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3823 results in Surgery

Page 129 of 192

  • Section 2 - Preparation and pre-operative evaluation/management

  • Edited by Adrian Alvarez, Jay B. Brodsky, Stanford University School of Medicine, California, Hendrikus J. M. Lemmens, Stanford University School of Medicine, California, John M. Morton, Stanford University School of Medicine, California
  • Book:
    Morbid Obesity
    Published online:
    04 May 2010
    Print publication:
    11 March 2010, pp -

  • Summary

    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.

  • 11 - Effects of obesity on anesthetic agents

  • from Section 3 - Intra-operative management
  • Edited by Adrian Alvarez, Jay B. Brodsky, Stanford University School of Medicine, California, Hendrikus J. M. Lemmens, Stanford University School of Medicine, California, John M. Morton, Stanford University School of Medicine, California
  • Book:
    Morbid Obesity
    Published online:
    04 May 2010
    Print publication:
    11 March 2010, pp -

  • Summary

    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.

  • 18 - Post-operative rhabdomyolysis

  • from Section 4 - Post-operative conditions
  • Edited by Adrian Alvarez, Jay B. Brodsky, Stanford University School of Medicine, California, Hendrikus J. M. Lemmens, Stanford University School of Medicine, California, John M. Morton, Stanford University School of Medicine, California
  • Book:
    Morbid Obesity
    Published online:
    04 May 2010
    Print publication:
    11 March 2010, pp -

  • Summary

    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.

Principles of Surgery Vivas for the MRCS
  • Rupen Dattani, Ridzuan Farouk
  • Published online:
    11 March 2010
    Print publication:
    01 May 2007
  • Written for the Principles of Surgery viva of the MRCS exam by an examiner at both the London and Glasgow Colleges of Surgery and a successful recent MRCS candidate, Principles of Surgery Vivas for the MRCS provides the reader with sample viva questions to enable them to prepare fully for this section of the examinations. In A-Z format for quick reference, this book will be invaluable to MRCS candidates, undergraduate medical students and those sitting the FRCOG examinations. It will also serve as a valuable 'aide memoire' for the training surgeon or doctor at all levels of experience, especially those training junior staff.

  • 13 - Ventilatory strategies during anesthesia

  • from Section 3 - Intra-operative management
  • Edited by Adrian Alvarez, Jay B. Brodsky, Stanford University School of Medicine, California, Hendrikus J. M. Lemmens, Stanford University School of Medicine, California, John M. Morton, Stanford University School of Medicine, California
  • Book:
    Morbid Obesity
    Published online:
    04 May 2010
    Print publication:
    11 March 2010, pp -

  • Summary

    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.

  • Section 5 - Special topics

  • Edited by Adrian Alvarez, Jay B. Brodsky, Stanford University School of Medicine, California, Hendrikus J. M. Lemmens, Stanford University School of Medicine, California, John M. Morton, Stanford University School of Medicine, California
  • Book:
    Morbid Obesity
    Published online:
    04 May 2010
    Print publication:
    11 March 2010, pp -

  • Summary

    Reports of anesthesia-related deaths in obstetric practice point to difficulties with airway management in morbid obesity (MO) parturients as the primary cause. A large proportion of patients recruited for airway studies in MO are recruited from bariatric surgical populations, which typically exhibit a large preponderance of female patients. Numerous anatomic factors contribute to difficult airway management in the MO patient. This chapter presents options for airways management in an order that reflects their application in the American Society of Anesthesiologists (ASA) Difficult Airway Algorithm. Awake intubation maintains airway patency and spontaneous respiration, but is not without hazard in this difficult patient group. Flexible fiberoptic laryngoscopy is the most common technique chosen for awake intubation, but visualization may be difficult when excess fat deposition results in airway narrowing and redundant folds of tissue. Equal care and equipment should be available for extubation as well as intubation.

  • Section 3 - Intra-operative management

  • Edited by Adrian Alvarez, Jay B. Brodsky, Stanford University School of Medicine, California, Hendrikus J. M. Lemmens, Stanford University School of Medicine, California, John M. Morton, Stanford University School of Medicine, California
  • Book:
    Morbid Obesity
    Published online:
    04 May 2010
    Print publication:
    11 March 2010, pp -

  • Summary

    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.

  • 19 - Nursing considerations

  • from Section 4 - Post-operative conditions
  • Edited by Adrian Alvarez, Jay B. Brodsky, Stanford University School of Medicine, California, Hendrikus J. M. Lemmens, Stanford University School of Medicine, California, John M. Morton, Stanford University School of Medicine, California
  • Book:
    Morbid Obesity
    Published online:
    04 May 2010
    Print publication:
    11 March 2010, pp -

  • Summary

    Intra-operative positioning considerations are more important for the obese patient. The supine position causes a marked increase in intra-abdominal pressure, which results in a splinting effect of abdominal contents on the diaphragm. Awake, spontaneously breathing obese patients should be in a head-up position. The Trendelenburg position can be used to engorge neck veins to facilitate central venous cannulation. Spontaneously breathing obese patients generally do not tolerate the Trendelenburg position. In mild to moderately obese patients, respiratory mechanics, lung volumes, and oxygenation all increase when changing from the supine to prone position. Due to the difficulties moving and positioning mobidly obese (MO) patients, procedures routinely performed prone are often done in the lateral decubitus position. In the lithotomy position the patient is on their back with their legs and thighs flexed at right angles. MO patients are at special risk for rhabdomyolysis (RML), a potentially fatal post-operative complication.

