GASTRIC SLEEVE
A gastric sleeve, also known as a sleeve gastrectomy, is a type of bariatric surgery that is often used as a treatment for severe obesity when diet and exercise have not been effective. This surgery involves removing about 75-80% of the stomach, leaving a thin vertical "sleeve" that is about the size of a banana.
The procedure is typically done laparoscopically, which means it's minimally invasive. The surgeon makes small incisions and uses a camera and special tools to perform the operation.
The main goal of the gastric sleeve surgery is to reduce the size of the stomach, which in turn limits the amount of food a person can eat at one time. The operation also impacts gut hormones and other factors that affect hunger, satiety, and blood sugar control. This surgery does not involve any bypass of the intestines, so nutrient absorption is not as affected as with some other types of weight-loss surgeries.
Anesthetic Implications for Gastric Sleeve
Anesthesia type: General
Airway: Endotracheal tube
Preoperative:
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Sleeve gastrectomy is a permanent method of reducing the size of the stomach
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Assess for difficult airway
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Consider video laryngoscopy
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Difficult or failed intubation is more common in obese patient
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OSA can be associated with pulmonary hypertension
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Obesity affects every organ system
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Patients with centralized obesity tend to have less favorable airway anatomy
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Special attention is needed in obese patients regarding airway and cardiorespiratory status
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Protect pressure areas because pressure sores and neural injuries are common in obese patients
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Tracheal intubation should be performed in all patients undergoing laparoscopic bariatric surgery
Intraoperative:
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Multimodal analgesic technique
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Most anesthetic medications are highly lipophilic
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The supine position is not well tolerated by a morbidly obese patient
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Atelectasis is common after induction of anesthesia of morbidly obese
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The reverse Trendelenburg position maximizes oxygenation because it increases functional residual capacity (FRC)
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Duration: 1-2 hours
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Position: Supine and reverse Trendelenburg, arms abducted
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A bougie is placed orally against the lesser curvature of the stomach to size the pouch
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Body habitus and a pneumoperitoneum can result in high peak airway pressures
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Tidal volume 6–8 ml kg−1 based on IBW, and a sufficient level of PEEP should be applied (5–10 cmH2O)
Postoperative:
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Obese patients are at higher risk for postoperative complications
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TAP block for pain management
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Optimal analgesia
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Wound care
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Deep vein thrombosis prophylaxis
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Fluid management
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Patients with obesity were at high risk of airway obstruction, hypoventilation and regurgitation at extubation
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Neuromuscular block must be reversed fully at the end of surgery before extubation
Complications:
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Bleeding
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Nausea and vomiting
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Thromboembolic events
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Aspiration
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Postoperative wound infection
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Gastric leak
Sources:
Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice.
Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.).
Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.
Soleimanpour H, Safari S, Sanaie S, Nazari M, Alavian SM. Anesthetic Considerations in Patients Undergoing Bariatric Surgery: A Review Article. Anesth Pain Med. 2017 Jul 11;7(4):e57568. doi: 10.5812/aapm.57568. PMID: 29430407; PMCID: PMC5797674.