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Sleeve Gastrectomy and Gallstones Disease
327
References
1. Angrisani L, Santonicola A, Lovino P et al. IFSO worldwide survey 2016: primary, endolu-
minal, and revisional procedures. OBES SURG. 2018; 28:3783–94.
2. Scragg RK, McMichael AJ, Baghurst PA. Diet, alcohol, and relative weight in gall stone dis-
ease: a case-control study. Br Med J (Clin Res Ed). 1984; 288(6424):1113–19.
3. Erlinger S. Gallstones in obesity and weight loss. Eur J Gastroenterol Hepatol. 2000;
12(12):1347–52.
4. Maclure KM, Hayes KC, Colditz GA, et al. Weight, diet, and the risk of symptomatic gall-
stones in middle-aged women. N Engl J Med. 1989;321(9):563–9.
5. World Health Organization. Obesity: preventing and managing the global epidemic. Part
I. The problem of overweight and obesity. WHO Technical Report Series No. 894. WHO:
Geneva. 2000:5–15.
6. Barbara L, Sama C, Morselli Labate AM, Taroni F, Rusticali AG, Festi D, et al. A population
study on the prevalence of gallstone disease: the Sirmione study. Hepatology. 1987;7:913–7.
7. Layde PM, Vessey MP, Yeates D. Risk factors for gall-bladder disease: a cohort study
of young women attending family planning clinics. J Epidemiol Community Health.
1982;36(274–8):7.
8. The epidemiology of gallstone disease in Rome, Italy. Part II. Factors associated with dis-
ease. The Rome Group for Epidemiology and Prevention of Cholelithiasis (GREPCO).
Hepatology. 1988; 8:907–13.
9. Jorgensen T. Gallstones in a Danish population. Relation to weight, physical activity, smok-
ing, coffee consumption, and diabetes mellitus. Gut. 1989; 30:528–34.
10. Maurer KR, Everhart JE, Knowler WC, Shawker TH, Roth HP. Risk factors for gallstone dis-
ease in the Hispanic populations of the United States. Am J Epidemiol. 1990;131:836–44.
11. Sichieri R, Everhart JE, Roth HP. Low incidence of hospitalization with gallbladder disease
among blacks in the United States. Am J Epidemiol. 1990;131:826–35.
12. Stampfer MJ, Maclure KM, Colditz GA, Manson JE, Willett WC. Risk of symptomatic gall-
stones in women with severe obesity. Am J Clin Nutr. 1992;55:652–8.
13. Yang H, Petersen GM, Roth MP, Schoenfield LJ, Marks JW. Risk factors for gallstone forma-
tion during rapid loss of weight. Dig Dis Sci. 1992; 37:912–8.]
14. Broomfield PH, Chopra R, Sheinbaum RC, Bonorris GG, Silverman A, Schoenfield LJ, et al.
Effects of ursodeoxycholic acid and aspirin on the formation of lithogenic bile and gallstones
during loss of weight. N Engl J Med. 1988;319:1567–72.
15. Liddle RA, Goldstein RB, Saxton J. Gallstone formation during weight-reduction dieting.
Arch Intern Med. 1989;149:1750–3.
16. Festi D, Orsini M, Bassi SL, Cerel C, Sangermano A, Parenti M, et al. Risk of gallstone
formation during rapid weight loss: protective role of gallbladder motility (Abstract).
Gastroenterology. 1992;102:A311.
17. Hoy K, Blank B, Grasset E, Schamacher D, Ritch D, Heymsfield S. Cholelithiasis in obese
patients before and after short term weight loss (Abstract). Int J Obesity. 1991;15(Suppl
3):20.
18. Gebhard RL, Prigge WF, Ansel HJ, Schlasner L, Ketover SR, Sande D, et al. The role of gall-
bladder emptying in gallstone formation during diet-induced rapid weight loss. Hepatology.
1996; 24:544–8. Weight.
19. Erlinger S. Gallstones in obesity and weight loss. Eur J Gastroenterol Hepatol.
2000;12(12):1347–52.
20. Everhart JE. Contributions of obesity and weight loss to gallstone disease. Ann Intern Med.
1993;119(10):1029–35.
21. Sichieri R, Everhart JE, Roth HP. A prospective study of hospitalization with gallstone dis-
ease among women: role of dietary factors, fasting period, and dieting. Am J Public Health.
