Previous article Table of Contents  Next article

REVIEW ARTICLE
Year : 2022  |  Volume : 16  |  Issue : 3  |  Page : 299-305

Patients with sleep-disordered breathing for bariatric surgery


Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, United States

Correspondence Address:
Tiffany S Moon
5323 Harry Hines Blvd., Dallas, TX
United States
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sja.sja_300_22

Rights and Permissions
Date of Submission09-Apr-2022
Date of Acceptance10-Apr-2022
Date of Web Publication20-Jun-2022
 

  Abstract 


The prevalence of patients with obesity continues to rise worldwide and has reached epidemic proportions. There is a strong correlation between obesity and sleep-disordered breathing (SDB), and, in particular, obstructive sleep apnea (OSA). OSA is often undiagnosed in the surgical population. Bariatric surgery has been recognized as an effective treatment option for both obesity and OSA. Laparoscopic bariatric procedures, particularly laparoscopic sleeve gastrectomy (LSG), have become the most frequently performed procedures. OSA has been identified as an independent risk factor for perioperative complications and failure to recognize and prepare for patients with OSA is a major cause of postoperative adverse events, suggesting that all patients undergoing bariatric surgery should be screened preoperatively for OSA. These patients should be treated with an opioid-sparing analgesic plan and continuous positive airway pressure (CPAP) perioperatively to minimize respiratory complications. With the number of bariatric surgical patients with SDB likely to continue rising, it is critical to understand the best practices to manage this patient population.

Keywords: Anesthesia, bariatric surgery, obesity, OSA, sleep-disordered breathing


How to cite this article:
Oh MW, Chen JL, Moon TS. Patients with sleep-disordered breathing for bariatric surgery. Saudi J Anaesth 2022;16:299-305

How to cite this URL:
Oh MW, Chen JL, Moon TS. Patients with sleep-disordered breathing for bariatric surgery. Saudi J Anaesth [serial online] 2022 [cited 2022 Nov 28];16:299-305. Available from: https://www.saudija.org/text.asp?2022/16/3/299/347755




  Introduction Top


According to data from the American Society for Metabolic and Bariatric Surgery (ASMBS), the number of bariatric surgeries performed each year continues to increase.[1] Worldwide, the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) Worldwide Survey reported that almost 700,000 bariatric surgeries were performed in 2018.[2] With the worldwide prevalence of obesity reaching epidemic proportions and continuing to rise, the number of patients seeking bariatric procedures will likely continue to rise as well.

The prevalence of sleep-disordered breathing (SDB) has been estimated to be around 34% and 17% in 30–70-year-old men and women, respectively.[3] The prevalence of obstructive sleep apnea (OSA), the most common form of SDB, among patients with obesity ranges from 35–94%, with several studies reporting a prevalence greater than 60%.[4],[5],[6],[7],[8] Furthermore, the high prevalence of SDB may be underestimated when considering the number of undiagnosed patients.[9]

SDB is characterized by upper airway dysfunction during sleep and encompasses a wide spectrum of conditions including increased resistance to and reduction in airflow, snoring, and apnea. In the perioperative period, especially postoperatively, patients with SDB have been found to have a higher rate of pulmonary and cardiovascular complications compared to patients without SDB.[10],[11],[12],[13],[14],[15],[16] Given the likely increase of bariatric surgical patients in the future, there is special interest in understanding the best practices to care for these patients including preoperative screening, intraoperative management, and postoperative monitoring.


  Methods Top


A literature review was conducted using the PubMed search engine and the search terms “bariatric surgery,” “obstructive sleep apnea,” and “obesity.” Publications were filtered by publication date within 10 years. Any articles that were not published in English were excluded. More articles were found beyond this initial search from key studies referenced within other articles. A total yield of 89 articles was included based on their relevancy to the subject matter and publication date.


  Bariatric Surgery as a Treatment for Obesity and OSA Top


Bariatric surgery is indicated as an effective treatment option for both obesity and OSA.[4],[17],[18],[19],[20] The 1991 National Institutes of Health guidelines, which remain widely used to this day, recommend that patients with a body mass index (BMI) ≥40 kg/m2 or with a BMI ≥35 kg/m2 with serious obesity-related comorbidity be considered for bariatric surgery.[20] For patients with obesity, bariatric surgery has been found to be associated with long-term weight loss and improvements in obesity-related comorbidities, including type 2 diabetes mellitus, sleep apnea, and hypertension.[19],[20] With regard to OSA specifically, bariatric surgery has been shown to be associated with favorable anatomic airway remodeling and reductions in the apnea–hypopnea index (AHI).[18],[21] Further research with long-term follow-ups is necessary to determine if the improvements in OSA from bariatric surgery extend beyond the first one to two years postoperatively, as a systematic review found that there was a higher probability of OSA relapse beyond the short/medium-term time period.[22] The variability in the effectiveness of the different procedures for improving SDB can be attributed to differences in weight-dependent effects, weight-independent effects, anti-inflammatory effects, and central nervous system cytokine changes.


