Zentralbl Chir 2009; 134(1): 43-49
DOI: 10.1055/s-0028-1098806
Übersicht

© Georg Thieme Verlag Stuttgart ˙ New York

Postoperatives Management bei Patienten mit einem BMI > 40 kg / m2

Postoperative Management of Patients with BMI > 40 kg / m2 M. Kaffarnik1 , S. Utzolino1
  • 1Abteilung für Allgemein- und Viszeralchirurgie, Chirurgische Universitätsklinik Freiburg i. Br.
Further Information

Publication History

Publication Date:
25 February 2009 (online)

Zusammenfassung

In der bariatrischen Chirurgie, speziell bei morbid-adipösen Patienten, kann es zu schwerwiegenden Komplikationen kommen. Neben chirurgischen Komplikationen können vorbestehende Erkrankungen während der peri- und postoperativen Phase exazerbieren. Bariatrische Patienten benötigen ein spezielles angepasstes Infusions- und Schmerzmanagement, die Therapie des Obesitas-Hypoventilationssyndroms, eine frühzeitige Mobilisierung und präventive Maßnahmen zur Verhinderung von Druckulzera. Eine besondere Herausforderung ist das frühzeitige Erkennen und Management der postoperativen abdominalen Sepsis (IAS) bevor es zum Organversagen kommt. Eine frühe und regelmäßige Mobilisation reduziert das Risiko für die Entstehung von Druckulzera, tiefer Beinvenenthrombosen, Resedierung, Schmerz, pulmonalen Atelektasen und Pneumonien. Zum Schutz des Personals ist es unumgänglich, spezielle Arbeitshilfen wie Spezialbetten sowie Hebe- und Transfervorrichtungen, bereitzustellen.

Abstract

Bariatric surgery, especially in the morbidly obese, can be associated with serious postoperative problems. Apart from surgical complications requiring reoperation, pre-existing disease can worsen during the postoperative period. Bariatric patients require particular therapeutic approaches such as adapted fluid and pain management, management of obstructive sleep apnoea-hypopnea, early ambulation and measures for preventing pressure ulcers. Another challenging issue is the early identification and management of postoperative intraabdominal sepsis (IAS) before the onset of organ dysfunction. Early and frequent ambulation is thought to reduce risk of pressure ulcers, deep vein thrombosis, resedation, pain, pneumonia and atelectasis. To prevent spine injury of health care workers it is necessary to provide appropriate support with special beds, lifting and transfer devices.

