Laparoscopic sleeve gastrectomy: a novel procedure for weight loss.

INTRODUCTION: Morbid obesity is associated with increased morbidity and mortality. Bariatric surgery offers morbidly obese individuals substantial and sustainable weight loss and reduction in obesity-related comorbidities. Laparoscopic sleeve gastrectomy (LSG) is a new restrictive procedure in bariatric surgery. We aimed to evaluate our experience with LSG with regard to its safety and feasibility and early weight loss. METHODS: The surgical outcome, complications and early clinical results of all patients who underwent LSG at Singapore General Hospital were studied. RESULTS: 30 patients underwent LSG between December 2008 and October 2010. The mean preoperative weight of the patients was 113.4 (range 91.0-170.0) kg, while the mean body mass index (BMI) was 42.6 (range 33.0-60.0) kg/m². Diabetes mellitus was present in 39 percent of the patients, hypertension in 43 percent, hyperlipidaemia in 35 percent, obstructive sleep apnoea in 30 percent and osteoarthritis in 22 percent. The majority of patients had two or more obesity-related comorbidities (52 percent). Mean operative time was 142 (range 80-220) minutes and median duration of postoperative stay was three days. At two weeks, one, three and six months post operation, the mean BMI was 38.6 kg/m², 37.8 kg/m², 34.5 kg/m² and 30.8 kg/m², the mean percentage of excess weight loss was 17.7 percent, 23.3 percent, 40.9 percent and 56.7 percent, and absolute weight loss was 8.00 kg, 11.52 kg, 18.77 kg and 26.85 kg, respectively. CONCLUSION: LSG is a promising procedure for surgical treatment of obesity, with good early weight loss and low morbidity.

Anaesthetic management of bronchopleural fistula in a patient with myasthenia gravis.

Patients with bronchopleural fistula present with specific airway management and ventilatory concerns, which makes the anaesthetic management of these patients challenging. Myasthenia gravis is another condition requiring specific anaesthetic management, with possible unpredictable delays in recovery. A combination of both these conditions in a patient makes management even more difficult. Our patient with myasthenia gravis underwent repair of the bronchopleural fistula, during which a multimodal approach to intraoperative and postoperative analgesia was adopted. Positive pressure ventilation was started only after we confirmed the isolation of the lung.

Patient-controlled epidural analgesia after thoracic and upper abdominal surgery using sufentanil with and without bupivacaine 0.125%.

BACKGROUND: Epidural sufentanil can relieve postoperative pain after thoracic and upper abdominal surgery but it has some unwanted side effects. Patient-controlled epidural analgesia (PCEA) allows patients to titrate and reduce their analgesic requirements. OBJECTIVE: The study aims to assess the use of demand-only PCEA after thoracotomy and upper abdominal surgery using sufentanil with or without bupivacaine in terms of pain control, amount of analgesic required and side effect profile. METHODS: After the Hospital Ethics Committee approval and written informed consent, 34 ASA I and II patients were enrolled in this prospective, randomised, double-blinded controlled study. Post-operatively, after achieving adequate analgesia in the recovery, the patients were randomised to receive either sufentanil 1 microg/ml in normal saline (Group S) or sufentanil 1 microg/ml with bupivacaine 0.125% (Group SB) in a demand-only PCEA programme. Pain scores, side effects and amount of analgesia used were reviewed every hour. RESULTS: The demographic profile of both groups was similar. The amount of sufentanil used was higher in Group S than in Group SB but it was not statistically significant. The numbers of patients with high pain scores at rest and during movement were not significantly different between the two groups. The side effect profiles of both groups were similar. CONCLUSIONS: The PCEA demand-only programme using sufentanil 1 microg/ml with and without bupivacaine 0.125% was satisfactory after thoracotomy and upper abdominal surgery in our patient population. The addition of bupivacaine to sufentanil did not significantly reduce the amount of sufentanil required, the pain scores or the side effects.

The effect of heat and moisture exchanger and gas flow on humidity and temperature in a circle anaesthetic system.

OBJECTIVE: The aim of the study was to measure the humidity and temperature of the inspired gas in a circle absorber system at fresh gas flows of 11/min and 31/min and assess the need of a heat and moisture exchanger (HME). METHODS: This prospective randomised controlled study received the Hospital Ethics Committee approval and informed consent. Forty adult ASA 1 and 11 patients were randomised into four groups to receive with or without HME fresh gas flow of 1L/min or 3L/min. Temperature and the relative humidity readings were taken at the start and every 10 minutes for the first hour of anaesthesia. RESULTS: There was a significantly higher relative humidity, absolute humidity and temperatures of the inspired gases at fresh gas flow of 1L/min and 3L/min with a HME compared to 3L/min without HME. Patients receiving fresh gas flows of lL/min had higher relative and absolute humidity than patients with fresh gas flows of 3L/min. However, the addition of the HME improved the absolute and relative humidity of the inspired gas in patients receiving fresh gas flow of 3l/min to a comparable level. However, the addition of a HME to a fresh gas flow of 1L/min did not significantly improve the humidity of the inspired gas. CONCLUSION: This suggests that the inherent humidifying property of the circle system at low fresh gas flow of 1L/min was sufficient in short surgeries lasting less than one hour and that the addition of a HME may not be necessary.

Rapid preparation of a patient with pheochromocytoma with labetolol and magnesium sulfate.

PURPOSE: To describe the rapid perioperative optimization and control of blood pressure in a young patient who presented with pheochromocytoma. He was non-compliant with phenoxybenzamine but insisted on early surgery. He was scheduled for laparoscopic resection of the tumour. CLINICAL FEATURES: This 32-yr-old man presented with uncontrolled hypertension for a few years for which he was treated with nifedipine. He subsequently defaulted follow-up. The patient presented again approximately three months from the day of surgery and was diagnosed to have a pheochromocytoma. The endocrinologist prescribed phenoxybenzamine and propanolol in addition to the nifedipine but the patient stopped taking both drugs six weeks prior to surgery due to their side effects. The patient was admitted the evening before surgery to the intensive care unit for rapid control of his blood pressure. Blood pressure was optimized with an infusion of labetolol and volume expansion titrated under central venous catheter and intraarterial blood pressure guidance throughout the night. On the morning of surgery, a magnesium sulfate infusion was started. The laparoscopic surgery proceeded uneventfully and the patient was hemodynamically stable. There were two transient periods of hypotension after induction and at removal of tumour respectively which were corrected with a brief adrenaline infusion. No adverse outcome was noted. CONCLUSION: This case highlights the possibility of a more rapid perioperative control of pheochromocytoma using high doses of labetolol and a magnesium sulfate infusion to achieve stable intraoperative hemodynamics during laparoscopic resection of pheochromocytoma.