  Bariatric Surgery Techniques Top


Since its introduction in 1993, laparoscopic bariatric procedures have rapidly surpassed open bariatric procedures in popularity due to the decreased risk of wound infection and incisional hernias, reduced healing time, and lower incidence of pneumonia, pulmonary complications, and mortality.[19],[23],[24] The ASMBS officially recommends laparoscopic sleeve gastrectomy (LSG) as an approved primary bariatric procedure due to the low rate of complications and mortality, improved quality of life, improvements in medical comorbidities, and significant and long-lasting weight loss.[2] Other benefits associated with LSG include the absence of foreign material, avoidance of gastrointestinal (GI) anastomosis and malabsorption, short operative time, simpler surgical technique, and high patient acceptance.[25] Thus, the LSG has become the most frequently performed bariatric procedure worldwide, making up 61.4% of all cases.[1] Following LSG, the next most commonly performed procedures worldwide are Roux-en-Y gastric bypass (RYGB) (17.0%), revision procedures (15.4%), balloon placement (2.0%), gastric band (GB) (1.1%), and biliopancreatic diversion-duodenal switch (BPD-DS) (0.8%).[1]


  Preoperative Evaluation Top


OSA screening

OSA is undiagnosed in up to 80% of patients at the time of surgery. Failure to recognize OSA preoperatively can lead to perioperative complications including oxygen desaturation and adverse cardiac events. Thus, all bariatric surgical patients should be preoperatively screened for OSA.[16],[26],[27] Currently, the gold standard in the diagnosis of OSA is polysomnography (PSG), a resource-intensive sleep test that monitors the electroencephalogram (EEG), and electrooculogram (EOG), and submental electromyogram (EMG) during sleep. A study performed by Hallowell et al.[28] found a significant reduction in intensive care unit (ICU) admissions related to respiratory complications when mandatory PSG screening and preoperative treatment were implemented in patients undergoing gastric bypass procedures. Ideally, all bariatric patients would undergo PSG evaluation. However, routine use of preoperative PSG for every bariatric surgical patient may not be feasible or cost-effective and may delay the surgical treatment of obesity and SDB. If PSG is not feasible, it is still recommended that all patients be screened for OSA to risk-stratify patients and determine the need for and ideal level of continuous positive airway pressure (CPAP), as well as to plan for postoperative monitoring.[29],[30],[31] Patients at high risk for SDB may be identified by utilizing the classic triad of observed apnea or snoring with hypopnea during sleep, arousal from sleep, and daytime sleepiness or fatigue. The most widely used screening tool for detecting OSA is the STOP-Bang (snoring, tiredness, observed apnea, blood pressure, body mass index, age, neck size, gender) questionnaire, which provides an 8-point OSA prediction score and has been found to be both easy to use and a good predictor of severe OSA (AHI >30).[32] For a STOP-Bang score ≥3, this screening tool has a sensitivity of 93% and specificity of 43% at an AHI >15 and a sensitivity of 100% and specificity of 37% for an AHI >30.[33],[34] Other OSA screening tools include the Berlin questionnaire, the American Society of Anesthesiologists (ASA) checklist, abbreviated versions of the STOP-Bang questionnaire, Epworth sleepiness scale, and type III portable sleep monitors.[35],[36],[37]

If patients are suspected of having OSA based on clinical criteria, a definitive diagnosis with PSG and preoperative CPAP should be considered.[27] Although further research needs to be performed regarding preoperative CPAP administration in the bariatric surgical population specifically, preoperative CPAP for patients with OSA undergoing a variety of other surgeries has shown to reduce the risk of postoperative adverse events and complications,[29],[30] improve underlying conditions including hypertension,[38] and reduce ICU and hospital length of stay.[39]

Obesity hypoventilation syndrome (OHS) screening

OHS is another common SDB and is characterized by alveolar hypoventilation leading to oxygen desaturation and high arterial carbon dioxide levels.[4] It consists of a triad of components: BMI ≥30 kg/m2, daytime hypoxemia, and hypercapnia. OHS has been found to coexist in up to 20% of patients with OSA, and it is an independent risk factor for severe desaturation.[40] The combination of both OHS and OSA is associated with higher morbidity and mortality in patients undergoing bariatric surgery.[30],[41] Furthermore, patients with OSA undergoing elective, non-cardiac procedures who were hypercapnic experienced higher incidences of ICU admission, longer hospital and ICU lengths of stay, and acute heart failure and respiratory failure compared to patients with OSA who were not hypercapnic.[41] Therefore, all bariatric patients should be screened for both OSA and OHS to identify those at increased risk for perioperative complications.[40] To screen patients for the coexistence of OHS, it is recommended to perform venous bicarbonate measurements, with a bicarbonate value >27 mEq/L suggestive of OHS.[40]


  Intraoperative Management Top


Airway management

Patients with OSA and obesity can have more collapsible upper airways and reduced functional residual capacity (FRC) that predispose them to rapid desaturation, even after short periods of apnea or hypoventilation.[42],[43] OSA has been found to be a risk factor for difficult tracheal intubation (DI)[43] and difficult mask ventilation (DMV).[12],[44],[45],[46],[47] Furthermore, the Fourth National Audit Project (NAP4), found that patients with obesity (BMI 30–35 kg/m2) and morbid obesity (BMI >35 kg/m2) had twice and four times as many serious airway complications as patients without obesity, respectively.[48] Thus, it is imperative that special precautions be taken when securing the airway of this patient population.

Patients with diagnosed or suspected OSA undergoing bariatric surgery should be positioned in the ramped or head-elevated laryngoscopy position (HELP), which improves the laryngoscopic view during intubation, increases FRC, and elevates arterial oxygen tension.[49],[50] Patients with obesity have a much shorter safe apnea time, so it is imperative that these patients are maximally preoxygenated, and the use of apneic oxygenation should be considered.[42],[44],[49],[50],[51],[52]

Perioperative opioid use

When managing patients with OSA and obesity, it is advantageous to utilize an opioid-sparing technique to reduce the risk of postoperative respiratory complications. Opioids impair the neural input to the upper airway dilator muscles and decrease the ventilatory response to hypoxemia and hypercarbia. Furthermore, patients with obesity may have increased sensitivity to both the central and peripheral effects of opioids. These suggest that patients with obesity and OSA may require reduced opioid dosing for comparable levels of analgesia compared to patients without these comorbidities.[53],[54] Thus, it is recommended that anesthesiologists utilize a multimodal and opioid-sparing approach that includes the use of non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, N-methyl-D-aspartate (NMDA) antagonists, α-2 agonists, dexamethasone, lidocaine, and regional anesthesia whenever possible.

