Impact of retrograde transillumination while securing the airway in obese patients undergoing bariatric surgery

Video laryngoscopy (VL) is a well-established technique used in anaesthetising obese patients who present with higher risks of airway-related difficulties and desaturations due to shorter safe apnoea periods. However, VL has certain limitations and may fail. We present the Infrared Red Intubation System (IRRIS), a new technique facilitating glottis identification in severely obese patients undergoing anaesthesia for bariatric surgery. This single-centre, prospective trial assessed the efficacy of the IRRIS for VL tracheal intubation in 20 severely obese adult patients undergoing elective bariatric surgery under general anaesthesia. We assessed the ability of the IRRIS to differentiate the transilluminated glottis from the oesophagus and laryngeal folds and evaluated the ease of intubation. The average weight in the investigated patient cohort was 145 ± 29 kg, the suprasternal tissue thickness was 12 ± 4 mm. The median IQR [range] larynx recognition time was 10 [2–50] s, which was similar to that of lean patients. The degree of obesity correlated with the duration to achieve optimal laryngoscopic view and complete the intubation procedure. We achieved successful VL insertion on the first attempt in 13 of 20 cases (65%), and on the second attempt in 7 cases (35%), emphasising the increased probability of successful intubation on the first attempt. Tracheal intubation with the IRRIS lasted 50 [IQR 20–100] s. The lowest SpO2 during intubation was 98 [IQR 83–100] %. Addition of IRRIS to VL insertion facilitated the intubation of difficult airways in severely obese patients. IRRIS improves the visualization of the intubation pathway by selectively highlighting the airway entrance and shortens the time to successfully conclude the intubation procedure

EAES rapid guideline: systematic review, network meta-analysis, CINeMA and GRADE assessment, and European consensus on bariatric surgery-extension 2022

Background: The European Association for Endoscopic Surgery Bariatric Guidelines Group identified a gap in bariatric surgery recommendations with a structured, contextualized consideration of multiple bariatric interventions. Objective: To provide evidence-informed, transparent and trustworthy recommendations on the use of sleeve gastrectomy, Roux-en-Y gastric bypass, adjustable gastric banding, gastric plication, biliopancreatic diversion with duodenal switch, one anastomosis gastric bypass, and single anastomosis duodeno-ileal bypass with sleeve gastrectomy in patients with severe obesity and metabolic diseases. Only laparoscopic procedures in adults were considered. Methods: A European interdisciplinary panel including general surgeons, obesity physicians, anesthetists, a psychologist and a patient representative informed outcome importance and minimal important differences. We conducted a systematic review and frequentist fixed and random-effects network meta-analysis of randomized-controlled trials (RCTs) using the graph theory approach for each outcome. We calculated the odds ratio or the (standardized) mean differences with 95% confidence intervals for binary and continuous outcomes, respectively. We assessed the certainty of evidence using the CINeMA and GRADE methodologies. We considered the risk/benefit outcomes within a GRADE evidence to decision framework to arrive at recommendations, which were validated through an anonymous Delphi process of the panel. Results: We identified 43 records reporting on 24 RCTs. Most network information surrounded sleeve gastrectomy and Roux-en-Y gastric bypass. Under consideration of the certainty of the evidence and evidence to decision parameters, we suggest sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass over adjustable gastric banding, biliopancreatic diversion with duodenal switch and gastric plication for the management of severe obesity and associated metabolic diseases. One anastomosis gastric bypass and single anastomosis duodeno-ileal bypass with sleeve gastrectomy are suggested as alternatives, although evidence on benefits and harms, and specific selection criteria is limited compared to sleeve gastrectomy and Roux-en-Y gastric bypass. The guideline, with recommendations, evidence summaries and decision aids in user friendly formats can also be accessed in MAGICapp: https://app.magicapp.org/#/guideline/Lpv2kE Conclusions: This rapid guideline provides evidence-informed, pertinent recommendations on the use of bariatric and metabolic surgery for the management of severe obesity and metabolic diseases. The guideline replaces relevant recommendations published in the EAES Bariatric Guidelines 2020

Impact of retrograde transillumination while securing the airway in obese patients undergoing bariatric surgery

