean age 38.5 +/- 13.5, range 18-61 years old). Mortality, intraoperative, and 30-day major complications were absent. One or more preoperative co-morbidities were diagnosed in 90 of 95 (94.7%) patients. After 1 year, co-morbidity-free patients increased from five of 95 (5.3%) to 27 of 95 (28%; p < 0.001). Patients with three or more co-morbidities decreased from 62 of 95 (65.3%) to 0 (p < 0.001). Mean BMI was 43.6 in 95 of 95, 37.9 in 55 of 55, 29.1 in 11 of 11, and 28.9 in five of five patients at 12, 24, 36, and 48 months, respectively. At the same time, %EWL was 53.6, 69.7, 81.3, and 82.1 and %EBL was 50, 66, 90, and 91. CONCLUSIONS: LAGB can be considered an appropriate bariatric surgical option in super-superobese patients both for low morbidity rate and weight loss. The end-point of BMI < 30 can be achieved with a multidisciplinary follow-up. Additional studies with more patients and longer follow-up are needed to confirm these observations.