Opioid-free total intravenous anaesthesia reduces postoperative nausea and vomiting in bariatric surgery beyond triple prophylaxis.

BACKGROUND: Patients undergoing bariatric surgery are at high risk of postoperative nausea and vomiting (PONV). Despite triple PONV prophylaxis, up to 42.7% of patients require antiemetic rescue medication (AERM). METHODS: This prospective, randomized study was conducted from November 2011 to October 2012. In the Classic group (n=59), patients underwent general anaesthesia with volatile anaesthetics and opioids. In the Total i.v. anaesthesia (TIVA) group (n=60), patients underwent opioid-free TIVA with propofol, ketamine, and dexmedetomidine. The severity of PONV was assessed using a Likert scale (none, mild, moderate, and severe). RESULTS: Patients in both groups had similar clinical characteristics, surgical procedure, and PONV risk scores and required similar amounts of postoperative opioid. In the Classic group, 22 patients (37.3%) reported PONV compared with 12 patients (20.0%) in the TIVA group [P=0.04; risk 1.27 (1.01-1.61)]. The absolute risk reduction was 17.3% (number-needed-to-treat=6). The severity of nausea was statistically different in both groups (P=0.02). The severity of PONV was significantly worse in the Classic group. There was no difference either in the number of patients requiring AERM in the postoperative period or in the number of AERM doses required. CONCLUSIONS: This prospective randomized study demonstrates that opioid-free TIVA is associated with a large reduction in relative risk of PONV compared with balanced anaesthesia. Clinical trial registration NCT 01449708 (ClinicalTrials.gov).

Esophageal motility disorders in the morbidly obese population.

BACKGROUND: Most studies investigating esophageal motility among the morbidly obese have focused on the relationship between lower esophageal sphincter (LES) pressure and gastroesophageal reflux disease (GERD). Very few studies in the literature have examined motility disorders among the morbidly obese population in general outside the context of GERD. This study aimed to determine the prevalence of esophageal motility disorders in obese patients selected for bariatric surgery. METHODS: A total of 116 obese patients (81 women and 35 men) selected for laparoscopic gastric banding underwent manometric evaluation of their esophagus from January to March 2003. Tracings were retrospectively reviewed for the end points of LES resting pressure, LES relaxation, and esophageal peristalsis. RESULTS: The study patients had a body mass index (BMI) of 42.9 kg/m2, and a mean age of 48.6 years. The following abnormal manometric findings were demonstrated in 41% of the patients: nonspecific esophageal motility disorders (23%), nutcracker esophagus (peristaltic amplitude >180 mmHg) (11%), isolated hypertensive LES pressure (>35 mmHg) (3%), isolated hypotensive LES pressure (<12 mmHg) (3%), diffuse esophageal spasm (1%), and achalasia (1%). Only one patient with abnormal esophageal motility reported noncardiac chest pain. CONCLUSIONS: Despite a high prevalence of esophageal dysmotility in our morbidly obese study population, there was a conspicuous absence of symptoms. Although the patients in this study were not directly questioned with regard to esophageal symptoms, several studies in the literature support our conclusion.