Video laryngoscopy (VL) is a well-established technique used in anaesthetising obese patients who present with higher risks of airway-related difficulties and desaturations due to shorter safe apnoea periods. However, VL has certain limitations and may fail. We present the Infrared Red Intubation System (IRRIS), a new technique facilitating glottis identification in severely obese patients undergoing anaesthesia for bariatric surgery. This single-centre, prospective trial assessed the efficacy of the IRRIS for VL tracheal intubation in 20 severely obese adult patients undergoing elective bariatric surgery under general anaesthesia. We assessed the ability of the IRRIS to differentiate the transilluminated glottis from the oesophagus and laryngeal folds and evaluated the ease of intubation. The average weight in the investigated patient cohort was 145 ± 29 kg, the suprasternal tissue thickness was 12 ± 4 mm. The median IQR [range] larynx recognition time was 10 [2–50] s, which was similar to that of lean patients. The degree of obesity correlated with the duration to achieve optimal laryngoscopic view and complete the intubation procedure. We achieved successful VL insertion on the first attempt in 13 of 20 cases (65%), and on the second attempt in 7 cases (35%), emphasising the increased probability of successful intubation on the first attempt. Tracheal intubation with the IRRIS lasted 50 [IQR 20–100] s. The lowest SpO2 during intubation was 98 [IQR 83–100] %. Addition of IRRIS to VL insertion facilitated the intubation of difficult airways in severely obese patients. IRRIS improves the visualization of the intubation pathway by selectively highlighting the airway entrance and shortens the time to successfully conclude the intubation procedure

The First Modified Delphi Consensus Statement for Resuming Bariatric and Metabolic Surgery in the COVID-19 Times.

The purpose of this study was to achieve consensus amongst a global panel of expert bariatric surgeons on various aspects of resuming Bariatric and Metabolic Surgery (BMS) during the Coronavirus Disease-2019 (COVID-19) pandemic. A modified Delphi consensus-building protocol was used to build consensus amongst 44 globally recognised bariatric surgeons. The experts were asked to either agree or disagree with 111 statements they collectively proposed over two separate rounds. An agreement amongst ≥ 70.0% of experts was construed as consensus as per the predetermined methodology. We present here 38 of our key recommendations. This first global consensus statement on the resumption of BMS can provide a framework for multidisciplinary BMS teams planning to resume local services as well as guide future research in this area

Clinical practice guidelines of the European Association for Endoscopic Surgery (EAES) on bariatric surgery : update 2020 endorsed by IFSO-EC, EASO and ESPCOP

Altres ajuts: This work was funded by the European Association for Endoscopic Surgery (EAES).Surgery for obesity and metabolic diseases has been evolved in the light of new scientific evidence, long-term outcomes and accumulated experience. EAES has sponsored an update of previous guidelines on bariatric surgery. A multidisciplinary group of bariatric surgeons, obesity physicians, nutritional experts, psychologists, anesthetists and a patient representative comprised the guideline development panel. Development and reporting conformed to GRADE guidelines and AGREE II standards. Systematic review of databases, record selection, data extraction and synthesis, evidence appraisal and evidence-to-decision frameworks were developed for 42 key questions in the domains Indication; Preoperative work-up; Perioperative management; Non-bypass, bypass and one-anastomosis procedures; Revisional surgery; Postoperative care; and Investigational procedures. A total of 36 recommendations and position statements were formed through a modified Delphi procedure. This document summarizes the latest evidence on bariatric surgery through state-of-the art guideline development, aiming to facilitate evidence-based clinical decisions. The online version of this article (10.1007/s00464-020-07555-y) contains supplementary material, which is available to authorized users

EAES Recommendations for Recovery Plan in Minimally Invasive Surgery Amid COVID-19 Pandemic

