Anesthesiology and Pain Medicine

Published by: Kowsar

Anesthetic Considerations in Patients Undergoing Bariatric Surgery: A Review Article

Hassan Soleimanpour 1 , Saeid Safari 2 , * , Sarvin Sanaie 3 , Mehdi Nazari 4 and Seyed Moayed Alavian 5 , 6
Authors Information
1 Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
2 Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
3 Tuberculosis and Lung Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
4 Anesthesiology Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
5 Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences, Tehran, Iran
6 Tehran Hepatitis Center, Tehran, Iran
Article information
  • Anesthesiology and Pain Medicine: August 2017, 7 (4); e57568
  • Published Online: July 11, 2017
  • Article Type: Review Article
  • Received: August 20, 2016
  • Revised: October 3, 2016
  • Accepted: June 12, 2017
  • DOI: 10.5812/aapm.57568

To Cite: Soleimanpour H, Safari S, Sanaie S, Nazari M, Alavian S M. Anesthetic Considerations in Patients Undergoing Bariatric Surgery: A Review Article, Anesth Pain Med. 2017 ; 7(4):e57568. doi: 10.5812/aapm.57568.

Copyright © 2017, Anesthesiology and Pain Medicine. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License ( which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.
1. Context
2. Pharmacological Management of Obesity
3. Surgical Management of Obesity
4. Evidence Acquisition
5. Results
6. Intraoperative Considerations
7. Monitoring
8. Pharmacologic Considerations
9. General Anesthesia
10. Ventilation
11. Postoperative Considerations
12. Conclusions
  • 1. NIH conference. Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel. Ann Intern Med. 1991; 115(12): 956-61[PubMed]
  • 2. Renquist K. Obesity classification. Obes Surg. 1997; 7(6): 523[DOI][PubMed]
  • 3. Bray GA. Pathophysiology of obesity. Am J Clin Nutr. 1992; 55(2 Suppl): 488S-94S[PubMed]
  • 4. Obesity and overweight: World Health Organization global strategy on diet, physical activity and health. 2008;
  • 5. Kopelman PG. Obesity as a medical problem. Nature. 2000; 404(6778): 635-43[DOI][PubMed]
  • 6. Apovian CM, Aronne LJ, Bessesen DH, McDonnell ME, Murad MH, Pagotto U, et al. Pharmacological management of obesity: an endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2015; 100(2): 342-62[DOI][PubMed]
  • 7. FDA drug safety communication: FDA recommends against the continued use of Meridia (sibutramine). 2014;
  • 8. Sjostrom L, Rissanen A, Andersen T, Boldrin M, Golay A, Koppeschaar HP, et al. Randomised placebo-controlled trial of orlistat for weight loss and prevention of weight regain in obese patients. European Multicentre Orlistat Study Group. Lancet. 1998; 352(9123): 167-72[PubMed]
  • 9. Davidson MH, Hauptman J, DiGirolamo M, Foreyt JP, Halsted CH, Heber D, et al. Weight control and risk factor reduction in obese subjects treated for 2 years with orlistat: a randomized controlled trial. JAMA. 1999; 281(3): 235-42[PubMed]
  • 10. Hauptman J, Lucas C, Boldrin MN, Collins H, Segal KR. Orlistat in the long-term treatment of obesity in primary care settings. Arch Fam Med. 2000; 9(2): 160-7[PubMed]
  • 11. Mahan LK, Raymond JL. Krause's Food & the Nutrition Care Process-E-Book. 2016;
  • 12. Dixon JB, O'Brien PE, Playfair J, Chapman L, Schachter LM, Skinner S, et al. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA. 2008; 299(3): 316-23[DOI][PubMed]
  • 13. Sjostrom L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004; 351(26): 2683-93[DOI][PubMed]
  • 14. Sjostrom L, Narbro K, Sjostrom CD, Karason K, Larsson B, Wedel H, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007; 357(8): 741-52[DOI][PubMed]
