Massimiliano Sorbello, Radmilo J Jankovic
The globesity pandemic is quickly spreading around the whole world, doubling the obese population between 1980 and 2008, unevenly affecting countries, genders, and ages. The World Health Organization reports that in 2017 over 50% of both men and women in Europe were overweight (BMI> 25), 23% of women and 20% of men being frankly obese (BMI > 30); on other side of the Atlantic Ocean, the US Department of Health and Human Services reports obesity prevalence to be over 36% in adults and 17% in those younger than 17 years, and generally more frequent among middle-aged adults (40%). The annual number of bariatric procedures in the US increased from 158,000 in 2011 to 216,000 in 2016.1
Should these patients need surgery, either bariatric or non-bariatric, similar numbers depict a really challenging scenario for all physicians and for any healthcare system involved in their perioperative care, anaesthesiologists being in the first line.
The weight of such a situation has been clearly addressed in the work of ESA, which is in the process of releasing the updated preoperative evaluation guidelines,2 with s special chapter for obese patients. The ESA has been supporting and working with the subcommittees and subspecialty societies including the European Society for the Perioperative Management of Obese Patients and the European Airway Management Society, which have recently both endorsed the SIAARTI workgroup consensus paper for perioperative and peri-procedural airway management and respiratory safety for the obese patient.3
Many advancements have been promoted in the last years for the management of critically obese patients, with increased knowledge for complex pharmacokinetic issues, including the opioid-free or opioid-sparing approaches,4 and opportunities for neuromuscular monitoring, titration, and reversal,5 with precise diagnostic tools for comorbidities (just think of the STOP-Bang questionnaire and polysomnography) and endocrine-metabolic reverberations of metabolic syndrome, with development of targeted protocols, sophisticated tools (from videolaryngoscopes and fiberoptic bronchoscopes to ultrasounds and anaesthetic depth monitoring) including hand-held and portable instruments to grant a higher level of postoperative care monitoring, and including (transcutaneous) carbon dioxide monitoring, which is considered of paramount importance for early detection of postoperative apnoea episodes or respiratory complications. Sleep apnoea has recently been claimed to be the silent perioperative killer, as it was clearly identified to be associated with airway management issues and above all responsible, or an important co-factor, for severe postoperative complications due to hypoxia and hypercarbia, including cardiac arrest and brain damage. The only way to counteract such an expert and insidious sniper is to work on preoperative identification of OSAS patients and on adequately planned, arranged (including CPAP), and monitored post-surgical course.
In obese patients, postoperative pulmonary complications are other important and common complications, whose prevention needs to be initiated with preoperative evaluation, minimized apnoeic phases during anaesthetic induction, and protective ventilation, including low Vt policy and targeted recruitment and PEEP application, considering eventual use of non-invasive ventilation during recovery. Rabdomyolysis, acute kidney failure, or pulmonary embolism, surgical infection, and need for re-intervention are only some of the many possible complications that need to be considered, evaluated, screened, and above all anticipated for their specific higher incidence and morbidity in the bariatric population.
One of the most significant achievements for obese patients’ perioperative care, apart from single scientific advancements in the different fields, is undoubtedly awareness that obesity is a multilevel challenge offered to the perioperative (delicate and not error-proof) process. From the idea that single doctors needed to deal with singular and discipline-specific issues (each of them with their experience and competence), a new approach has arisen, the obese patient becoming the centre of a multi-disciplinary and multi-professional teamwork developed around dedicated devices, good clinical practice clinical pathways, experience, and cooperation.
Obese patients need to be extensively studied preoperatively to plan adequate induction and airway management strategies, opportune monitoring, devices, and resources, including staff, and safe postoperative level of care planning, including not only ICU beds if required, but also surgical ward monitored beds and adequately trained teams working on precise protocols and early warning systems and criteria (MEWS) in a continuum of care that needs to be maintained at all steps of the process.
The future of obese patients’ perioperative care probably lies in growing evidence of benefits coming from fast-track approach and ERAS protocols; nevertheless, the bariatric population seems to be a category of patients in which similar goals seem extremely demanding and even harder to achieve.5,6
The role of anaesthesiologists, as Perioperative Medicine leaders, is of paramount importance in such a setting, and it must be achieved by mostly understanding (or abandoning the idea) that the globesity challenge is not an individual task, but that it can be managed only as the result of teamwork, preparedness, organization, and knowledge. Head before hands, and brain before tools. This is one of the reasons why the ESA is strongly sustaining research and education, with impressive didactical effort also during Euroanaesthesia 2018, to be held in Copenhagen, aiming to recognize the leadership role of anaesthesiologists and to increase the lighter safety of our heavier patients.
- American Society for Metabolic and Bariatric Surgery. Estimate of Bariatric Surgery Numbers, 2011-2016. (2016). https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers.
- Kristensen SD, Knuuti J, Saraste A, et al. Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur J Anaesthesiol 2014;31:517-73.
- Petrini F, Di Giacinto I, Cataldo R, et al. Perioperative and periprocedural airway management and respiratory safety for the obese patient. 2016 SIAARTI Consensus. Minerva Anestesiol 2016;82:1314-35.
- Sorbello M, Pulvirenti GS, Panascia E, Di Giacinto I. Weighting (also) the risk of post-operative nausea and vomiting in bariatric surgery: time for opioid free anesthesia. Acta Anaesthesiol Scand 2017;61:856-7.
- Dinic VD, Stojanovic MD, Markovic D, et al. enhanced Recovery in thoracic surgery: A review. Front Med 2018;5:14.
- Jonsson A, Lin E, Patel L, et al. Barriers to Enhanced recovery after surgery after laparoscopic sleeve gastrectomy. J Am Coll Surg (2018), doi: 10.1016/j.jamcollsurg.2017.12.028.