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Introduction: Bariatric surgery is the most effective procedure for sustained weight loss and control of obesity-associated comorbidities among morbidly obese patients. Successful bariatric surgery depends on a multidisciplinary approach involving all healthcare workers, including the primary care physicians, from the referral of patients to long-term follow-up. The present study assessed the knowledge, attitude, and potential referral barriers of primary care physicians to bariatric surgery and associated sociodemographic factors. Materials and methods: The present analytical cross-sectional study was conducted among 280 randomly selected primary care physicians using a standard and validated data collection tool. We performed an independent t-test and one-way ANOVA to find the association between sociodemographic characteristics and knowledge, attitude, and referral barrier scores. Furthermore, multilinear regression analysis was executed to determine the association among knowledge, attitude, and barriers. Results: The current study found that 52.9%, 19.3%, and 59.3% had a low score in the knowledge, attitude, and barriers categories. The attitude scores were significantly associated with the education status (p = 0.005) and current position at primary health centers (p = 0.012), and the referral barriers score was significantly associated with the work experience duration (p = 0.004). We found a positive relationship between knowledge and attitude (regression coefficient (β) [95% CI]:0.389 [0.154 to 0.585], p = 0.001) and a negative relationship between knowledge and referral barriers (β [95% CI]: −0.291 [−0.127 to −0.058], p = 0.007). Conclusions: Our survey findings suggest that a lack of knowledge regarding bariatric surgery led to several concerns and referral barriers among the physicians. Therefore, the recommendation is to improve the primary care physicians' knowledge through continuing medical education, symposium, and other suitable training methods with a special focus on obesity care in the curriculum. Furthermore, a mixed-method survey involving other provinces of the KSA is warranted to formulate the region-specific training needs. [ABSTRACT FROM AUTHOR]

Background: Quadratus lumborum block has been claimed to provide effective analgesia in abdominal surgeries by covering both somatic as well as visceral pain. However, its utility in morbidly obese patients has not been reported or evaluated. Case presentation: In this case report, of laparoscopic hernia repair in a morbidly obese patient (weight 110 kg, height 1.53 m, BMI 46.9 kg/m2), there was excellent perioperative analgesia with no rescue opioid consumption in intraoperative period and average VAS score of 3 in 24 h postoperatively. The first recue analgesic was administered in the form of intravenous (IV) diclofenac 75 mg (diluted in 100 ml normal saline) 12 h after surgery when the patient reported a VAS of 5. Conclusions: QL block is an effective, feasible, and safe option for providing analgesia for laparoscopic hernia repair in morbidly obese patients. [ABSTRACT FROM AUTHOR]

This case report describes the use of high flow nasal oxygen (HFNO) in a patient with morbid obesity (BMI = 90 kg/m²) who underwent emergency laparotomy under general anesthesia. This 54‑year‑old female patient with American Society of Anesthesia classification 4 E is known to have COVID pneumonia with Obstuctive Sleep Apnea. She was admitted in the ICU for 3 days and she was on Bilevel Positive Airway Pressure (BiPAP) alternating with HFNO to keep her SpO2 91%–92%, on FiO2 60%, and respiratory rate (RR) 40–45/min. The plan for airway management was rapid sequence intubation with preoxygenation using the HFNO. We here report this case to show the usefulness of HFNO, which adds a new dimension in airway management of similar cases. [ABSTRACT FROM AUTHOR]