Opioid-sparing agents

The use of NSAIDs for patients undergoing bariatric surgery has been shown to provide analgesia without the risk of respiratory depression and decrease post-anesthesia care unit (PACU) length of stay.[55],[56],[57] Ketorolac has been found to significantly reduce hospital length of stay and decrease total in-hospital opioid consumption for bariatric surgical patients compared to patients receiving opioids alone.[58] Although many hospitals and institutions seek to limit the use of NSAIDs due to potential GI complications, a study analyzing 400 sleeve gastrectomy patients reported no GI complications attributed to postoperative NSAID use.[59] Acetaminophen is an alternative that can be considered as it does not increase the risk of GI ulcers and has been shown to have a more favorable side effect profile compared to NSAIDs while reducing opioid consumption and pain scores in patients undergoing bariatric surgery.[60],[61],[62]

NMDA antagonists, including ketamine and magnesium, have been shown to reduce morphine consumption without increasing pain scores in patients undergoing bariatric surgery.[63],[64] However, further research is necessary to determine whether postoperative pulmonary complications can be reduced with their use. Intraoperative dexmedetomidine can also be considered for patients with OSA undergoing bariatric surgery as it provides analgesia through α-2 receptor agonism and has minimal respiratory depressant effects. Studies evaluating patients undergoing laparoscopic bariatric surgery have shown that dexmedetomidine infusions significantly reduced PACU length of stay, reduced opioid requirements, and were associated with a reduced time to meet discharge criteria.[65],[66] Lidocaine infusions are controversial as studies have yielded conflicting results. Some studies have found decreased pain scores as well as decreased need for postoperative opioids with the use of lidocaine infusions. However, other studies have found no effect on postoperative pain, nausea and vomiting, and PACU and hospital lengths of stay.[13],[67],[68] If lidocaine infusions are utilized, providers should ensure there are adequate protocols and infrastructure in place for the identification and treatment of local anesthetic systemic toxicity.

Regional anesthetic techniques can be incorporated as a component of the anesthetic and analgesic regimen for bariatric surgical patients. Intraperitoneal administration of local anesthetics or transverse abdominis plane (TAP) blocks can be used. A study conducted by Safari et al.[69] found that the use of intraperitoneal lavage with 0.2% bupivacaine significantly decreased pain levels and reduced opioid consumption for up to 24 h postoperatively. However, a systematic review and meta-analysis of TAP blocks in laparoscopic bariatric surgery found that there was no association with decreased opioid consumption or pain scores.[70] Although further research must be conducted to determine the utility of regional anesthetics in laparoscopic bariatric procedures, regional anesthetic techniques should be considered when these patients are expected to have higher postoperative pain scores or increased opioid consumption. For minimally invasive procedures, local anesthetic infiltration has been shown to reduce pain scores, postoperative morphine consumption, and the need for rescue analgesia.[71] Local anesthetic infiltration is a simple and efficient method of reducing incisional pain and should be considered for all patients.


  Postoperative Considerations Top


Enhanced recovery after bariatric surgery (ERABS)

The ERABS pathways integrate a multimodal approach designed to facilitate early return of bodily function, reduce physiological stress, and decrease hospital length of stay. These pathways have been implemented in many centers performing bariatric procedures and have been shown to reduce hospital length of stay, morbidity, 30-day readmission rates, and complications.[72],[73],[74] Although further research is needed to assess the efficacy of ERABS protocols in reducing healthcare resource utilization and improving outcomes in the bariatric surgical population with OSA specifically, it is recommended that these protocols are followed for most patients undergoing bariatric surgery.[4],[75]

Postoperative complications in bariatric surgery patients with OSA

Although the incidence of serious complications following bariatric surgery is low (1–2.5%) and continues to decrease, special precautions must be taken when managing patients with OSA.[76] In the general surgical population, OSA significantly increases the risk of ICU admission, cardiac events, and postoperative respiratory complications.[14] In bariatric surgery, OSA is recognized as an independent risk factor for postoperative bleeding, hospital readmission, and emergency department visits,[77] but there is no clear association between OSA and mortality, ICU admission, hospital length of stay, and cardiorespiratory morbidity.[78] Serious complications in bariatric surgical patients with OSA are generally low because of an increasing trend toward minimally invasive procedures, improvements in the perioperative care of patients with OSA, and advancements in anesthetic and surgical techniques. Providers and healthcare entities need to balance the risk of complications with the optimization of healthcare resource utilization when creating care pathways for bariatric surgery patients with OSA.