Literatur

  • 1 Ballantyne J C, Carr D B, de Ferranti S et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analysis of randomized, controlled trials.  Anesth Analg. 1998;  86 598-612
  • 2 Beattie W S, Badner N H, Choi P. Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis.  Anesth Analg. 2001;  93 853-858
  • 3 Blackstone R, Kieran J, Davis M et al. Continuous perioperative insulin infusion therapy for patients with type 2 diabetes undergoing bariatric surgery.  Surg Endosc. 2007;  21 1316-1322
  • 4 Bohnen J, Boulanger M, Meakins J L et al. Prognosis in generalized peritonitis. Relation to cause and risk factors.  Arch Surg. 1983;  118 285-290
  • 5 Cooper K R, Phillips B A. Effect of short-term sleep loss on breathing.  J Appl Physiol. 1982;  53 855-858
  • 6 Davidson J E, Callery C. Care of the obesity surgery patient requiring immediate-level care or intensive care.  Obes Surg. 2001;  11 93-97
  • 7 Davidson J E, Callery C. Making the most of your time: the benefits of converting patient education programs into continuing nursing education.  Obes Surg. 2000;  10 482-483
  • 8 Dellinger R P, Levy M M, Carlet J M et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008.  Crit Care Med. 2008;  36 296-327
  • 9 Dixon J B, Pories W J, O’Brien P E. Surgery as an effective early intervention for diabesity: why the reluctance? (review).  Diabetes Care. 2005;  28 472-474
  • 10 Eichenberger A S, Proietti S, Wicky S et al. Morbid obesity and postoperative pulmonary atelectasis: an underestimated problem.  Anesth Analg. 2002;  95 1788-1792
  • 11 Elmore M F, Gallagher S C, Jones J G et al. Esophagogastric decompression and enteral feeding following cholecystectomy: a controlled, randomized prospective trial.  JPEN J Parenter Enteral Nutr. 1989;  13 377-381
  • 12 Erstad B L. Dosing of medications in morbidly obese patients in the intensive care unit setting.  Intensive Care Med. 2004;  30 18-21
  • 13 Evans T W. International Consensus Conference in Intensive Care Medicine: Non-invasive positive pressure ventilation in acute respiratory failure, organized jointly by the American Thoracic Society, the European Society of Intensive Care Medicine, and the Société de Réanimation de Langue Française, and approved by the ATS Board of directors, December 2000.  Int Care Med. 2001;  27 166-178
  • 14 Fearon K C, Ljungqvist O, von Meyenfeldt M et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection.  Clin Nutr. 2005;  24 466-477
  • 15 Gallagher S M. Morbid obesity: a chronic disease with an impact on wounds and related problems.  Ostomy Wound Management. 1997;  43 18-24
  • 16 Gaszynski T, Tokarz A, Piotrowski D et al. Boussignac CPAP in the postoperative period in obese patients.  Obesity Surgery. 2007;  17 452-456
  • 17 Gleeson K, Zwillich C W, White D P. The influence of increasing ventilatory effort on arousal from sleep.  Am Rev Respir Dis. 1990;  142 295-300
  • 18 Goldfeder L B, Ren C J, Gill J R. Fatal complications of bariatric surgery.  Obes Surg. 2006;  16 1050-1056
  • 19 Gonzalez R, Nelson L G, Gallagher S F et al. Anastomotic leaks after laparoscopic gatric bypass.  Obes Surg. 2004;  14 1299-1307
  • 20 Green B, Duffull S B. Development of a dosing strategy for enoxaparin in obese patients.  Br J Clin Pharmacol. 2003;  56 96-103
  • 21 Greisen J, Juhl C B, Grofte T et al. Acute pain induces insulin resistance in humans.  Anesthesiology. 2001;  95 578-584
  • 22 Grocott M P, Mythen M G, Gan T J. Perioperative fluid management and clinical outcomes in adults.  Anesth Analg. 2005;  100 1093-1106
  • 23 Hainer J W, Barrett J S, Assaid C A et al. Dosing in heavyweight / obese patients with the low molecular weight heparin tinzaparin: a pharmacodynamic study.  Thromb Haemost. 2002;  87 817
  • 24 Hamilton E C, Sims T L, Hamilton T T et al. Clinical predictors of leak after laparoscopic Roux-en-Y gastric bypass for morbid obesity.  Surg Endosc. 2003;  17 679-684
  • 25 Hausel J, Nygren J, Thorell A et al. Randomized clinical trial of the effects of oral preoperative carbohydrates on postoperative nausea and vomiting after laparoscopic cholecystectomy.  Br J Surg. 2005;  92 51-58
  • 26 Holte K, Kehlet H. Fluid therapy and surgical outcome in elective surgery: a need for reassessment in fast-track surgery.  J Am Coll Surg. 2006;  202 971-981
  • 27 Huerta S, DeShields S, Shpiner R et al. Safety and efficiacy of postoperative continuous positive airway pressure to prevent pulmonary complications after Roux-en-Y gastric bypass.  J Gatrointest Surg. 2002;  6 354-358
  • 28 Jaber S, Delay J M, Chanques G et al. Outcomes of patients with acute respiratory failure after abdominal surgery treated with noninvasive positive pressure ventilation.  Chest. 2005;  128 2688-2695
  • 29 Jadad A R, Browman G P. The WHO analgesic ladder for cancer pain management. Stepping up the quality of its evaluation.  JAMA. 1995;  274 1870-1873
  • 30 Jorgensen H, Wetterslev J, Moiniche S et al. Epidural local anaesthetics versus opioid-based analgesic regiments on postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery (Cochrane review) 2002. Cochrane Library, Issue 1. update software, Oxford
  • 31 Kalfarentzos F, Stavropoulou F, Yarmenitis S et al. Prophylaxis of venous thromboembolism using two different doses of low-molecular-weight heparin (nadroparin) in bariatric surgery: a prospective randomized trial.  Obes Surg. 2001;  11 670
  • 32 Kamelgard J I, Kim K A, Atlas G. Combined preemptive and preventive analgesia in morbidly obese patients undergoing open gastric bypass: a pilot study.  Surg Obes Rel Dis. 2005;  1 12-16