Background: Sugammadex reverses rocuronium more effective than neostigmine during deeper neuromuscular blockade levels. Relying upon the high cost of sugammadex we hypothesized that combined neostigmine with half-dose sugammadex (1.2 mg/kg) would be as effective as the full dose (2.4 mg/kg IBW) in reversing rocuronium-induced deep neuromuscular block in obese patients. A multimodal approach would be an effective cost saving strategy, while preserving the advantages of this novel agent. Patient and methods: A prospective randomized study done on 50 morbid obese patients undergoing elective laparoscopic sleeve gastrectomy operation. Patients were allocated into two groups each of 25. Group NS received sugammadex 1.2 mg/kg and neostigmine 50 μg/kg with atropine 20 μg/kg. Group S received sugammadex 2.4 mg/kg and 10 mL of normal saline. Primary outcome: Interval between administration of reversal and reaching TOF of 90%. Secondary outcomes: Total dose of rocuronium (mg), duration between last dose rocuronium and reverse, number of patients reached TOF of 90% within 5 min, duration between IV reversal and extubation, and the number of patients with residual neuromuscular blockade. Results: Number of patients who reached TOF 90% within 5 min, the interval between reversal and 90% TOF, the interval between reversal and extubation were comparable between the study groups. Conclusion: As regards neuromuscular blocker reversal in obese patients, the neostigmine 50 μg/kg plus sugammadex half dose (1.2 mg/kg) is as effective as full-dose sugammadex (2.4 mg/kg) alone. Trial registration: Institutional Research Board: (IRB code number): MS/17.12.195 on 16 January 2018. [ABSTRACT FROM AUTHOR]

Background: Postoperative pain, nausea, vomiting (PONV) and hypoxia are common in relation to laparoscopic bariatric surgery. Sympatholytic drugs might decrease the need for intravenous or inhalation anaesthetics and opioids and also decrease postoperative adverse events. Method: Sixty patients were included. Propofol, fentanyl and rocuronium were used for induction. Study groups were as follows; group E, esmolol infusion was added to sevoflurane and fentanyl, group N only sevoflurane and fentanyl was used during maintenance of anaesthesia. Patients were monitored during the intraoperative period and postoperatively for 24 h for analgesic requirements and PONV. Visual analog scale (VAS) scores for pain was also assessed. Results: Analgesic and anaesthetic requirements were significantly lower in group E than in group N (P-value <0.05). VAS scores were significantly lower in group E than in group N (Pvalue <0.05). PONV incidence was significantly lower in group E than in group N (Pvalue <0.05). Heart rates and blood pressures were significantly lower in group E compared to group N (P-value <0.05). Conclusion: Using esmolol during anaesthetic maintenance of laparoscopic bariatric surgery significantly decreases anaesthetic and analgesic requirements, postoperative pain, PONV and postoperative hypoxia. [ABSTRACT FROM AUTHOR]

Aim of the study: The aim was to perform a morphometric analysis of subcutaneous and visceral adipose tissue of morbidly obese women and to determine the relationship between adipocyte size and the development of type 2 diabetes (T2D). Materials and methods: White adipose tissue of morbidly obese women was obtained from subcutaneous and omental adipose tissue during bariatric surgery. The same tissues were obtained at judicial autopsy in non-obese (lean) non-diabetic patients. The harvested tissue was embedded in paraffin and 5 μm thick hematoxylin-eosin stained sections were analyzed by the Olympus cellSens system. Statistical evaluation was performed by GraphPad Prism 6.1 software. Results: We found a relationship between adipocyte size and the presence of T2D. The most pronounced changes were seen in visceral adipocytes (cell diameter increased from 61.9 μm in controls to 79.5 μm in patients with T2D). Also, the size of the subcutaneous adipocytes increased against the control. A statistically significant difference between diabetic and non-diabetic patients was not proven in subcutaneous adipocytes. We also observed differences in the distribution of adipocyte mean diameters. Whilst in the control group there was a normal (Gaussian) distribution, in the morbidly obese we found an asymmetric distribution with a positive skewness to the right. Conclusion: We have demonstrated that in morbidly obese women a significant increase in visceral adipocyte size is associated with the development of both insulin resistance and T2D. [ABSTRACT FROM AUTHOR]

