Hazards of Anaesthesia for Laparoscopic Gastric Banding

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Overview

Laparoscopic Adjustable Gastric Banding (LAGB) for the treatment of obesity is the most commonly performed bariatric surgical procedure in Australia. Advantages of this type of surgery include the laparoscopic approach, reversibility of the surgery and the ability to adjust the band. The health benefits of the procedure have been well documented.1 However the Victorian Consultative Council on Anaesthetic Mortality and Morbidity has received a number of reports of morbidity and mortality of patients undergoing bariatric surgery, in some instances in suboptimal conditions.

Poor pre-operative assessment and lack of planning have been identified as key issues. As the risks of elective surgery are markedly increased due to co-morbidities, involvement of the whole peri-operative team is essential. Multidisciplinary input can optimize patients with diabetes, asthma, hypertension and obstructive sleep apnoea all of whom may benefit from preoperative intervention.

Airway management is of prime concern to the anaesthetist, with the risk of reflux on one hand and difficulty in securing the airway on the other. Thus a thorough and unhurried pre-operative assessment must include careful evaluation of the airway enabling adequate planning for a difficult or failed intubation.2 Pulmonary aspiration occurs most commonly during induction and laryngoscopy when sub-optimal conditions, including multiple attempts at intubation contribute to the risk. The role of cricoid pressure in the prevention of aspiration has been questioned as it has been suggested that it may be ineffective and impede ventilation and intubation.3 It is, however, essential that first class assistance is always available to help in securing the airway.

The incidence of oesophageal reflux is high with a direct correlation between BMI and reflux. There is also a different pathophysiology in the obese with hyperacidity, hiatus hernia, raised intraabdominal pressure as well as vagal abnormalities. Gastric banding itself may cause reflux (especially with slipping or erosion of the band.)

Management of post-operative pain is usually not difficult but care must be taken with the use of sedatives or analgesics as excessive sedation can compound obstructive sleep apnoea and increase respiratory depression.They should be used carefully in a monitored environment. The need for postoperative ventilation in an Intensive Care Unit is rare but there is a frequent requirement for a high dependency unit to manage patients with poorly controlled obstructive sleep apnoea, hypertension, diabetes, asthma and cardiac disease.

Occupational health and safety issues for staff handling heavy patients also need to be addressed. Provision of adequate staff is necessary and beds, lifting devices and operating tables should be designed for use with heavy loads. Whenever possible patients should be encouraged to move themselves.

Staff education about the special needs of the obese should include recognition of the psychological impact of obesity on this socially marginalized group and issues of privacy and respect need to be reinforced

Dr J Carden (Vic)
Specialist Anaesthetist
Member of: Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM)

In conjunction with and endorsed by: VCCAMM
September 2007

1 Health Outcomes of Severely Obese Type 2 Diabetic Subjects 1 year after laparoscopic adjustable gastric banding. Dixon JB, O’Brien PE Diabetes Care 2002; 25:358-363

2 Morbid Obesity and Tracheal Intubation. Brodsky JB, Lemmens HJ, Brock-Utne JG, Vierra M, Saidman LJ Anesth Analg 2002; 94:732-736

3 Strategies for Prophylaxis and Treatment of Aspiration, Kalinowski CPK, Kirsch JR Best practice and research clinical anaesthesiology 2004; 18: 719-737

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Hazards of Anaesthesia for Laparoscopic Gastric Banding (18kb, pdf)

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