  • 33 Kehlet H. Modification of responses to surgery by neural blockade: clinical implications. In: Cousins MJ, Bridenbaugh PS (eds). Neural blockade in clinical anesthesia and management of pain. 3rd edn. Philadelphia, Pennsylvania: Lippincott-Raven; 1998: 129–175
  • 34 Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation.  Br J Anaesth. 1997;  78 606-617
  • 35 Kehlet H. The surgical stress response: should it be prevented?.  Can J Surg. 1991;  34 565-567
  • 36 Kermarrec N, Marmuse J P, Faivre J. High mortality rate for patients requiring intensive care after surgical revision following bariatric surgery.  Obes Surg. 2008;  18 171-178
  • 37 Koenig S M. Pulmonary complications in obesity.  Am J Med Sci. 2001;  321 249-279
  • 38 Lamvu G, Zolnoun D, Boggess J et al. Obesity: physiologic changes and challenges during laparoscopy.  Am J Obstet Gynecol. 2004;  191 669-674
  • 39 Ljungqvist O, Nygren J, Thorell A et al. Preoperative nutrition – elective surgery in the fed or the overnight fasted state.  Clin Nutr. 2001;  20 (Suppl) 167-171
  • 40 Ljungqvist O, Nygren J, Thorell A. Modulation of post-operative insulin resistance by pre-operative carbohydrate loading.  Proc Nutr Soc. 2002;  61 329-336
  • 41 Lobo D N, Bostock K A, Neal K R et al. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial.  Lancet. 2002;  359 1812-1818
  • 42 Mannan M A, Rahman M S, Siddiqui N I. Obesity management in patients with type 2 diabetes mellitus (review).  Mymensingh Med J. 2004;  13 95-99
  • 43 McGlinch B P, Que F G, Nelson J L et al. Perioperative care of patients undergoing bariatric surgery.  Mayo Clin Proc. 2006;  81 (suppl.) S 25-S 33
  • 44 Mismetti P, Laporte S, Darmon J Y et al. Meta-analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery.  Br J Surg. 2001;  88 913
  • 45 Nascimento J, Posner D, Rogers M et al. Risk of noninvasive positive pressure ventilation postoperatively in laparoscopic gastric bypass patients.  Crit Care Med. 2006;  33 183-191
  • 46 Petrelli N J, Stulc J P, Rodriguez-Bigas M et al. Nasogastric decompression following elective colorectal surgery: a prospective randomized study.  Am Surg. 1993;  59 632-635
  • 47 Piper A J, Sullivan C E. Effects of short-term NIPPV in the treatment of patients with severe obstructive sleep apnea and hypercapnia.  Chest. 1994;  105 434-440
  • 48 Hirsch J, Guyatt G, Albers G W et al. Proceedings of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: evidence-based guidelines.  Chest. 2004;  126 (3 Suppl) 172 S-696 S
  • 49 Ramaswamy A, Gonzales R, Smith C D. Extensive preoperative testing is not necessary in morbidly obese patients undergoing gastric bypass.  J Gastrointest Surg. 2004;  8 159-164
  • 50 Rapoport D M, Garay S M, Epstein H et al. Hypercapnia in the obstructive sleep apnea syndrom: a reevaluation of the “Pickwickian syndrome”.  Chest. 1986;  89 627-635
  • 51 Rocha A T, Vasconcellos A G, da Luz Neto E R et al. Risk of VTE and efficacy of thromboprophylaxis in hospitalized obese medical patients and in obese patients undergoing bariatric surgery.  Obesity Surg. 2006;  16 1645
  • 52 Schricker T, Gougeon R, Eberhart L et al. Type 2 diabetes mellitus and the catabolic response to surgery.  Anesthesiology. 2005;  102 320-326
  • 53 Schwenk W, Bohm B, Haase O et al. Laparoscopic versus conventional colorectal resection: a prospective randomised study of postoperative ileus and early postoperative feeding.  Langenbecks Arch Surg. 1998;  383 49-55
  • 54 Seiler C A, Brugger L, Forssmann U et al. Conservative surgical treatment of intra-abdominal infection.  Surgery. 2000;  127 178-184
  • 55 Soop M, Carlson G L, Hopkins J et al. Randomized clinical trail of the effects of immediate enteral nutrition on metabolic responses to major colorectal surgery in an enhanced recovery protocol.  Br J Surg. 2004;  91 1138-1145
  • 56 Encke A, Beckmann M W, Breddin H K et al. Stationäre und ambulante Thromboembolie-Prophylaxe in der Chirurgie und der perioperativen Medizin. AWMF-S 2-Leitlinie 2003. www.awmf.org Stand: 15.12.2008
  • 57 Valentin N, Lombolt B, Jensen J S et al. Spinal or general anaeshesia for surgery of the fractured hip? A prospective study of mortality in 578 patients.  Br J Anaesth. 1986;  58 284-291
  • 58 Van den Berghe G, Wouters P, Weekers F et al. Intensive insulin therapy in the surgical intensive care unit.  N Engl J Med. 2001;  345 1359-1367
  • 59 Vanhoerebeek I, De Vos R, Mesotten D et al. Protection of hepatocyte mitochondrial ultrastructure and function by strict blood glucose control with insulin in critically ill patients.  Lancet. 2005;  365 53-59
  • 60 Walder B, Schafer M, Henzi I et al. Efficiacy and safety of patient-controlled opioid analgesia for acute postoperative pain. A quantitative systematic review.  Acta Aneasthesiol Scand. 2001;  45 795-804
  • 61 Weimann A, Braga M, Harsanyi L et al. ESPEN Guidelines on Enteral Nutrition: Surgery including organ transplantation.  Clin Nutr. 2006;  25 224-244
  • 62 Yuill K A, Richardson R A, Davidson H I et al. The administration of an oral carbohydrate-containing fluid prior to major elective upper-gastrointestinal surgery preserves skeletal muscle mass postoperatively – a randomised clinical trial.  Clin Nutr. 2005;  24 32-37

Dr. med. M. Kaffarnik

Abteilung für Allgemein- und Viszeralchirurgie · Chirurgische Universitätsklinik Freiburg i. Br.

Hugstetter Str. 55

79106 Freiburg i. Br.

Phone: 07 61 / 2 70 26 44

Fax: 07 61 / 2 70 28 04

Email: magnus.kaffarnik@uniklinik-freiburg.de