1991;81:880–4.
H. M. Alghamdi328
22. Bennion LJ, Grundy SM. Risk factors for the development of cholelithiasis in man. N Engl J
Med. 1978;299(21):1161–7.
23. Trotman BW, Petrella EJ, Soloway RD, Sanchez HM, Morris TA, 3rd, Miller WT. Evaluation
of radiographic lucency or opaqueness of gallstones as a means of identifying cholesterol or pigment stones. Correlation of lucency or opaqueness with calcium and mineral.
Gastroenterology. 1975; 68:1563–6.]
24. Busch N, Matern S. Current concepts in cholesterol gallstone pathogenesis. Eur J Clin Invest.
1991; 21:453–60.
25. Hay DW, Carey MC. Pathophysiology and pathogenesis of cholesterol gallstone formation.
Semin Liver Dis. 1990; 10:159–70.
26. Paumgartner G. Sauerbruch T. Gallstones: pathogenesis. Lancet. 1991;338:1117–21.
27. Bennion LJ, Grundy SM. Effects of obesity and caloric intake on biliary lipid metabolism in
man. J Clin Invest. 1975;56:996–1011.
28. Angelin B, Einarsson K, Ewerth S, Leijd B. Biliary lipid composition in obesity. Scand J
Gastroenterol. 1981;16:1015–9.
29. Reuben A, Qureshi Y, Murphy GM, Dowling RH. Effect of obesity and weight reduction on
biliary cholesterol saturation and the response to chenodeoxycholic acid. Eur J Clin Invest.
1986;16:133–42.
30. Gustafsson U1, Benthin L, Granström L et al. Changes in gallbladder bile composition and
crystal detection time in morbidly obese subjects after bariatric surgery. Hepatology. 2005;
41(6):1322–8.
31. Tsirline VB, Keilani ZM, El Djouzi S, Phillips RC, Kuwada TS, Gersin K, Simms C,
Stefanidis D. How frequently and when do patients undergo cholecystectomy after bariatric
surgery? Surg Obes Relat Dis. 2014 Mar−Apr; 10(2):313–21.
32. Altieri MS, Yang J, Nie L, Docimo S, Talamini M, Pryor AD et al. Incidence of cholecystec-
tomy after bariatric surgery. Surg Obes Relat Dis. 2018; 14(7):992–6.
33. Chang J, Corcelles R, Boules M, Jamal MH, Schauer PR, Kroh MD. Predictive factors of
biliary complications after bariatric surgery. Surgery for Obesity and Related Diseases.
2016;12(9):1706–10.
34. Nagem RG, Lázaro-da-Silva A, de Oliveira RM, Morato VG. Gallstone-related complica-
tions after Roux-en-Y gastric bypass: a prospective study. Hepatobiliary Pancreat Dis Int.
2012 Dec 15; 11(6):630−5.
35. Tustumi F, Bernardo WM, Santo MA. Ivan cecconello. cholecystectomy in patients submit-
ted to bariatric procedure: a systematic review and meta-analysis. OBES SURG. 2018; 28:
3312–20.
36. Warschkow R, Tarantino I, Ukegjini K, et al. Concomitant cholecystectomy during lapa-
roscopic Roux-en-Y gastric bypass in obese patients is not justified: a meta-analysis. Obes
Surg. 2013;23(3):397–407.
37. Worni M, Guller U, Shah A, et al. Cholecystectomy concomitant with laparoscopic gas-
tric bypass: a trend analysis of the nationwide inpatient sample from 2001 to 2008. OBES
SURG. 2012;22:220–9.
38. Villegas, L., Schneider, B., Provost, D. Craig Chang, Daniel Scott, Thomas Sims, BS et al. Is
routine cholecystectomy required during laparoscopic gastric bypass? OBES SURG. 2004;
14:206–11.
39. Fobi M, Lee H, Igwe D, et al. Prophylactic cholecystectomy with gastric bypass operation:
incidence of gallbladder disease. OBES SURG. 2002;12:350–3.
40. Hamad GG, Ikramuddin S, Gourash WF, et al. Elective cholecystectomy during laparoscopic
Roux-En-Y gastric bypass: is it worth the wait? OBES SURG. 2003;13:76–81.
