Bergland A, Gislason H, Raeder J
Department of Anaesthesia, Aleris Hospital, Oslo, Norway.
Acta Anaesthesiol Scand. 2008 Nov;52(10):1394-9. doi: 10.1111/j.1399-6576.2008.01782.x.
Bariatric surgery for morbid obesity implies challenges in anaesthesiological handling. We report our experience from 500 consecutive patients during 3 years.
The patients were due for laparoscopic Roux-en-Y gastric bypass and enteral bypass. Sleep was induced after pre-oxygenation with target control infusions (TCI) of remifentanil and propofol; vecuronium was supplied for facilitating endotracheal intubation. The propofol infusion was stopped and desflurane 3-6% was given for BIS-titrated anaesthetic maintenance together with remifentanil TCI. Antiemetic prophylaxis was supplied with intravenous (IV) droperidol, ondansetron and dexamethasone; post-operative pain prophylaxis was IV paracetamol, parecoxib and bupivacaine infiltration. The patients were extubated in the operating room and kept in the post-operative care unit for 3-4 h, being tested for a 20 m walk before discharge to the ward.
The procedure was uncomplicated peri-operatively in all 500 cases and in 497 patients (99.4%) post-operatively. Three patients had one complication, which resolved without sequelae: oesophageal rupture from gastric tubing, reoperation for anastomosis leakage and pneumonia. The mean duration of surgery was 57 min (range 37-91). The mean time from the start of anaesthesia until the start of surgery and time from the end of surgery until the end of anaesthesia were both significantly reduced throughout the study period, from 23 to 7.8 and 5.8 to 1.9 min, respectively (P<0.001). The mean total hospital stay was reduced from 3 days at start to 2 days in the end of the series (P<0.05).
Safe bariatric short-stay surgery is feasible with a dedicated anaesthesiological concept in an expert surgical team.
肥胖症手术治疗病态肥胖对麻醉处理提出了挑战。我们报告了连续3年500例患者的经验。
患者计划接受腹腔镜Roux-en-Y胃旁路术和肠旁路术。预充氧后，通过瑞芬太尼和丙泊酚的靶控输注（TCI）诱导睡眠；给予维库溴铵以利于气管插管。停止丙泊酚输注，给予3%-6%的地氟醚用于脑电双频指数（BIS）滴定的麻醉维持，并联合瑞芬太尼TCI。静脉注射氟哌利多、昂丹司琼和地塞米松进行预防性止吐；术后疼痛预防采用静脉注射对乙酰氨基酚、帕瑞昔布和布比卡因浸润。患者在手术室拔管，并在术后护理单元停留3-4小时，出院前进行20米步行测试。
所有500例患者手术期间均无并发症，497例患者（99.4%）术后也无并发症。3例患者出现1种并发症，均无后遗症而痊愈：胃管致食管破裂、因吻合口漏再次手术和肺炎。平均手术时间为57分钟（范围37-91分钟）。在整个研究期间，从麻醉开始到手术开始的平均时间以及从手术结束到麻醉结束的平均时间均显著缩短，分别从23分钟降至7.8分钟和从5.8分钟降至1.9分钟（P<0.001）。平均总住院时间从开始时的3天降至系列结束时的2天（P<0.05）。
在专业手术团队中采用专门的麻醉理念，安全的肥胖症短期手术是可行的。