  • 15. Adams TD, Gress RE, Smith SC, Halverson RC, Simper SC, Rosamond WD, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007; 357(8): 753-61[DOI][PubMed]
  • 16. Balsiger BM, Murr MM, Poggio JL, Sarr MG. Bariatric surgery. Surgery for weight control in patients with morbid obesity. Med Clin North Am. 2000; 84(2): 477-89[PubMed]
  • 17. Griffen WJ, Bivins BA, Bell RM. The decline and fall of the jejunoileal bypass. Surg Gynecol Obstet. 1983; 157(4): 301-8[PubMed]
  • 18. Elder KA, Wolfe BM. Bariatric surgery: a review of procedures and outcomes. Gastroenterology. 2007; 132(6): 2253-71[DOI][PubMed]
  • 19. Trelles N, Gagner M. Updated Review of Sleeve Gastrectomy. Open Gastroenterol J. 2008; 2(1): 41-9[DOI]
  • 20. Buchwald H, Williams SE. Bariatric surgery worldwide 2003. Obes Surg. 2004; 14(9): 1157-64[DOI][PubMed]
  • 21. Scott DJ, Provost DA, Jones DB. Laparoscopic Roux-en-Y gastric bypass: transoral or transgastric anvil placement? Obes Surg. 2000; 10(4): 361-5[DOI][PubMed]
  • 22. Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000; 232(4): 515-29[PubMed]
  • 23. O'Brien PE, Dixon JB, Brown W, Schachter LM, Chapman L, Burn AJ, et al. The laparoscopic adjustable gastric band (Lap-Band): a prospective study of medium-term effects on weight, health and quality of life. Obes Surg. 2002; 12(5): 652-60[PubMed]
  • 24. Fisher A, Waterhouse TD, Adams AP. Obesity: its relation to anaesthesia. Anaesthesia. 1975; 30(5): 633-47[PubMed]
  • 25. Konduri GG, Garcia DC, Kazzi NJ, Shankaran S. Adenosine infusion improves oxygenation in term infants with respiratory failure. Pediatrics. 1996; 97(3): 295-300[PubMed]
  • 26. Juvin P, Lavaut E, Dupont H, Lefevre P, Demetriou M, Dumoulin JL, et al. Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg. 2003; 97(2): 595-600[PubMed]
  • 27. Lundstrom LH, Moller AM, Rosenstock C, Astrup G, Wetterslev J. High body mass index is a weak predictor for difficult and failed tracheal intubation: a cohort study of 91,332 consecutive patients scheduled for direct laryngoscopy registered in the Danish Anesthesia Database. Anesthesiology. 2009; 110(2): 266-74[DOI][PubMed]
  • 28. Ezri T, Medalion B, Weisenberg M, Szmuk P, Warters RD, Charuzi I. Increased body mass index per se is not a predictor of difficult laryngoscopy. Can J Anaesth. 2003; 50(2): 179-83[DOI][PubMed]
  • 29. Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985; 32(4): 429-34[PubMed]
  • 30. Samsoon GL, Young JR. Difficult tracheal intubation: a retrospective study. Anaesthesia. 1987; 42(5): 487-90[PubMed]
  • 31. Combes X, Jabre P, Jbeili C, Leroux B, Bastuji-Garin S, Margenet A, et al. Prehospital standardization of medical airway management: incidence and risk factors of difficult airway. Acad Emerg Med. 2006; 13(8): 828-34[DOI][PubMed]
  • 32. Kristensen MS. Airway management and morbid obesity. Eur J Anaesthesiol. 2010; 27(11): 923-7[DOI][PubMed]
  • 33. Brodsky JB, Lemmens HJ, Brock-Utne JG, Vierra M, Saidman LJ. Morbid obesity and tracheal intubation. Anesth Analg. 2002; 94(3): 732-6[PubMed]
  • 34. Jupiter JB, Ring D, Rosen H. The complications and difficulties of management of nonunion in the severely obese. J Orthop Trauma. 1995; 9(5): 363-70[PubMed]
  • 35. Sawyer RJ, Richmond MN, Hickey JD, Jarrratt JA. Peripheral nerve injuries associated with anaesthesia. Anaesthesia. 2000; 55(10): 980-91[PubMed]
  • 36. Perilli V, Sollazzi L, Bozza P, Modesti C, Chierichini A, Tacchino RM, et al. The effects of the reverse trendelenburg position on respiratory mechanics and blood gases in morbidly obese patients during bariatric surgery. Anesth Analg. 2000; 91(6): 1520-5[PubMed]
