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Morbid Obesity
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Book description

The world is experiencing an obesity epidemic. In both industrialized and emerging countries, the percentage of adults and children with obesity is increasing annually. It is no longer unusual to encounter a patient with extreme or morbid obesity in the operating room; these patients are routinely scheduled for every type of surgical procedure. Everyone involved in the peri-operative management of the surgical patient with morbid obesity – surgeons, anesthesiologists, internists, psychologists, nurses, nutritionists, respiratory therapists – must be aware of the special needs of these patients. Morbid Obesity: Peri-operative Management, 2nd edition considers the perioperative care of the morbidly obese patient, from preoperative preparation to intraoperative management and through to their postoperative course. Edited by leading experts in the management of the morbidly obese surgical patient, Morbid Obesity: Peri-operative Management, second edition, provides clear, practical clinical guidance on the management of the extremely obese surgical patient.


Praise for the first edition:'Alvarez's lucid presentation of these complex and timely issues is an achievement in itself, but even more so is his production of a very readable book. This book is assured to inform and complement the busy clinician. I recommend it to every physician involved in the care of the morbidly obese patient.'

Source: Obesity Surgery

'I enjoyed reading this organized, appropriately illustrated, and well-references book. …Although this, by intention, is not a textbook of anaesthesia for obesity, it contains a wealth of anaesthetic-related information and I have no reservation in recommending it as essential reading for any anaesthetist involved in the care of patients suffering obesity. In my opinion, it will also appeal to surgeons, physicians, intensivists, theatre, recovery and ward nursing staff, psychologists, dieticians, and managers involved in the care of these complex and frequently challenging patients.

Source: British Journal of Anaesthesia

'… the text is well illustrated and … organised. The authors come from varied clinical backgrounds … Each chapter is well researched and appropriately referenced … an excellent resource for anaesthetists, surgeons and intensivists who wish to develop skills to recognise potential complications and provide quality peri-operative care to obese patients.'

Source: Critical Care (

'… this book should be on the shelf of any provider who regularly cares for obese patients. [Its] easy-to-read chapters and efficiently indexed information make it a very useful tool for quick reference in the operating room or preoperative assessment setting. The text is filled with easy-to-read figures and tables, which only enhances its usefulness in clinical practice. The editors even provide a list of abbreviations in the front of the book. [They] have clearly achieved their goal of providing a comprehensive yet very accessible manual for the care of the morbidly obese patient.'