Postoperative monitoring and disposition

Postoperative non-invasive positive-pressure ventilation (PPV) should be applied to patients with OSA after bariatric surgery to prevent airway collapse and improve lung function and gas exchange.[79],[80] A retrospective study analyzing patients with OSA undergoing bariatric procedures found that patients with OSA who used CPAP preoperatively and postoperatively had a shorter length of stay compared to patients with OSA who did not use CPAP.[39] Furthermore, a study evaluating patients with mild to severe OSA undergoing bariatric surgery found that postoperative CPAP use in the PACU and up to 24 h after discharge from the PACU during sleep were associated with decreased postoperative complications.[81] As several studies have demonstrated the decrease in postoperative complications and adverse events when utilizing CPAP for patients with OSA, it is recommended that patients with OSA or presumptive OSA are treated with postoperative CPAP and pulse oximetry monitoring as soon as possible after surgery.[29],[39],[82],[83],[84],[85]

Requirements for postoperative monitoring and disposition of patients undergoing bariatric procedures depend on patient-specific factors (e.g., associated comorbidities, severe OSA, high BMI), anesthetic technique, type and duration of the procedure, intraoperative course, and institutional and national practices and standards.[86] Patients with OSA undergoing bariatric procedures have been shown to have similar rates of respiratory complications, 30-day major complication rates, and lengths of PACU and hospital stay compared to patients without OSA when they are properly managed with continuous pulse oximetry monitoring, postoperative CPAP, and adequate nursing experience.[87],[88] The majority of adverse events have been found to occur within the first 24 h after surgery and higher levels of postoperative monitoring are associated with better outcomes.[10],[89] With adequate postoperative monitoring, patients with OSA can have similar dispositions to those without OSA. For patients with severe OSA undergoing extensive surgical procedures that require significant opioid analgesia, closer monitoring may be necessary. A study reviewing OSA patients with death or near-death complications found that 81% of adverse events occurred within the first 24 h and factors associated with these complications were related to suboptimal use of postoperative CPAP, morbid obesity, undiagnosed OSA, administration of opioids and sedatives, and lack of monitoring.[89] These studies suggest that patients with OSA undergoing bariatric surgery may have improved outcomes with preoperative OSA screening, an opioid-sparing pain regimen, and adequate monitoring in the postoperative period with continuous pulse oximetry and CPAP.


  Conclusion Top


As the incidence of obesity and SDB continues to rise, more bariatric surgical procedures are being performed worldwide. Bariatric surgery is not only an obesity treatment, but it is also effective as a treatment for SDB and OSA. Anesthesiologists must be cognizant of the best practices to manage this patient population. For patients undergoing bariatric surgery, a thorough perioperative screening should be conducted to identify and risk-stratify patients with SDB. Even though preoperative PSG may not be feasible for all patients, all patients can be screened using tools such as the STOP-Bang questionnaire. Patients with moderate to severe OSA should be treated with CPAP preoperatively to minimize postoperative complications and optimize their preoperative pulmonary status. It is also necessary to develop and utilize a multimodal, opioid-sparing intraoperative and postoperative analgesic plan. In the postoperative period, patients with OSA are predisposed to airway obstruction and desaturation. Thus, adequate postoperative monitoring, use of CPAP, and continuous pulse oximetry monitoring are recommended.

Authors' contributions

Matthew W. Oh, B.S.: Drafting and revision of the manuscript; Joy. L Chen, M.D.: Drafting and revision of the manuscript; Tiffany S. Moon, M.D.: Drafting and revision of the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
English WJ, DeMaria EJ, Hutter MM, Kothari SN, Mattar SG, Brethauer SA, et al. American society for metabolic and bariatric surgery 2018 estimate of metabolic and bariatric procedures performed in the United States. Surg Obes Relat Dis 2020;16:457-63.  Back to cited text no. 1
    
2.
Angrisani L, Santonicola A, Iovino P, Ramos A, Shikora S, Kow L. Bariatric surgery survey 2018: Similarities and disparities among the 5 IFSO chapters. Obes Surg 2021;31:1937-48.  Back to cited text no. 2
    
3.
Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol 2013;177:1006-14.  Back to cited text no. 3
    
4.
de Raaff CAL, Gorter-Stam MAW, de Vries N, Sinha AC, Jaap Bonjer H, Chung F, et al. Perioperative management of obstructive sleep apnea in bariatric surgery: A consensus guideline. Surg Obes Relat Dis 2017;13:1095-109.  Back to cited text no. 4
    
5.
Peromaa-Haavisto P, Tuomilehto H, Kössi J, Virtanen J, Luostarinen M, Pihlajamäki J, et al. Prevalence of obstructive sleep apnoea among patients admitted for bariatric surgery. A prospective multicentre trial. Obes Surg 2016;26:1384-90.  Back to cited text no. 5
    
6.
Sareli AE, Cantor CR, Williams NN, Korus G, Raper SE, Pien G, et al. Obstructive sleep apnea in patients undergoing bariatric surgery--a tertiary center experience. Obes Surg 2011;21:316-27.  Back to cited text no. 6
    
7.
Ojeda Castillejo E, García Angulo J, Rodriguez Gonzalez-Moro JM, Lopez Martin S, Sanchez Muñoz G, De Lucas Ramos P. Prevalence of sleep apnea syndrome in morbidly obese patients. Eur Respir J 2013;42(Suppl 57):P2547.  Back to cited text no. 7
    
8.
Palla A, Digiorgio M, Carpenè N, Rossi G, D'Amico I, Santini F, et al. Sleep apnea in morbidly obese patients: Prevalence and clinical predictivity. Respiration 2009;78:134-40.  Back to cited text no. 8
    
9.
Ravesloot MJ, van Maanen JP, Hilgevoord AA, van Wagensveld BA, de Vries N. Obstructive sleep apnea is underrecognized and underdiagnosed in patients undergoing bariatric surgery. Eur Arch Otorhinolaryngol 2012;269:1865-71.  Back to cited text no. 9
    