  • 37. Dybec RB. Intraoperative positioning and care of the obese patient. Plast Surg Nurs. 2004; 24(3): 118-22[PubMed]
  • 38. Ogunnaike BO, Jones SB, Jones DB, Provost D, Whitten CW. Anesthetic considerations for bariatric surgery. Anesth Analg. 2002; 95(6): 1793-805[PubMed]
  • 39. Emerick DR. An evaluation of non-invasive blood pressure (NIBP) monitoring on the wrist: comparison with upper arm NIBP measurement. Anaesth Intensive Care. 2002; 30(1): 43-7[PubMed]
  • 40. Block FE, Schulte GT. Ankle blood pressure measurement, an acceptable alternative to arm measurements. Int J Clin Monit Comput. 1996; 13(3): 167-71[PubMed]
  • 41. Adams JP, Murphy PG. Obesity in anaesthesia and intensive care. Br J Anaesth. 2000; 85(1): 91-108[PubMed]
  • 42. Greenblatt DJ, Abernethy DR, Locniskar A, Harmatz JS, Limjuco RA, Shader RI. Effect of age, gender, and obesity on midazolam kinetics. Anesthesiology. 1984; 61(1): 27-35[PubMed]
  • 43. Abernethy DR, Greenblatt DJ, Smith TW. Digoxin disposition in obesity: clinical pharmacokinetic investigation. Am Heart J. 1981; 102(4): 740-4[PubMed]
  • 44. Christoff PB, Conti DR, Naylor C, Jusko WJ. Procainamide disposition in obesity. Drug Intell Clin Pharm. 1983; 17(7-8): 516-22[PubMed]
  • 45. Egan TD, Huizinga B, Gupta SK, Jaarsma RL, Sperry RJ, Yee JB, et al. Remifentanil pharmacokinetics in obese versus lean patients. Anesthesiology. 1998; 89(3): 562-73[PubMed]
  • 46. Varin F, Ducharme J, Theoret Y, Besner JG, Bevan DR, Donati F. Influence of extreme obesity on the body disposition and neuromuscular blocking effect of atracurium. Clin Pharmacol Ther. 1990; 48(1): 18-25[PubMed]
  • 47. Juvin P, Vadam C, Malek L, Dupont H, Marmuse JP, Desmonts JM. Postoperative recovery after desflurane, propofol, or isoflurane anesthesia among morbidly obese patients: a prospective, randomized study. Anesth Analg. 2000; 91(3): 714-9[PubMed]
  • 48. Sollazzi L, Perilli V, Modesti C, Annetta MG, Ranieri R, Tacchino RM, et al. Volatile anesthesia in bariatric surgery. Obes Surg. 2001; 11(5): 623-6[PubMed]
  • 49. Torri G, Casati A, Albertin A, Comotti L, Bignami E, Scarioni M, et al. Randomized comparison of isoflurane and sevoflurane for laparoscopic gastric banding in morbidly obese patients. J Clin Anesth. 2001; 13(8): 565-70[PubMed]
  • 50. Collins JS, Lemmens HJ, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: a comparison of the "sniff" and "ramped" positions. Obes Surg. 2004; 14(9): 1171-5[DOI][PubMed]
  • 51. Jense HG, Dubin SA, Silverstein PI, O'Leary-Escolas U. Effect of obesity on safe duration of apnea in anesthetized humans. Anesth Analg. 1991; 72(1): 89-93[PubMed]
  • 52. Visick WD, Fairley HB, Hickey RF. The effects of tidal volume and end-expiratory pressure on pulmonary gas exchange during anesthesia. Anesthesiology. 1973; 39(3): 285-90[PubMed]
  • 53. Bardoczky GI, Yernault JC, Houben JJ, d'Hollander AA. Large tidal volume ventilation does not improve oxygenation in morbidly obese patients during anesthesia. Anesth Analg. 1995; 81(2): 385-8[PubMed]
  • 54. Sprung J, Whalley DG, Falcone T, Wilks W, Navratil JE, Bourke DL. The effects of tidal volume and respiratory rate on oxygenation and respiratory mechanics during laparoscopy in morbidly obese patients. Anesth Analg. 2003; 97(1): 268-74[PubMed]
  • 55. Perilli V, Sollazzi L, Modesti C, Annetta MG, Sacco T, Bocci MG, et al. Comparison of positive end-expiratory pressure with reverse Trendelenburg position in morbidly obese patients undergoing bariatric surgery: effects on hemodynamics and pulmonary gas exchange. Obes Surg. 2003; 13(4): 605-9[DOI][PubMed]