  • 8 - Pre-operative management:

  • from Section 2 - Preparation and pre-operative evaluation/management
  • Edited by Adrian Alvarez, Jay B. Brodsky, Stanford University School of Medicine, California, Hendrikus J. M. Lemmens, Stanford University School of Medicine, California, John M. Morton, Stanford University School of Medicine, California
  • Book:
    Morbid Obesity
    Published online:
    04 May 2010
    Print publication:
    11 March 2010, pp -

  • Summary

    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.

  • 15 - Post-operative analgesia

  • from Section 4 - Post-operative conditions
  • Edited by Adrian Alvarez, Jay B. Brodsky, Stanford University School of Medicine, California, Hendrikus J. M. Lemmens, Stanford University School of Medicine, California, John M. Morton, Stanford University School of Medicine, California
  • Book:
    Morbid Obesity
    Published online:
    04 May 2010
    Print publication:
    11 March 2010, pp -

  • Summary

    This chapter discusses different modalities for post-operative pain management in the morbidly obese (MO) patient undergoing laparoscopic and open abdominal surgery. Currently, parenteral opioids are among the most effective analgesic techniques for the relief of moderate to severe pain. Like any other surgical patient, adequate post-operative pain control for the MO is important not only for patient comfort and satisfaction, but also to reduce potential cardiopulmonary complications. By using a multimodal approach, the amount of individual analgesic drugs can be significantly reduced, while providing quality pain relief and simultaneously reducing the incidence of side effects. Patients in the non-opioid group received a combination of ketorolac, clonidine, lidocaine, ketamine, and magnesium sulfate. Pre-emptive analgesia may improve the efficacy of postoperative pain relief while allowing further reductions in opioid requirements. Obese patients with obstructive sleep apnea (OSA) appear to be much more sensitive than normal individuals to even minimal levels of s.

  • Section 4 - Post-operative conditions

  • Edited by Adrian Alvarez, Jay B. Brodsky, Stanford University School of Medicine, California, Hendrikus J. M. Lemmens, Stanford University School of Medicine, California, John M. Morton, Stanford University School of Medicine, California
  • Book:
    Morbid Obesity
    Published online:
    04 May 2010
    Print publication:
    11 March 2010, pp -

  • Summary

    This chapter discusses different modalities for post-operative pain management in the morbidly obese (MO) patient undergoing laparoscopic and open abdominal surgery. Currently, parenteral opioids are among the most effective analgesic techniques for the relief of moderate to severe pain. Like any other surgical patient, adequate post-operative pain control for the MO is important not only for patient comfort and satisfaction, but also to reduce potential cardiopulmonary complications. By using a multimodal approach, the amount of individual analgesic drugs can be significantly reduced, while providing quality pain relief and simultaneously reducing the incidence of side effects. Patients in the non-opioid group received a combination of ketorolac, clonidine, lidocaine, ketamine, and magnesium sulfate. Pre-emptive analgesia may improve the efficacy of postoperative pain relief while allowing further reductions in opioid requirements. Obese patients with obstructive sleep apnea (OSA) appear to be much more sensitive than normal individuals to even minimal levels of s.

  • 12 - Airway management

  • from Section 3 - Intra-operative management
  • Edited by Adrian Alvarez, Jay B. Brodsky, Stanford University School of Medicine, California, Hendrikus J. M. Lemmens, Stanford University School of Medicine, California, John M. Morton, Stanford University School of Medicine, California
  • Book:
    Morbid Obesity
    Published online:
    04 May 2010
    Print publication:
    11 March 2010, pp -

  • Summary

    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.

  • 5 - Choice of bariatric operation

  • from Section 2 - Preparation and pre-operative evaluation/management
  • Edited by Adrian Alvarez, Jay B. Brodsky, Stanford University School of Medicine, California, Hendrikus J. M. Lemmens, Stanford University School of Medicine, California, John M. Morton, Stanford University School of Medicine, California
  • Book:
    Morbid Obesity
    Published online:
    04 May 2010
    Print publication:
    11 March 2010, pp -

  • Summary

    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.

  • 20 - Long-term complications following surgery

  • from Section 4 - Post-operative conditions
  • Edited by Adrian Alvarez, Jay B. Brodsky, Stanford University School of Medicine, California, Hendrikus J. M. Lemmens, Stanford University School of Medicine, California, John M. Morton, Stanford University School of Medicine, California
  • Book:
    Morbid Obesity
    Published online:
    04 May 2010
    Print publication:
    11 March 2010, pp -

  • Summary

    This chapter focuses on bariatric surgery patients. It considers the late complications following the most commonly performed procedures: Roux en Y gastric bypass (RYGB), laparoscopic adjustable gastric band (LAGB), vertical-banded gastroplasty, and biliopancreatic diversion (BPD). Incisional hernias are a potential complication of most operations. Another common complication after the significant weight loss following bariatric surgery is the development of gallstones. The major complications following LAGB include band slippage or erosion, gastric prolapse, port/tubing malfunction, pouch/esophageal dilation, esophagitis and infection. Obese patients sustain greater risks when undergoing any surgical procedures, due to both co-morbidities and anatomic factors. Bariatric surgery confers multiple benefits including weight loss, resolution of co-morbidities, and potentially improved quality of life. Knowledge of the technical details as they relate to the potential complications of each bariatric procedure is critical for early diagnosis and treatment, allowing patients to benefit optimally from their weight loss.

  • 14 - Regional anesthesia and obesity

  • from Section 3 - Intra-operative management
  • Edited by Adrian Alvarez, Jay B. Brodsky, Stanford University School of Medicine, California, Hendrikus J. M. Lemmens, Stanford University School of Medicine, California, John M. Morton, Stanford University School of Medicine, California
  • Book:
    Morbid Obesity
    Published online:
    04 May 2010
    Print publication:
    11 March 2010, pp -

  • Summary

    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.

Page 129 of 192