10.
Bolden N, Posner KL, Domino KB, Auckley D, Benumof JL, Herway ST, et al. Postoperative critical events associated with obstructive sleep apnea: Results from the society of anesthesia and sleep medicine obstructive sleep apnea registry. Anesth Analg 2020;131:1032-41.  Back to cited text no. 10
    
11.
Opperer M, Cozowicz C, Bugada D, Mokhlesi B, Kaw R, Auckley D, et al. Does obstructive sleep apnea influence perioperative outcome? A qualitative systematic review for the society of anesthesia and sleep medicine task force on preoperative preparation of patients with sleep-disordered breathing. Anesth Analg 2016;122:1321-34.  Back to cited text no. 11
    
12.
Memtsoudis SG, Cozowicz C, Nagappa M, Wong J, Joshi GP, Wong DT, et al. Society of anesthesia and sleep medicine guideline on intraoperative management of adult patients with obstructive sleep apnea. Anesth Analg 2018;127:967-87.  Back to cited text no. 12
    
13.
Kaw R, Chung F, Pasupuleti V, Mehta J, Gay PC, Hernandez AV. Meta-analysis of the association between obstructive sleep apnoea and postoperative outcome. Br J Anaesth 2012;109:897-906.  Back to cited text no. 13
    
14.
Kaw R, Pasupuleti V, Walker E, Ramaswamy A, Foldvary-Schafer N. Postoperative complications in patients with obstructive sleep apnea. Chest 2012;141:436-41.  Back to cited text no. 14
    
15.
Hai F, Porhomayon J, Vermont L, Frydrych L, Jaoude P, El-Solh AA. Postoperative complications in patients with obstructive sleep apnea: A meta-analysis. J Clin Anesth 2014;26:591-600.  Back to cited text no. 15
    
16.
Chan MTV, Wang CY, Seet E, Tam S, Lai HY, Chew EFF, et al. Association of unrecognized obstructive sleep apnea with postoperative cardiovascular events in patients undergoing major noncardiac surgery. JAMA 2019;321:1788-98.  Back to cited text no. 16
    
17.
Currie AC, Kaur V, Carey I, Al-Rubaye H, Mahawar K, Madhok B, et al. Obstructive sleep apnea remission following bariatric surgery: A national registry cohort study. Surg Obes Relat Dis 2021;17:1576-82.  Back to cited text no. 17
    
18.
Nastalek P, Polok K, Celejewska-Wójcik N, Kania A, Sładek K, Małczak P, et al. Impact of bariatric surgery on obstructive sleep apnea severity and continuous positive airway pressure therapy compliance—prospective observational study. Sci Rep 2021;11:5003. doi: 10.1038/s41598-021-84570-6.  Back to cited text no. 18
    
19.
Nguyen NT, Varela JE. Bariatric surgery for obesity and metabolic disorders: State of the art. Nat Rev Gastroenterol Hepatol 2017;14:160-9.  Back to cited text no. 19
    
20.
Arterburn DE, Telem DA, Kushner RF, Courcoulas AP. Benefits and risks of bariatric surgery in adults: A review. JAMA 2020;324:879-87.  Back to cited text no. 20
    
21.
Al-Jumaily AM, Ashaat S, Martin B, Pohle-Krauza R, Krauza M, Dan A, et al. A pilot study on the biomechanical assessment of obstructive sleep apnea pre and post bariatric surgery. Respir Physiol Neurobiol 2018;250:1-6. doi: 10.1016/j.resp. 2018.01.007.  Back to cited text no. 21
    
22.
Quintas-Neves M, Preto J, Drummond M. Assessment of bariatric surgery efficacy on obstructive sleep apnea (OSA). Rev Port Pneumol (2006) 2016;22:331-6.  Back to cited text no. 22
    
23.
Reoch J, Mottillo S, Shimony A, Filion KB, Christou NV, Joseph L, et al. Safety of laparoscopic vs open bariatric surgery: A systematic review and meta-analysis. Arch Surg 2011;146:1314-22.  Back to cited text no. 23
    
24.
Antoniou SA, Antoniou GA, Koch OO, Kohler G, Pointner R, Granderath FA. Laparoscopic versus open obesity surgery: A meta-analysis of pulmonary complications. Dig Surg 2015;32:98-107.  Back to cited text no. 24
    
25.
Angrisani L. 2014: The year of the sleeve supremacy. Obes Surg 2017;27:1626-7.  Back to cited text no. 25
    
26.
Memtsoudis SG, Besculides MC, Mazumdar M. A rude awakening--the perioperative sleep apnea epidemic. N Engl J Med 2013;368:2352-3.  Back to cited text no. 26
    
27.
Adesanya AO, Lee W, Greilich NB, Joshi GP. Perioperative management of obstructive sleep apnea. Chest 2010;138:1489-98.  Back to cited text no. 27
    
28.
Hallowell PT, Stellato TA, Petrozzi MC, Schuster M, Graf K, Robinson A, et al. Eliminating respiratory intensive care unit stay after gastric bypass surgery. Surgery 2007;142:608-12; discussion 612.e1. doi: 10.1016/j.surg. 2007.08.002.  Back to cited text no. 28
    
29.
Mutter TC, Chateau D, Moffatt M, Ramsey C, Roos LL, Kryger M. A matched cohort study of postoperative outcomes in obstructive sleep apnea: Could preoperative diagnosis and treatment prevent complications? Anesthesiology 2014;121:707-18.  Back to cited text no. 29
    