Source: Anesthesiology

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Page 1 of 2

  • Section 3 - Intra-operative management
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    The metabolic syndrome is associated with cardiovascular deterioration and encompasses a constellation of risk factors, which include excess abdominal visceral fat (AVF), atherogenic dyslipidemia etc. At ideal BMI, adipokines have purely beneficial effects on metabolism, cardiac function, and vascular endothelial well-being. Obesity is characterized by a hyperdynamic circulation. Increases in stroke volume (SV) and cardiac output (CO) are usually described as being linear and directly proportional to increased BMI. Histologically, the most common post-mortem finding in obesity is myocyte hypertrophy. Obesity cardiomyopathy or congestive heart failure (CHF) associated with obesity, can be caused by primary systolic heart failure (SHF), usually associated with eccentric hypertrophy and systolic dysfunction. Atrial fibrillation is commonly associated with morbid obesity (MO). Surgically induced weight loss reverses many of the maladaptive functional and structural cardiovascular changes associated with MO and reduces overall risk.
  • 11 - Effects of obesity on anesthetic agents
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    This chapter summarizes current knowledge about changes in pulmonary physiology associated with obesity. It describes the pathophysiology of obstructive sleep apnea (OSA) and obesity hypoventilation syndrome (OHS). In obese individuals with OSA, increased soft tissue deposition in the pharyngeal region and tongue contributes to a decreased upper airway size. The polysomnography (PSG) remains the standard for diagnosis and assessment of the severity of OSA. Expert consensus concluded that the degree of peri-operative risk for patients with OSA depends on the severity of the OSA and the type of surgery. Obesity hypoventilation syndrome is a diagnosis of exclusion and requires the absence of other reasons for chronic hypoventilation such as chronic lung or neuromuscular disease. Additional treatment options for OHS similar to those for OSA are available including pharmacotherapy. The significant potential cardio-pulmonary co-morbidities present in OHS patients mandate a high index of suspicion to identify these patients preoperatively.
  • 12 - Airway management
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    This chapter looks at several aspects of metabolic and digestive diseases associated with obesity. Obesity is associated with a dual problem for these metabolic processes: excessive delivery of fat and carbohydrate to the liver and reduced effectiveness of insulin in regulating fat metabolism. It is now believed that type 2 diabetes (T2D) is a disease characterized by hepatic steatosis as well as dysregulation of glucose metabolism. Non-alcoholic steatohepatitis (NASH) is an inflammatory disease that results from hepatic steatosis. Insulin resistance is commonly associated with, but not unique to, obesity. The distribution of body fat has significant impact on the development of metabolic disease. Obesity is not an essential component of metabolic syndrome (MetS); however, there is a strong correlation between visceral fat deposits and MetS. Although there are no data implicating stress hyperglycemia and adverse outcomes in bariatric surgery, substantial data exists in other clinical and laboratory conditions.
  • 13 - Ventilatory strategies during anesthesia
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    Pneumoperitoneum with CO2 gas begins the process of systemic acidification by altering the ultrastructural, metabolic, and immune functions of the peritoneum. Both direct and indirect effects of CO2 can be seen in numerous aspects of the cardiovascular system. Both obese and non-obese patients undergo laparoscopy at 15 mm Hg of CO2 gas in order to provide adequate visualization while minimizing the detrimental effects of increased intra-abdominal pressure (IAP). An overall decrease in renal perfusion and a resultant increase in hormonal activity occur with pneumoperitoneum. Patients with chronic obstructive pulmonary disease (COPD) often require lower IAP during laparoscopy. Effective preventions or control of detrimental effects of CO2 pneumoperitoneum are key to maintaining the safety profile of laparoscopy. Nevertheless, with the numerous benefits that stem from sequential compression devices (SCDs), their routine use has become widely recommended for all laparoscopic surgery.
  • 14 - Regional anesthesia and obesity
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    This chapter reviews the factors involved in deciding which operation to perform for an operative candidate. Roux-en-y gastric bypass is the most common weight loss procedure performed in the United States and is a mixed restrictive and malabsorptive procedure. For many patients, government policy may also determine the operative procedure options. Patients are generally better informed and capable of deciding which bariatric operative procedure would be best for them. Past surgical history of a patient can factor into the decision making process. This information can change the surgeon's operative approach, especially if the patient has had prior gastric surgery. Patients with a history of eating high calorie liquids, such as ice cream, must change their eating habits as this is one way to fail any bariatric procedure. Some patients will have personality characteristics that may make them better candidates for one procedure over another.
  • 16 - Post-anesthesia care unit: Management of anesthetic and surgical complications
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    This chapter reviews the doctrine of informed consent focusing especially on the tensions that have arisen between the competing principles of patient autonomy and physician beneficence. Surgeons were expected to get consent from patients for the operations to be performed and the patients' options were to "take it or leave it". The right to informed consent becomes progressively more important as proposed diagnostic or therapeutic options entail greater risks. True patient autonomy allows choices to be made in the absence of external control. Physician beneficence versus respect for the patient as a person has arisen into a contemporary moral tension between two important ethical principles. Autonomy of the individual in making decisions on healthcare treatment has been a priority of the legal system. In the future, non-procedural information, such as financial considerations and individual physician performance will assume greater importance.
  • 17 - Intensive care management of the critically ill obese patient
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    The pre-operative assessment of candidates for bariatric procedures is based on the principle of identifying modifiable health concerns and implementing risk reducing treatments to reduce peri-operative morbidity and mortality. Most bariatric patients have known conditions, which are already being treated by a primary care physician (PCP), alleviating the need to perform additional probing tests. Patients with unlimited exercise tolerance have half the risk of serious post-operative complications compared to those with a low tolerance. Excessive weight infringes on the chest wall, rib cage, and diaphragm, directly affecting pulmonary function in morbidly obese (MO) patients. Although psychiatric evaluation for patients seeking bariatric surgery is considered important, at the present time there is a lack of consensus as to how to proceed. Nutritional evaluation should also be initiated prior to surgery. Appropriate evaluation of the bariatric patient seeks to identify modifiable risk factors and can exclude poor candidates prior to surgery.
  • 18 - Post-operative rhabdomyolysis
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    The evaluation process for bariatric surgery needs to be multidisciplinary with evaluation and optimization of physical and mental health, as well as identification of prior obstacles for successful weight loss. Pre-operative evaluations for medical conditions that increase the risk of peri-operative risk, as well as an evaluation for conditions that may worsen post-operatively, are essential elements of the work-up. A psychologic assessment is an integral part of the evaluation of the patient seeking bariatric surgery, yet no consensus exists regarding necessary components of the evaluation. It is evident that patients seeking bariatric surgery have lifestyles incompatible with successful management of their weight. Tracking non-compliance with pre-operative recommendations often helps identify patients who are unmotivated and who may have poor compliance with dietary, physical activity, and vitamin/mineral supplements post-operatively. Bariatric surgery is an important tool for the management of the patient with medically complicated obesity.

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