Background Being a major health problem, surgical management of obesity has become a successful variant. Many laparoscopic procedures are readily available with their advantages and drawbacks. One of the major determinants of the choice of procedure is the expected weight loss. Laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB) are well-known procedures with a good reputation regarding postoperative weight loss. Aim The aim of this study was to compare excess weight loss (EWL) percentage between both procedures after 1 and 2 years postoperatively. Patients and methods This study included 60 morbidly obese patients divided equally into two groups: group A patients underwent LSG and group B patients underwent LAGB. %EWL was compared between both groups after 1 and 2 years in the postoperative period. Results All LSG cases continued follow-up for 2 years while four cases of the LAGB group discontinued follow-up due to band removal. Both procedures achieved a satisfactory weight loss over 1 and 2 years with better results in LSG. Conclusion Both LSG and LAGB are the commonly performed restrictive procedures for morbid obesity with acceptable results. LSG achieved more reduction of BMI and higher %EWL after a follow-up of 12 and 24 months. [ABSTRACT FROM AUTHOR]

Background Awake endotracheal intubation using the fiberoptic bronchoscope is the gold standard in morbidly obese patients. It needs special skills and high training. The disposable Airtraq laryngoscope had been used for difficult intubation. It can have some advantages compared with the fiberoptic bronchoscope during awake orotracheal intubation. Patients and methods In this study, 60 morbidly obese patients were randomly assigned to be intubated awake with either the fiberoptic bronchoscope (30 patients) or the Airtraq laryngoscope (30 patients). Time needed for intubation, the number of intubation attempts, success rate, and complications were assessed in the two groups. Results The time needed for intubation was significantly shorter in the Airtraq group compared with the bronchoscope group. As regards the number of attempts, there was a nonsignificant difference between the two groups. All patients were intubated successfully with a nonsignificant incidence of complications between the two groups. Conclusion The Airtraq laryngoscope can be used safely as the fiberoptic bronchoscope for awake orotracheal intubation in morbidly obese patients. [ABSTRACT FROM AUTHOR]

Introduction Laryngoscopy as well as tracheal intubation causes changes in the hemodynamics of the patient owing to stress response. C-MAC videolaryngoscope (VL) is a relatively recent development that improves the success of tracheal intubation. Aim The aim of this study was to compare and evaluate the effects of dexmedetomidine for attenuation of hemodynamic responses during laryngoscopy using Macintosh laryngoscope versus C-MAC laryngoscope. Patients and methods A total of 60 patients, ASA II, 18–60 years old, scheduled for different surgeries under general anesthesia with BMI up to 40 kg/m2 were included in the study. Patients were divided into two groups (30 patients each) and were appropriately positioned, and intubation was done. Hemodynamic stress response to intubation was recorded, and plasma epinephrine level was estimated at baseline and at 1 and 5 min after intubation. Success rate, duration, attempts of intubation, and SpO2% were assessed. Results Plasma epinephrine level (ng/ml) at baseline and at 1 and 5 min after intubation showed no statistically significant difference in both groups, but there were highly significant differences at 1 and 5 min after intubation compared with baseline values (P<0.0001 and <0.0007, respectively) in each group. Intubation time was longer in ML (17±4.47 s) compared within VL (12±3.4 s). There were no significant differences between both groups after intubation regarding hemodynamic changes, SpO2, or EtCO2. Conclusion The stress response in both laryngoscopic techniques appears to be the same as detected by the nonsignificant difference in plasma epinephrine levels and hemodynamic changes in both groups, so 1 μg/kg dexmedetomidine is not enough to obtund the stress response completely. C-MAC VL is an efficient and suitable intubating device and provides excellent visualization of laryngeal structures in shorter time with less intubation attempts than Macintosh (Techron Surgical, Sialkot, P, Pakistan) laryngoscopy. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic sleeve gastrectomy (SG) is gaining widespread popularity as a definitive bariatric operation that provides satisfactory and durable weight loss as well as comorbidity resolution. Although SG is being increasingly offered to patients of all ages, there is a paucity of reported outcomes in patients ≥62 years of age. The purpose of this study was to perform a comparative analysis of the outcomes of SG in patients >62 years versus a younger age group, with an emphasis on safety and efficacy. Methods: A retrospective analysis was performed from a prospectively collected database on patients who underwent SG from 2007 to 2012. All patients who were ≥62 years old were compared to those <62 years. Results: There were 182 patients who underwent SG, 17 of whom were ≥62 years old. There were no significant differences in demographics or comorbidity characteristics between the groups. The mean follow-up was 1 year. There was no 30-day mortality in either group. The percent excess weight loss for the younger age group was 44 ± 21 % and the older group was 44 ± 25 %. The percent total body weight loss was 22 ± 10 and 21 ± 10 %, respectively. Weight loss outcomes were maintained for up to 3 years. Comorbidity resolution and improvement rates were equivalent in both groups. Conclusions: SG is safe and effective in patients ≥62 years. Weight loss and the beneficial effects on comorbidities are equivalent among elderly and younger patients. SG should be offered to elderly patients who are deemed to be appropriate candidates. [ABSTRACT FROM AUTHOR]