30.
Chung F, Memtsoudis SG, Ramachandran SK, Nagappa M, Opperer M, Cozowicz C, et al. Society of anesthesia and sleep medicine guidelines on preoperative screening and assessment of adult patients with obstructive sleep apnea. Anesth Analg 2016;123:452-73.  Back to cited text no. 30
    
31.
Practice guidelines for the perioperative management of patients with obstructive sleep apnea: An updated report by the American society of anesthesiologists task force on perioperative management of patients with obstructive sleep apnea. Anesthesiology 2014;120:268-86.  Back to cited text no. 31
    
32.
Chiu HY, Chen PY, Chuang LP, Chen NH, Tu YK, Hsieh YJ, et al. Diagnostic accuracy of the Berlin questionnaire, STOP-BANG, STOP, and Epworth sleepiness scale in detecting obstructive sleep apnea: A bivariate meta-analysis. Sleep Med Rev 2017;36:57-70.  Back to cited text no. 32
    
33.
Chung F, Abdullah HR, Liao P. STOP-Bang questionnaire: A practical approach to screen for obstructive sleep apnea. Chest 2016;149:631-8.  Back to cited text no. 33
    
34.
Ramachandran SK, Josephs LA. A meta-analysis of clinical screening tests for obstructive sleep apnea. Anesthesiology 2009;110:928-39.  Back to cited text no. 34
    
35.
Chung SA, Yuan H, Chung F. A systemic review of obstructive sleep apnea and its implications for anesthesiologists. Anesth Analg 2008;107:1543-63.  Back to cited text no. 35
    
36.
Miller JN, Berger AM. Screening and assessment for obstructive sleep apnea in primary care. Sleep Med Rev 2016;29:41-51.  Back to cited text no. 36
    
37.
Chung F, Yegneswaran B, Liao P, Chung SA, Vairavanathan S, Islam S, et al. Validation of the Berlin questionnaire and American Society of Anesthesiologists checklist as screening tools for obstructive sleep apnea in surgical patients. Anesthesiology 2008;108:822-30.  Back to cited text no. 37
    
38.
Martínez-García MA, Capote F, Campos-Rodríguez F, Lloberes P, Díaz de Atauri MJ, Somoza M, et al. Effect of CPAP on blood pressure in patients with obstructive sleep apnea and resistant hypertension: The HIPARCO randomized clinical trial. JAMA 2013;310:2407-15.  Back to cited text no. 38
    
39.
Proczko MA, Stepaniak PS, de Quelerij M, van der Lely FH, Smulders JF, Kaska L, et al. STOP-Bang and the effect on patient outcome and length of hospital stay when patients are not using continuous positive airway pressure. J Anesth 2014;28:891-7.  Back to cited text no. 39
    
40.
de Raaff CAL, de Vries N, van Wagensveld BA. Obstructive sleep apnea and bariatric surgical guidelines: Summary and update. Curr Opin Anaesthesiol 2018;31:104-9.  Back to cited text no. 40
    
41.
Kaw R, Bhateja P, Paz YMH, Hernandez AV, Ramaswamy A, Deshpande A, et al. Postoperative complications in patients with unrecognized obesity hypoventilation syndrome undergoing elective noncardiac surgery. Chest 2016;149:84-91.  Back to cited text no. 41
    
42.
Wong DT, Yee AJ, Leong SM, Chung F. The effectiveness of apneic oxygenation during tracheal intubation in various clinical settings: A narrative review. Can J Anaesth 2017;64:416-27.  Back to cited text no. 42
    
43.
Seet E, Chung F, Wang CY, Tam S, Kumar CM, Ubeynarayana CU, et al. Association of obstructive sleep apnea with difficult intubation: Prospective multicenter observational cohort study. Anesth Analg 2021;133:196-204.  Back to cited text no. 43
    
44.
Seet E, Nagappa M, Wong DT. Airway management in surgical patients with obstructive sleep apnea. Anesth Analg 2021;132:1321-7.  Back to cited text no. 44
    
45.
Leong SM, Tiwari A, Chung F, Wong DT. Obstructive sleep apnea as a risk factor associated with difficult airway management - A narrative review. J Clin Anesth 2018;45:63-8.  Back to cited text no. 45
    
46.
Roesslein M, Chung F. Obstructive sleep apnoea in adults: Peri-operative considerations: A narrative review. Eur J Anaesthesiol 2018;35:245-55.  Back to cited text no. 46
    
47.
Moon TS, Fox PE, Somasundaram A, Minhajuddin A, Gonzales MX, Pak TJ, et al. The influence of morbid obesity on difficult intubation and difficult mask ventilation. J Anesth 2019;33:96-102.  Back to cited text no. 47
    
48.
Cook T, Woodall N, Frerk C, editors. 4th National Audit Project of the Royal College of Anaesthetists and The Difficult Airway Society: Major Complications of Airway Management in the United Kingdom: Report and Findings. London: The Royal College of Anaesthetists; 2011.  Back to cited text no. 48
    
49.
Dixon BJ, Dixon JB, Carden JR, Burn AJ, Schachter LM, Playfair JM, et al. Preoxygenation is more effective in the 25 degrees head-up position than in the supine position in severely obese patients: A randomized controlled study. Anesthesiology 2005;102:1110-5; discussion 5A.  Back to cited text no. 49
    
50.
Moon TS, Tai K, Kim A, Gonzales MX, Lu R, Pak T, et al. Apneic oxygenation during prolonged laryngoscopy in obese patients: A randomized, double-blinded, controlled trial of nasal cannula oxygen administration. Obes Surg 2019;29:3992-9.  Back to cited text no. 50
    