41. Bernabé M Quesada, Gustavo Kohan, Hernán E Roff, Carlos M Canullán, Luis T Chiappetta
Porras. Management of gallstones and gallbladder disease in patients undergoing gastric
bypass. World J Gastroenterol. 2010; 16(17):2075–9.
42. Sugerman HJ, Brewer WH, Shiffman ML, Brolin RE, Fobi MA, Linner JH, et al. A mul-
ticenter, placebo-controlled, randomized, double-blind, prospective trial of prophylactic
Sleeve Gastrectomy and Gallstones Disease
ursodiol for the prevention of gallstone formation following gastric-bypass-induced rapid
weight loss. Am J Surg. 1995 Jan; 169(1):91–6; discussion 96–7.
43. Magouliotis DE, Tasiopoulou VS, Svokos AA, Svokos KA, Chatedaki C, Sioka E,
Zacharoulis D. Ursodeoxycholic acid in the prevention of gallstone formation after bariatric
surgery: an updated systematic review and meta-analysis. OBES SURG. 2017;27:3021–30.
44. Adams LB, Chang C, Pope J, Kim Y, Liu P, Yates A. Randomized, prospective comparison
of ursodeoxycholic acid for the prevention of gallstones after sleeve gastrectomy. Obes Surg.
2016;26(5):990–4.
329
LSG Under Block Anesthesia (PVB)
Mohamad Hayssam Elfawal, Saleh Kanawati
and Diya Aldeen Mohammed
1 Introduction
Laparoscopic sleeve gastrectomy (LSG) remains the gold standard technique to
achieve and maintain long term weight loss among the overweight population. The
current trend is to perform LSG under general anesthesia (GA) because of several
factors, including good muscle relaxation which allows better manipulation of laparoscopic tools, but this cannot be attained safely among severely co-morbid obese
patients where GA carries a high risk of complications or is considered a contraindication, and therefore, paravertebral blockade (PVB) could offer a safe alternative.
2 Review on General Anesthesia
2.1 General Overview
Almost all surgeries of the modern era share a common procedure that is anesthesia. The Oxford dictionary defines anesthesia as “Insensitivity to pain, especially
as artificially induced by the administration of gases or the injection of drugs
before surgical operations.” The act of abolishing surgical pain was always sought
M. H. Elfawal (*)
Clinical Assistant Professor of Surgery, CEO New You Center, Director Fellowship Program
Bariatric and Metabolic Surgery at Beirut Arab University, Beirut, Lebanon
e-mail: hayssamfawal@gmail.com
S. Kanawati
Department of Anesthesia, Chairman Department of Anesthesia, Makassed General Hospital,
Beirut, Lebanon
D. A. Mohammed
Bariatric Surgeon, New You Center, Beirut, Lebanon
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2021
S. Al-Sabah et al. (eds.), Laparoscopic Sleeve Gastrectomy,
https://doi.org/10.1007/978-3-030-57373-7_33
331
M. H. Elfawal et al.332
out throughout history, but it was in the nineteenth century that discoveries about
certain anesthetic agents made anesthesia possible and reproducible [1]. To date,
advancements in the field of anesthesia grow and evolve to try and perfect this procedure for a better and safer patient experience.
The objectives of anesthesia are to provide analgesia and amnesia during an
operative event. To achieve these objectives, the anesthesiologist can perform different types of anesthesia depending on the situation presented, and these are [2]:
1. General anesthesia
2. Neuraxial anesthesia (Spinal, Epidural)
3. Nerve Block
4. Regional (local) anesthesia
2.2 General Anesthesia in the Obese/bariatric Population
Obesity is well known for the overall risks it imparts on an individual, ranging
from an increased risk of metabolic syndrome to an increased risk in cardiovascular events and overall mortality [3]. In the normal population, complications
can occur with the use of general anesthesia either perioperatively or postoperatively, as stated earlier. However, obese patients, in whom comorbid diseases are
frequently encountered, are even more drastically impacted by general anesthesia
in this regard [4]. According to previously published data, the incidence of postoperative complications, ranging from the harmless vomiting to the fatal myocardial
ischemia, are all somewhat higher in the obese surgical patient [5].
The increased risk of perioperative complications stems from the concept that
morbidly obese patients possess unique pathophysiologic changes that makes this
population particularly more vulnerable to life threatening issues [5].