  • 56. Tusman G, Bohm SH, Vazquez de Anda GF, do Campo JL, Lachmann B. 'Alveolar recruitment strategy' improves arterial oxygenation during general anaesthesia. Br J Anaesth. 1999; 82(1): 8-13[PubMed]
  • 57. Rothen HU, Sporre B, Engberg G, Wegenius G, Hedenstierna G. Re-expansion of atelectasis during general anaesthesia: a computed tomography study. Br J Anaesth. 1993; 71(6): 788-95[PubMed]
  • 58. Rothen HU, Sporre B, Engberg G, Wegenius G, Hedenstierna G. Reexpansion of atelectasis during general anaesthesia may have a prolonged effect. Acta Anaesthesiol Scand. 1995; 39(1): 118-25[PubMed]
  • 59. Rothen HU, Sporre B, Engberg G, Wegenius G, Reber A, Hedenstierna G. Prevention of atelectasis during general anaesthesia. Lancet. 1995; 345(8962): 1387-91[PubMed]
  • 60. Rothen HU, Sporre B, Engberg G, Wegenius G, Reber A, Hedenstierna G. Atelectasis and pulmonary shunting during induction of general anaesthesia--can they be avoided? Acta Anaesthesiol Scand. 1996; 40(5): 524-9[PubMed]
  • 61. Lachmann B. Open up the lung and keep the lung open. Intensive Care Med. 1992; 18(6): 319-21[PubMed]
  • 62. Sprung J, Whalen FX, Comfere T, Bosnjak ZJ, Bajzer Z, Gajic O, et al. Alveolar recruitment and arterial desflurane concentration during bariatric surgery. Anesth Analg. 2009; 108(1): 120-7[DOI][PubMed]
  • 63. Whalen FX, Gajic O, Thompson GB, Kendrick ML, Que FL, Williams BA, et al. The effects of the alveolar recruitment maneuver and positive end-expiratory pressure on arterial oxygenation during laparoscopic bariatric surgery. Anesth Analg. 2006; 102(1): 298-305[DOI][PubMed]
  • 64. Jayaraman L, Sethi N, Sharma S, Sood J. Anaesthesia for bariatric surgery-Laparoscopic adjustable gastric banding case series. J Anaesthesiol Clin Pharmacol. 2006; 22(4): 403
  • 65. Sabharwal A, Christelis N. Anaesthesia for bariatric surgery. Continu Educ Anaesthes Crit Care Pain. 2010; 10(4): 99-103[DOI]
  • 66. Jones SB, Schumann R, Jones DB. Morbid Obesity Peri-operative Management. 2010;
  • 67. Tank Y, Gohil P. Anesthetic considerations for bariatric surgery. Gujart Med J. 2011; 66: 46-50
  • 68. Hassani V, Pazouki A, Nikoubakht N, Chaichian S, Sayarifard A, Shakib Khankandi A. The effect of gabapentin on reducing pain after laparoscopic gastric bypass surgery in patients with morbid obesity: a randomized clinical trial. Anesth Pain Med. 2015; 5(1)[DOI][PubMed]
  • 69. Alimian M, Imani F, Faiz SH, Pournajafian A, Navadegi SF, Safari S. Effect of oral pregabalin premedication on post-operative pain in laparoscopic gastric bypass surgery. Anesth Pain Med. 2012; 2(1): 12-6[DOI][PubMed]
  • 70. Imani F. Postoperative pain management. Anesth Pain Med. 2011; 1(1): 6-7[DOI][PubMed]
  • 71. Choi YK, Brolin RE, Wagner BK, Chou S, Etesham S, Pollak P. Efficacy and safety of patient-controlled analgesia for morbidly obese patients following gastric bypass surgery. Obes Surg. 2000; 10(2): 154-9[DOI][PubMed]
  • 72. Eriksson S, Backman L, Ljungstrom KG. The incidence of clinical postoperative thrombosis after gastric surgery for obesity during 16 years. Obes Surg. 1997; 7(4): 332-5[DOI][PubMed]
  • 73. Schumann R, Jones SB, Cooper B, Kelley SD, Bosch MV, Ortiz VE, et al. Update on best practice recommendations for anesthetic perioperative care and pain management in weight loss surgery, 2004-2007. Obesity (Silver Spring). 2009; 17(5): 889-94[DOI][PubMed]
  • 74. Alvarez A, Perez-Protto SE, Carey K, Sinha A. Morbid Obesity Peri-operative Management. 2010;
  • 75. 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(6): 1741-8[DOI][PubMed]
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