51.
El-Khatib MF, Kanazi G, Baraka AS. Noninvasive bilevel positive airway pressure for preoxygenation of the critically ill morbidly obese patient. Can J Anaesth 2007;54:744-7.  Back to cited text no. 51
    
52.
Cullen A, Ferguson A. Perioperative management of the severely obese patient: A selective pathophysiological review. Can J Anaesth 2012;59:974-96.  Back to cited text no. 52
    
53.
Alvarez A, Singh PM, Sinha AC. Postoperative analgesia in morbid obesity. Obes Surg 2014;24:652-9.  Back to cited text no. 53
    
54.
Lam KK, Kunder S, Wong J, Doufas AG, Chung F. Obstructive sleep apnea, pain, and opioids: Is the riddle solved? Curr Opin Anesthesiol 2016;29:131-40.  Back to cited text no. 54
    
55.
Abou Zeid H, Kallab R, Najm MA, Jabbour H, Noun R, Sleilati F, et al. Safety and efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) used for analgesia after bariatric surgery: A retrospective case-control study. Obes Surg 2019;29:911-6.  Back to cited text no. 55
    
56.
Soleimanpour H, Safari S, Sanaie S, Nazari M, Alavian SM. Anesthetic considerations in patients undergoing bariatric surgery: A review article. Anesth Pain Med 2017;7:e57568. doi: 10.5812/aapm. 57568.  Back to cited text no. 56
    
57.
Chopra A, Lieb J, Sullivan D, Gaprindashvili T, Golden L, Pranevicius M. A5080 - perioperative intravenous ibuprofen in bariatric surgery: A prospective double blind randomized controlled trial. Surg Obes Relat Dis 2017;13(Suppl):S102. doi 10.1016/j.soard. 2017.09.224.  Back to cited text no. 57
    
58.
Hariri K, Hechenbleikner E, Dong M, Kini SU, Fernandez-Ranvier G, Herron DM. Ketorolac use shortens hospital length of stay after bariatric surgery: A single-center 5-year experience. Obes Surg 2019;29:2360-6.  Back to cited text no. 58
    
59.
Begian A, Samaan JS, Hawley L, Alicuben ET, Hernandez A, Samakar K. The use of nonsteroidal anti-inflammatory drugs after sleeve gastrectomy. Surg Obes Relat Dis 2021;17:484-8.  Back to cited text no. 59
    
60.
Klotz U. Paracetamol (acetaminophen) - a popular and widely used nonopioid analgesic. Arzneimittelforschung 2012;62:355-9.  Back to cited text no. 60
    
61.
Lee Y, Yu J, Doumouras AG, Ashoorion V, Gmora S, Anvari M, et al. Intravenous acetaminophen versus placebo in post-bariatric surgery multimodal pain management: A meta-analysis of randomized controlled trials. Obes Surg 2019;29:1420-8.  Back to cited text no. 61
    
62.
Song K, Melroy MJ, Whipple OC. Optimizing multimodal analgesia with intravenous acetaminophen and opioids in postoperative bariatric patients. Pharmacotherapy 2014;34(Suppl 1):14S-21S.  Back to cited text no. 62
    
63.
Kasputyte G, Karbonskiene A, Macas A, Maleckas A. Role of ketamine in multimodal analgesia protocol for bariatric surgery. Medicina (Kaunas) 2020;56:96. doi: 10.3390/medicina56030096.  Back to cited text no. 63
    
64.
Jabbour H, Jabbour K, Abi Lutfallah A, Abou Zeid H, Nasser-Ayoub E, Abou Haidar M, et al. Magnesium and ketamine reduce early morphine consumption after open bariatric surgery: A prospective randomized double-blind study. Obes Surg 2020;30:1452-8.  Back to cited text no. 64
    
65.
Tufanogullari B, White PF, Peixoto MP, Kianpour D, Lacour T, Griffin J, et al. Dexmedetomidine infusion during laparoscopic bariatric surgery: The effect on recovery outcome variables. Anesth Analg 2008;106:1741-8.  Back to cited text no. 65
    
66.
Dholakia C, Beverstein G, Garren M, Nemergut C, Boncyk J, Gould JC. The impact of perioperative dexmedetomidine infusion on postoperative narcotic use and duration of stay after laparoscopic bariatric surgery. J Gastrointest Surg 2007;11:1556-9.  Back to cited text no. 66
    
67.
Plass F, Nicolle C, Zamparini M, Al Issa G, Fiant AL, Le Roux Y, et al. Effect of intra-operative intravenous lidocaine on opioid consumption after bariatric surgery: A prospective, randomised, blinded, placebo-controlled study. Anaesthesia 2021;76:189-98.  Back to cited text no. 67
    
68.
De Oliveira K, Eipe N. Intravenous lidocaine for acute pain: A single-institution retrospective study. Drugs Real World Outcomes 2020;7:205-12.  Back to cited text no. 68
    
69.
Safari S, Rokhtabnak F, Djalali Motlagh S, Ghanbari M, Pournajafian A. Effect of intraperitoneal bupivacaine on postoperative pain in laparoscopic bariatric surgeries. Surg Obes Relat Dis 2020;16:299-305.  Back to cited text no. 69
    
70.
Aamir MA, Sahebally SM, Heneghan H. Transversus abdominis plane block in laparoscopic bariatric surgery-a systematic review and meta-analysis of randomized controlled trials. Obes Surg 2021;31:133-42.  Back to cited text no. 70
    