Obese patients are characterized by an increased extracellular volume owing
to an enlarged cardiopulmonary vascular system, as well as increased metabolic
demands. This change ultimately leads to an increase in lung resistance and consequently a decrease in lung compliance, causing decreased ventilation and hypoxemia [5]. In addition to the hypervolemia, mechanical barriers such as excess fatty
tissue especially around the neck and trunk also negatively affect respiratory function leading to hypoxia [6]. Furthermore, reduced compliance of the diaphragm,
an important muscle for respiration, occurs during laparoscopic abdominal surgery
under general anesthesia, partly from the gases used to expand the abdomen, and
partly from the drugs used during anesthesia that cause a loss of muscular tone [6].
This reduced diaphragmatic compliance, as well as a documented cephalad diaphragmatic displacement in obese patients undergoing bariatric surgery, raises the
risk of basal atelectasis and ultimately the prevalence of chest infections [7]. That is
why obese patients are prone to develop respiratory complications and special care
is taken in general anesthetic protocols involving these patients for this reason [8].
Moving on from the respiratory standpoint, obesity by itself is a risk factor for
coronary artery disease, and hence these patients pose an increased risk of angina
LSG Under Block Anesthesia (PVB)
pectoris, heart failure, and even sudden death. Fatty infiltration of the cardiac conduction system may as well increase the risk of cardiac arrhythmias [7].
As a conclusion, this patient population represents a particular challenge for the
anesthesiologist. The presence of a vast difference in published data regarding the
matter results in difficulty establishing a well inscribed and universal general anesthesia regimen or even predict its outcome. That is why general anesthesia for the
morbidly obese patient is still regarded as holding a higher risk for major complications than the general population [8].
333
3 Review on Paravertebral Block (PVB)
Paravertebral nerve blockade (PVB) is an old technique that is being rejuvenated
and revisited for not only perioperative and post-operative pain relief but as a sole
anesthetic technique in many thoraco-abdominal surgeries.
Hugo Sellheim of Leipzig in 1905 was the pioneer concerning the concept
of paravertebral block, which was later refined by Lawen (1911) and Kappis
(1919) [9].
This technique was formally introduced by Eason and Wyatt (1979) with their
paper “paravertebral block-a reappraisal” [10]. However, it was really over the
last 20 years that paravertebral block generated interest initially for the patients
undergoing breast surgery, inguinal hernia repair and most recently bariatric procedures [11].
4 Anatomy
The paravertebral space in general is not well defined in anatomy books and references, it was first described however by Macintosh and Bryce Smith in their book
about local anesthesia in 1962 [12].
This space extends from T1 to the lumbar vertebral column, it is a wedge
shaped area posteriorly bounded by the superior costo-transverse ligament,
antero-laterally by the parietal pleura and medially by the posterolateral aspect of
the vertebra and intervertebral foramen (Fig. 1) [11].
The space communicates medially with the epidural space via the intervertebral
foramen and it is continuous with the intercostal space as well [10].
There are anatomical variations of the nerve in the lateral part of the space.
In some of Eason and Wyatt’s dissections the nerve was shown to divide into
multiple parts which may or may not re-join, and in one case it was seen to
deviate downwards to become an intercostal nerve running along the top of the
rib below [10].
In that space the spinal nerve root exits the intervertebral foramen to give the
dorsal and ventral rami, the sympathetic chain lies anteriorly to the intercostal
M. H. Elfawal et al.334
Fig. 1 Anatomy of the paravertebral space. [11] Source Batra RK, Krishnan K, Agarwal A.
Paravertebral block. J AnaesthesiolClinPharmacol. 2011;27(1):5–11.(11)
nerve communicating with it via the rami communicants. This explains why
blockade of that space causes, sensory and sympathetic block [13].
Also it was noted by Lönnqvist in 1992 that the paravertebral space is sealed
off caudally at the thoraco-lumbar junction by the psoas muscle, by instilling
dye via a catheter inserted in the paravertebral space at the 12th thoracic vertebrae level. This explains why the spread of the block to a level lower than T12 is
unlikely [14].
Furthermore the endothoracic fascia which lies between the parietal pleura and
the innermost intercostal muscle divides the paravertebral space into two fascial
compartments, the extra pleural compartment anteriorly and the subendothoracic
paravertebral compartment posteriorly (Fig. 2) [15].
4.1 Indication
Perioperative anesthesia or analgesia is the most frequent indication.
