ANAESTHETIC ASPECTS OF IMPROVING CONDITIONS OF ENDOSCOPIC GASTRECTOMY IN PATIENTS WITH MORBID OBESITY

The  OBJECTIVE  of the  study  is  to  improve  in the  surgical  condition  of endoscopic longitudinal  gastroplasty in patients with morbid  obesity.   MATERIAL AND METHODS.  The  prospective randomized controlled   research of 68  patients  who underwent endoscopic sleeve gastroplasty. The 1st  group  (n=23)  –  neuromuscular  blockade (NMB) was  performed  by bolus  injection  of rocuronium, the  patients on  the  operating table  were  in a  flat position.  The  2nd  group  (n=23)  –  NMB was   maintained  by  intravenous  infusion   of  rocuronium, patients  on  the   operating  table   were   in  the   Trendelenburg position.  The  3rd  group  (n=22)  –  basic  anesthesia in combination with prolonged epidural  analgesia (PEA),  NMB were maintained at  a  deep level  by  intravenous infusion  of rocuronium, patients  on  the  operating table  were  in the  «beach chair»   position.   Neuromuscular  monitoring,   monitoring   of  central   and   peripheral hemodynamics  were   performed. The elasticity  of the  anterior  abdominal wall (E), intra-abdominal pressure (IAP), intra-abdominal volume  (IAV) were  calculated. RESULTS.   During  the  analysis of  the  dynamics of  the  average level  of  intra-abdominal volume  and  pressure, it was found  that  the  mean IAV level  in the  3rd  group was significantly higher at all stages of the study than in the 1st  and the 2nd  groups, and  the  IAP level  was  significantly  lower  in the  3rd  group at all stages of the study than in the 1st  and the 2nd  groups. CONCLUSION.  The  maintaining of  muscle  relaxation at  a  deep level  under   the  regime   of  continuous infusion,  the  inclusion  of ropivacaine in the  anesthetic  regimen of PEA,  the  use   of the  «beach chair»  position  for the patient   on  the  operating table  contribute to  the  improvement of  surgical   condition  during  the  endoscopic  gastrectomy in  patients with  morbid  obesity.

1. Vasan R. S., Pencina M. J., Cobain M. et al. Estimated risks for developing obesity in the Framingham Heart Study // Ann. Intern. Med. 2005. № 143 (7). P. 473–480.

2. Intra-abdominal pressure and the morbidly obese patients : the effect of body mass index / A. Wilson, J. Longhi, C. Goldman, S. McNatt // J. Trauma. 2010. № 69 (1). P. 78–83.

3. Norum H. M., Breivik H. Thoracic paravertebral blockade and thoracic epidural analgesia : two extremes of a continuum // Anesth. Analg. 2011. № 112 (4). P. 990–991.

4. Ginosar Y., Weiniger C. F., Meroz Y. et al. Pulse oximeter perfusion index as an early indicator of sympathectomy after epidural anesthesia // Acta Anaesthesiol Scand. 2009. № 53 (8). P. 1018–1026.

5. Constantine T. Frantzides. Laparoscopic and Thoracoscopic Surgery. St. Louis, Missoury. Mosby-Year Book, Inc., 1995. 275 p.

6. van Ramshorst G. H., Salih M., Hop W. C. et al. Noninvasive assessment of intra-abdominal pressure by measurement of abdominal wall tension // J. Surg. Res. 2011. № 171 (1). P. 240–244.

7. Reintam Blaser A., Malbrain M. L., Starkopf J. et al. Gastrointestinal function in intensive care patients: terminology, definitions and management. Recommendations of the ESICM Working Group on Abdominal Problems // Intensive Care Med. 2012. № 38 (3). P. 384–394.

8. Anisimov M. A., Gorobec E. S., Jakushina I. A. Jeffektivnaya anesteziya pri vypolnenii onkoginekologicheskikh operacii u pacientok s soputstvujushhim morbidnym ozhireniem // Vestnik anesteziologii i reanimatologii. 2015. № 6. P. 46–52.

9. Ovechkin A. M. Klinicheskaya farmakologiya mestnykh anestetikov: klassicheskie predstavleniya I novye perspektivy primeneniya v intensivnoj terapii // Regionarnaya anesteziya i lechenie ostrojboli. 2013. № 5 (3). P. 6–16.

10. Jepshtejn S. A. Perioperacionnoe anesteziologicheskoe obespechenie bol’nyh s morbidnym ozhireniem // Regionarnaja anestezija i lechenie ostroj boli. 2012. № 4 (3). P. 5–27.

11. De Bel M., Jaumain M., Cantraine F. et al. EMG response in profound neuromuscular block : Stimulation artifact or direct stimulation? // Eur. J. Anaesthesiol. 2010. № 27 (47). P. 62.

12. Barrio J., San Miguel G., Carrion J. L. Does profound neuromuscular block improve abdominal compliance in laparosocpic surgery? // Eur. J. Anaesthesiol. 2013. № 30 (51). P. 146.

13. Mulier J. P., Dillemans B., Van Cauwenberge S. Impact of the patient’s body position on the intraabdominal workspace during laparoscopic surgery // Surg. Endosc. 2010. № 24. P. 1398–1402.