71.
Omar I, Abualsel A. Efficacy of intraperitoneal instillation of bupivacaine after bariatric surgery: Randomized controlled trial. Obes Surg 2019;29:1735-41.  Back to cited text no. 71
    
72.
Małczak P, Pisarska M, Piotr M, Wysocki M, Budzyński A, Pędziwiatr M. Enhanced recovery after bariatric surgery: Systematic review and meta-analysis. Obes Surg 2017;27:226-35.  Back to cited text no. 72
    
73.
Carron M, Ieppariello G, Linassi F. Enhanced recovery after bariatric surgery and obstructive sleep apnea: An undervalued relationship. Obes Surg 202131:5044-6.  Back to cited text no. 73
    
74.
Awad S, Carter S, Purkayastha S, Hakky S, Moorthy K, Cousins J, et al. Enhanced recovery after bariatric surgery (ERABS): Clinical outcomes from a tertiary referral bariatric centre. Obes Surg 2014;24:753-8.  Back to cited text no. 74
    
75.
Mechanick JI, Apovian C, Brethauer S, Garvey WT, Joffe AM, Kim J, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: Cosponsored by American association of clinical endocrinologists/American college of endocrinology, the obesity society, American society for metabolic & bariatric surgery, obesity medicine association, and American society of anesthesiologists - executive summary. Endocr Pract 2019;25:1346-59.  Back to cited text no. 75
    
76.
Kassir R, Debs T, Blanc P, Gugenheim J, Ben Amor I, Boutet C, et al. Complications of bariatric surgery: Presentation and emergency management. Int J Surg 2016;27:77-81.  Back to cited text no. 76
    
77.
Mocanu V, Dang JT, Delisle M, Switzer NJ, Birch DW, Karmali S. 30-day major adverse cardiac events (MACE) after elective bariatric surgery: The development and validation of the Bari-MACE clinical predictive tool. Surg Obes Relat Dis 2022;18:357-64.  Back to cited text no. 77
    
78.
de Raaff CA, Coblijn UK, de Vries N, van Wagensveld BA. Is fear for postoperative cardiopulmonary complications after bariatric surgery in patients with obstructive sleep apnea justified? A systematic review. Am J Surg 2016;211:793-801.  Back to cited text no. 78
    
79.
de Miguel J, Cabello J, Sanchez-Alarcos JM, Alvarez-Sala R, Espinos D, Alvarez-Sala JL. Long-term effects of treatment with nasal continuous positive airway pressure on lung function in patients with overlap syndrome. Sleep Breath 2002;6:3-10.  Back to cited text no. 79
    
80.
Verbraecken J, Willemen M, De Cock W, Van de Heyning P, De Backer WA. Continuous positive airway pressure and lung inflation in sleep apnea patients. Respiration 2001;68:357-64.  Back to cited text no. 80
    
81.
Weingarten TN, Flores AS, McKenzie JANguyen LT, Robinson WB, Kinney TM, et al. Obstructive sleep apnoea and perioperative complications in bariatric patients. Br J Anaesth 2011;106:131-9.  Back to cited text no. 81
    
82.
Neligan PJ, Malhotra G, Fraser M, Williams N, Greenblatt EP, Cereda M, et al. Continuous positive airway pressure via the Boussignac system immediately after extubation improves lung function in morbidly obese patients with obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesthesiology 2009;110:878-84.  Back to cited text no. 82
    
83.
Abdelsattar ZM, Hendren S, Wong SL, Campbell DA Jr, Ramachandran SK. The impact of untreated obstructive sleep apnea on cardiopulmonary complications in general and vascular surgery: A cohort study. Sleep 2015;38:1205-10.  Back to cited text no. 83
    
84.
Liao P, Luo Q, Elsaid H, Kang W, Shapiro CM, Chung F. Perioperative auto-titrated continuous positive airway pressure treatment in surgical patients with obstructive sleep apnea: A randomized controlled trial. Anesthesiology 2013;119:837-47.  Back to cited text no. 84
    
85.
Chung F, Nagappa M, Singh M, Mokhlesi B. CPAP in the perioperative setting: Evidence of support. Chest 2016;149:586-97.  Back to cited text no. 85
    
86.
Seet E, Chung F. Management of sleep apnea in adults - functional algorithms for the perioperative period: Continuing professional development. Can J Anaesth 2010;57:849-64.  Back to cited text no. 86
    
87.
Shearer E, Magee CJ, Lacasia C, Raw D, Kerrigan D. Obstructive sleep apnea can be safely managed in a level 2 critical care setting after laparoscopic bariatric surgery. Surg Obes Relat Dis 2013;9:845-9.  Back to cited text no. 87
    
88.
Grover BT, Priem DM, Mathiason MA, Kallies KJ, Thompson GP, Kothari SN. Intensive care unit stay not required for patients with obstructive sleep apnea after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2010;6:165-70.  Back to cited text no. 88
    
89.
Subramani Y, Nagappa M, Wong J, Patra J, Chung F. Death or near-death in patients with obstructive sleep apnoea: A compendium of case reports of critical complications. Br J Anaesth 2017;119:885-99.  Back to cited text no. 89
    




 

Top
 
Previous article    Next article
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  IN THIS Article
   Abstract
  Introduction
  Methods
   Bariatric Surger...
   Bariatric Surger...
   Preoperative Eva...
   Intraoperative M...
   Postoperative Co...
  Conclusion
   References

 Article Access Statistics
    Viewed1056    
    Printed26    
    Emailed0    
    PDF Downloaded192    
    Comments [Add]    

Recommend this journal