Obesity is defined as a body mass index (BMI) of more than 30 (1). Its frequency is variable according to social, economical and cultural situations. Approximately 15%–20% of the population of Europe, 40% in the United States, and up to 80% in some Native Americans and in pacific islands populations (1) are morbidly obese, defined as a BMI more than 39 (2).
Laparoscopic gastric banding is a surgical method of treating morbid obesity in patients unable to loose weight by regime (3,4). In laparoscopic gastric banding, a ring is put over the cardia to limit food intake.
Initial complications of gastric banding are relatively rare, but reoperations, such as repositioning or removal of the band around the cardia, are performed regularly (3–5). Removal of cutaneous excess and other unrelated interventions after gastric banding are becoming more common.
Specific problems and precautions are well described for anesthesia induction in morbidly obese patients. However, no specific recommendations have been issued for patients with a gastric band in place.
We have recently experienced 2 bronchial aspirations during anesthesia induction in patients with a gastric band who had lost 40 and 50 kg of body weight. These complications may be related to gastric banding.
A 26-year-old man presented for abdominoplasty and lipectomy 4 yr after gastric banding. After having lost 42 kg, he still weighed 107 kg for 187-cm height (BMI of 30.6). There were no concomitant morbidities and no complaints of altered esophago-gastric transit. He took his last meal, consisting of spaghetti, at 11 pm. After premedication with oral midazolam 7.5 mg, anesthesia was induced at 11 am, with IV propofol 200 mg and fentanyl 300 μg. Having no difficulty with ventilation via a mask, norcuronium 10 mg was given IV. A few seconds later, the patient began to cough, and regurgitated material appeared in his mouth. His trachea was immediately intubated. Bronchoscopy confirmed a bronchoaspiration of gastric contents, including clearly identifiable spaghetti. A bronchial cleansing was performed and the operation postponed. After extubation, he recovered uneventfully. Three months later, the intended operation was performed. The patient was hospitalized the day before the operation. Throughout the day, he only received fluid meals. On operation day, rapid-sequence induction with thiopental 625 mg, succinylcholine 100 mg, and fentanyl 300 μg was uneventful.
A 28-year-old woman presented for mammopexy and lipectomy 4 yr after gastric banding. After weight loss of 50 kg, she weighed 70 kg for 160-cm height (BMI of 27.3). She had no significant comorbidities and no complaints of altered esophago-gastric transit. She took the last meal the day before the operation. Oral midazolam 7.5 mg was given at 7 am, followed by anesthetic induction at 9 am. After fentanyl 200 μg, anesthesia was induced with propofol 100 mg; immediately afterwards, she vomited undigested alimentary material. Immediate tracheal intubation after succinylcholine 100 mg to secure the airway was performed without problems. The following bronchoscopy confirmed a bronchial aspiration of undigested alimentary material, which was removed. The operation was postponed. The patient recovered uneventfully. Five days later, the patient was readmitted the day before the operation and was given only liquid meals. Preoperatively, she received an oral premedication with midazolam 7.5 mg at 9 am, and anesthesia was induced at 11 am. Rapid-sequence induction of anesthesia and endotracheal intubation with fentanyl 300 μg, thiopental 500 mg, and succinylcholine 100 mg was uneventful. Through the gastric tube, placed after the anesthesia induction, 10 mL of clear gastric secretion was aspirated. Five minutes after tracheal intubation, the anesthesia level was becoming somewhat superficial, and the patient coughed with a reflux of 100 mL of the same clear gastric secretion. A bronchoscopy showed no intrabronchial material, thus no bronchial aspiration. The rest of the anesthesia and operation were uneventful.
In normal-weight people, the gastro-esophageal reflux is usually caused by transient lower esophageal sphincter relaxation, a vagovagal reflex produced mostly by gastric distention (6).
Our cases indicate that esophago-gastric peristalsis in patients with a gastric band may be significantly altered. Esophago-gastric peristalsis after gastric banding has been assessed with variable conclusions: both no effect of gastric banding on the gastro-esophageal function as well as an impairment of the lower esophageal sphincter relaxation with deterioration of the esophageal peristalsis and dilation of the esophagus have been described (4,7,8). Information about the influence of such perturbation of the peristalsis on the frequency of complications during anesthesia induction (vomiting and reflux of digestive contents) is lacking.
There are no specific recommendations concerning the anesthesia induction in obese patients treated with gastric banding. Based on our experience, we consider the esophago-gastric peristalsis in these patients as significantly altered. Such patients should consume only liquid meals the day before the operation, and we propose a rapid-sequence induction of anesthesia. In patients with an expected difficult airway, an awake intubation may be considered.
1. Bjorntorp P. Obesity. Lancet 1997;350:423–6.
3. Weiner R, Blanco-Englert R, Weiner S, et al. Outcome after laparoscopic adjustable gastric banding: 8 years experience. Obes Surg 2003;13:427–34.
4. Weiss HG, Nehoda H, Labeck B, et al. Adjustable gastric and esophagogastric banding: a randomized clinical trial. Obes Surg 2002;12:573–8.
5. Peterli R, Donadini A, Peters T, et al. Re-operations following laparoscopic adjustable gastric banding. Obes Surg 2002;12:851–6.
6. Wise J, Conklin JL. Gastroesophageal reflux disease and baclofen: is there a light at the end of a tunnel? Curr Gastroenterol Rep 2004;6:213–9.
7. Korenkov M, Kohler L, Yucel N, et al. Esophageal motility and reflux symptoms before and after bariatric surgery. Obes Surg 2002;12:72–6.
8. Weiss HG, Nehoda H, Labeck B, et al. Treatment of morbid obesity with laparoscopic adjustable gastric banding affects esophageal motility. Am J Surg 2000;180:479–82.