Background: The current tendency to use increasingly less aggressive procedures has facilitated the development of new minimally invasive techniques. In this context, single-port (SP) access procedures can become an alternative to the conventional laparoscopic approach. Methods: A total of 22 morbidly obese patients were submitted to pure SP Roux-en-Y gastric bypass without additional ports. Selection for this approach was based on distance from the xiphoid to the umbilicus less than 28 cm, body mass index (BMI) lower than 50 kg/m, and preferably peripheral obesity. Access to the cavity was obtained through a single transverse, transumbilical incision, with placement of a SILS Port device. Results: The mean age of the patients was 41 ± 8.98 years, and 95 % of the patients were women. The mean BMI of the series was 42.68 ± 2.28 kg/m, and the mean body weight was 111.34 ± 10.66 kg. Surgery was performed successfully in all cases through a transumbilical incision with a mean length of 26.68 ± 5.27 mm. The mean surgical time was 114.05 ± 21 min, and the mean hospital stay was 3.27 ± 1.01 days. No intraoperative or immediate postoperative deaths or complications occurred. The median postoperative BMI during a mean follow-up period of 12 months was 28 kg/m (range, 18-35 kg/m). The median weight loss was 39 kg, and the percentage loss of excess body weight was 86 %. In relation to improvement of the comorbidities, two of the three patients with arterial hypertension showed normalization of their blood pressure values. Likewise, the blood glucose levels were corrected in two of the three diabetic patients, as well as in the patient with altered fasting blood glucose. Conclusions: Single-port Roux-en-Y gastric bypass surgery seems to be a safe, viable, and reproducible technique, but randomized studies involving larger patient series and longer follow-up periods are needed to compare the SP access and the multiple-port laparoscopic approach. [ABSTRACT FROM AUTHOR]

The article discusses a study on the impact of weight loss on sexual function and hormones and highlights the effect of bariatric surgery on sperm quality. To study the case 20 morbidly obese men were taken and they were analyzed for serum estradiol, prolactin (PRL), luteinizing and follicle-stimulating hormones. The study revealed that surgery-induced massive weight loss has no effect on sperm quality but it increases the quality of sexual function.

Background: Bariatric surgery has a lot of problems in anesthesia. We retrospectively compared anesthesia for bariatric surgery in yellow race with that in normal weight patients. Methods: Twenty patients who received bariatric surgery and 20 normal body weight patients who received abdominal surgery in Japan were enrolled. Induction condition, depth of epidural space, dose of anesthetics, duration of the effects of muscle relaxants, ventilation, and fluid management in bariatric surgery were analyzed and compared with those in normal body weight patients. Results: An epidural catheterization was successful under ultrasound guide in the bariatric group. The depth epidural space was significantly larger in the bariatric group. Cormack and Lehane classification and the number of intubation attempt were not different between the two groups, while one bariatric case was once awakened to intubate blindly. Pressure-controlled ventilation was used in the bariatric group. Four bariatric patients were continuously ventilated after surgery. The doses of anesthetics and fluid infusion rate were not different between the two groups when calculated by ideal body weight in the bariatric group. The duration of the effects of rocuronium and pancuronium were shorter in the bariatric group. Conclusions: For anesthesia of yellow race patients undergoing bariatric surgery, intravenous anesthetics and acetate Ringer's solution with 1% glucose could be administered per ideal body weight, the effects of muscle relaxants lasted shorter, pressure-controlled ventilation could keep oxygenation with adequate carbon dioxide, and ultrasound assist was useful in epidural catheterization in the bariatric patients. [ABSTRACT FROM AUTHOR]