In anesthesia however indications are generally for breast surgery, [16–18]
inguinal hernia repair [19, 20] among other general surgeries, lithotripsy [21] and
video assisted thoracic surgeries [22].
LSG Under Block Anesthesia (PVB)
Fig. 2 Fascial compartments of the paravertebral space. [15] Source Karmakar, M. K., Kwok,
W. H., & Kew, J. (2000). Thoracic paravertebral block: Radiological evidence of contralateral
spread anterior to the vertebral bodies. British Journal of Anaesthesia, 84(2), 26.(15)
335
Single injection paravertebral blocks can be used for surgeries with mild to
moderate pain [23] such as hernioplasties and minimally invasive cardiac surgeries [24].
For minor abdominal surgeries such as prostatectomies [25], laparoscopic cholecystectomies and hysterectomies bilateral single paravertebral blocks are needed.
Alternatively, a continuous bilateral block is used for major surgeries whether
abdominal (pancreatectomy, colectomies…), cardiac or pelvic (cystectomy, hysterectomy, nephrectomies…) by placement of a PV catheter [26] (Table 1).
Table 1 Indications of paravertebral blocks and the level at which they should be performed
Continuous PVBs
Breast T1-T2 (axillary dissection) T2-T6
Esophagectomy\bariatric surgery Bilateral T2-T3 Thoracotomy including video assisted
thoracic surgery (VATS)
Liver resection Bilateral T6-T7 Umbilical hernia Bilateral T8 Bilateral T7-T9
Abdominal surgery Bilateral T8-T9 Pelvic surgery Bilateral T11-T12 T10-L1
Source Chelly, J. E. (2012). Paravertebral blocks. Anesthesiology Clin, 30, 75–90.(2-).
T4-T5 -
Single PVBs
M. H. Elfawal et al.336
Fig. 3 Lindgren needles.
[27] Source: James, C. D.,
& Bowers, J. R. (1968).
Aid to lumbar paravertebral
sympathetic block.
Anaesthesia, 23(4), 644–645
4.2 Techniques
Over time several techniques have been described concerning paravertebral block,
including: blind, nerve stimulator guided and Ultrasound guided technique.
Irrespective of the technique, first the patient needs to be properly positioned
ideally in a sitting position with his back in flexion; however it also can be performed with the patient in the lateral decubitus position especially in trauma
patients [10].
Light sedation is given prior to the block with a combination of midazolam and
fentanyl; however it could be performed with no preceding sedation [10].
The choice of needle is key, in 1968 Bryce and Bowers [27] found that
Lindgren needles (Fig. 3) which were initially used for carotid and femoral angiograms, are ideal due to their straight shaft, large bore and rigidity which allows for
an accurate placement.
However, Eason and Wyatt used a Tuohy needle, which is the needle that is
standardized for the use in paravertebral blockade (Fig. 4) [10].
4.2.1 Blind Technique
The patient should be sitting up or placed on his lateral side. After scrubbing and
cleaning the site, a skin weal is raised with local anesthetic solution 3 cm lateral
from the anatomical midline. The Tuohy needle is advanced through the wheal at
a 90 degree angle until striking the transverse process of the vertebra inferior to the
spinal process palpated at a depth of 2.5–3.5 cm. When bone is felt the needle is
redirected in a cephalad direction and advanced until passing above the transverse
process (1–1-5 cm) and do so until the superior costotransverse ligament is passed
(Fig. 5). This will manifest in loss of resistance when the needle enters areolar tissue
of the paravertebral space, the needle is then aspirated to make sure that neither the
Dural space nor the pleura nor a blood vessel has been punctured. Local anesthesia
is then administered or a catheter inserted if a prolonged block is needed [10].
LSG Under Block Anesthesia (PVB)
Fig. 4 The disposable epidural pressure measurement system. [28] Source N. Vaughan, V. N.
Dubey, M. Y. K. Wee, and R. Isaacs. Devices for accurate placement of epidural Tuohy needle for
Anaesthesia administration. Mech. Sci., 5, 1–6, 2014
337
Fig. 5 Longitudinal section to show direction of needle: (a) above, (b) below. [10] Source
Eason, M., & Wyatt, R. (1979). Paravertebral thoracic block-a reappraisal. Anaesthesia, 34(7),
638–642)