Background: COVID-19 pandemic presented an unexpected challenge for the surgical community in general and Minimally Invasive Surgery (MIS) specialists in particular. This document aims to summarize recent evidence and experts' opinion and formulate recommendations to guide the surgical community on how to best organize the recovery plan for surgical activity across different sub-specialities after the COVID-19 pandemic. Methods: Recommendations were developed through a Delphi process for establishment of expert consensus. Domain topics were formulated and subsequently subdivided into questions pertinent to different surgical specialities following the COVID-19 crisis. Sixty-five experts from 24 countries, representing the entire EAES board, were invited. Fifty clinicians and six engineers accepted the invitation and drafted statements based on specific key questions. Anonymous voting on the statements was performed until consensus was achieved, defined by at least 70% agreement. Results: A total of 92 consensus statements were formulated with regard to safe resumption of surgery across eight domains, addressing general surgery, upper GI, lower GI, bariatrics, endocrine, HPB, abdominal wall and technology/research. The statements addressed elective and emergency services across all subspecialties with specific attention to the role of MIS during the recovery plan. Eighty-four of the statements were approved during the first round of Delphi voting (91.3%) and another 8 during the following round after substantial modification, resulting in a 100% consensus. Conclusion: The recommendations formulated by the EAES board establish a framework for resumption of surgery following COVID-19 pandemic with particular focus on the role of MIS across surgical specialities. The statements have the potential for wide application in the clinical setting, education activities and research work across different healthcare systems

EAES Recommendations for Recovery Plan in Minimally Invasive Surgery Amid COVID-19 Pandemic

Background: COVID-19 pandemic presented an unexpected challenge for the surgical community in general and Minimally Invasive Surgery (MIS) specialists in particular. This document aims to summarize recent evidence and experts’ opinion and formulate recommendations to guide the surgical community on how to best organize the recovery plan for surgical activity across different sub-specialities after the COVID-19 pandemic. Methods: Recommendations were developed through a Delphi process for establishment of expert consensus. Domain topics were formulated and subsequently subdivided into questions pertinent to different surgical specialities following the COVID-19 crisis. Sixty-five experts from 24 countries, representing the entire EAES board, were invited. Fifty clinicians and six engineers accepted the invitation and drafted statements based on specific key questions. Anonymous voting on the statements was performed until consensus was achieved, defined by at least 70% agreement. Results: A total of 92 consensus statements were formulated with regard to safe resumption of surgery across eight domains, addressing general surgery, upper GI, lower GI, bariatrics, endocrine, HPB, abdominal wall and technology/research. The statements addressed elective and emergency services across all subspecialties with specific attention to the role of MIS during the recovery plan. Eighty-four of the statements were approved during the first round of Delphi voting (91.3%) and another 8 during the following round after substantial modification, resulting in a 100% consensus. Conclusion: The recommendations formulated by the EAES board establish a framework for resumption of surgery following COVID-19 pandemic with particular focus on the role of MIS across surgical specialities. The statements have the potential for wide application in the clinical setting, education activities and research work across different healthcare systems

30-Day morbidity and mortality of bariatric metabolic surgery in adolescence during the COVID-19 pandemic – The GENEVA study

Background: Metabolic and bariatric surgery (MBS) is an effective treatment for adolescents with severe obesity. Objectives: This study examined the safety of MBS in adolescents during the coronavirus disease 2019 (COVID-19) pandemic. Methods: This was a global, multicentre and observational cohort study of MBS performed between May 01, 2020, and October 10,2020, in 68 centres from 24 countries. Data collection included in-hospital and 30-day COVID-19 and surgery-specific morbidity/mortality. Results: One hundred and seventy adolescent patients (mean age: 17.75 ± 1.30 years), mostly females (n = 122, 71.8%), underwent MBS during the study period. The mean pre-operative weight and body mass index were 122.16 ± 15.92 kg and 43.7 ± 7.11 kg/m2, respectively. Although majority of patients had pre-operative testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (n = 146; 85.9%), only 42.4% (n = 72) of the patients were asked to self-isolate pre-operatively. Two patients developed symptomatic SARS-CoV-2 infection post-operatively (1.2%). The overall complication rate was 5.3% (n = 9). There was no mortality in this cohort. Conclusions: MBS in adolescents with obesity is safe during the COVID-19 pandemic when performed within the context of local precautionary procedures (such as pre-operative testing). The 30-day morbidity rates were similar to those reported pre-pandemic. These data will help facilitate the safe re-introduction of MBS services for this group of patients