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, range 28.0-79.1 kg/m; 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. [ABSTRACT FROM AUTHOR]

Background: There is a lack of long-term studies for metabolic syndrome after bariatric surgery. Our aim is to show the evolution of the parameters that define the metabolic syndrome after bariatric surgery, up to 10 years of follow-up, in order to clarify what technique gets better results with fewer complications. Methods: The IDF definition of the metabolic syndrome was used for this study. One hundred twenty-five morbid obese and superobese patients underwent vertical banded gastroplasty. Two hundred sixty-five morbid obese and superobese patients had biliopancreatic diversion (Scopinaro and modified biliopancreatic diversions), and 152 morbid obese patients underwent laparoscopic gastric bypass. A mean follow-up of up to 7 years was done in all groups. Results: Prior to surgery, metabolic syndrome was diagnosed in 114 patients of Scopinaro group (76%), in 85 patients of modified biliopancreatic diversion group (73.9%), in 81 patients of laparoscopic gastric bypass (53.4%), and in 98 patients of vertical banded gastroplasty (78.4%). When metabolic syndrome parameters were evaluated at 7 years of follow-up, owing to weight gain, these results changed nearby to preoperative values in both laparoscopic gastric bypass and vertical banded gastroplasty groups. Conclusion: According to our results, the best technique to resolve metabolic syndrome is the modified biliopancreatic diversion. Due to its high morbidity, it only must be considered in superobese patients. In obese patients, the laparoscopic gastric bypass may be a less agressive choice, but it should be coupled with lifestyle changes to keep away from the weight gain in the long run. Restrictive procedures may be indicated only in a few well-selected cases. [ABSTRACT FROM AUTHOR]

A morbidly obese male who sustained blunt trauma chest with bilateral pneumothorax was referred to the intensive care unit for management of his condition. Problems encountered in managing the patient were gradually increasing hypoxemia (chest trauma with multiple rib fractures with lung contusions) and difficult mask ventilation and intubation (morbid obesity, heavy jaw, short and thick neck). We performed awake endotracheal intubation using an intubating laryngeal mask airway (ILMA) size 4 and provided mechanical ventilation to the patient. This report suggests that ILMA can be very useful in the management of difficult airway outside the operating room and can help in preventing adverse events in an emergency setting. [ABSTRACT FROM AUTHOR]

Background: Analgesia, sedation, and anesthesia all can be dangerous in patients with obstructive sleep apnoea and have been associated with critical events during perioperative management. The risk further increases when obstructive sleep apnoea is associated with other comorbidities. Although regional anesthesia when feasible is preferred over general anesthesia, it is not a clear cut decision always. The dilemma and challenges for the management of such cases still persist.Case presentation: We present here a case of 58-year-old male, weighing 98 kg (body mass index 41.86 kg/m2), presented with bilateral forearm bone fractures that was planned for bilateral upper limb surgery in the same sitting. He was newly diagnosed as having obstructive sleep apnoea, a known case of morbid obesity, hypothyroidism, and orthopnea. He was also having anticipated difficult airway. The case was managed successfully under bilateral regional anesthesia. However, patients’ apprehension led to a new challenge which required different management strategies including titrated sevoflurane-based sedation.Conclusions: The case highlights the dilemmas and challenges faced by anesthesiologists, use of sevoflurane sedation, need of noninvasive ventilator support, and the limitations in the usual anesthesia machine and interface in the management of patients with obstructive sleep apnoea with multiple comorbidities. [ABSTRACT FROM AUTHOR]