Page 101 - Hospital Authority Convention 2017

Masterclasses

M5.3 Metabolic and Bariatric Surgery in Hong Kong 14:30 Room 423 & 424

Gist of Anaesthetic Care for the Morbidly Obese
Tsui CSY
Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Hong Kong HOSPITAL AUTHORITY CONVENTION 2017
The physiological and mechanical changes of obesity and treatment must be considered after a bariatric surgery is done for a
morbidly obese patient. It is believed that the most common adverse intra-operative event in bariatric surgery is anaesthesia
related (1%).

When do we need to do an awake intubation in obesity?
How to reliably assess the presence of obesity hypoventilation syndrome?
Do we need a post-operative intensive care support for bariatric patients and what are the selection criteria?
Can they be suitably extubated post-operatively?

Anaesthetists often encounter difficulty in airway management and ventilation in obese patients. They are also prone to
develop early desaturation following apnoea, and the effect can persist long after extubation. Peri-operative sleep disordered
breathing (SDB) also poses a significant impact on the overall outcome. The method of maximising oxygenation in these
patients will be shared.
Post-operative pain and analgesia are other challenges. The impact of multimodal intra-operative analgesia will be
highlighted. Together, their differences in side effect profiles and efficacy in the treatment of post-operative surgical pain in
obesity patients will also be discussed.

Obesity is also associated with important systemic changes that can potentially affect the pharmacological profile of
anaesthetic drugs. The majority of anaesthetic drugs are strongly lipophilic and unpredictable in dosage. Recent evidence in
utilisation of various types of pharmacokinetic model to assist dosing will be reviewed. Tuesday, 16 May

Enhanced recovery after surgery (ERAS) methodology has demonstrated consistent benefits in patients undergoing
colorectal, urological and thoracic surgeries. Principles of these protocols could be applied to bariatric surgery. The
anaesthetic components in its pre-operative, intra-operative and post-operative phase will be reviewed.

M5.4 Metabolic and Bariatric Surgery in Hong Kong 14:30 Room 423 & 424

Quality Assurance – Credentialing for Safe Metabolic Surgery
Ng E
Department of Surgery, The Chinese University of Hong Kong, Hong Kong

Obesity is now an endemic condition in many parts of the world. Its associated metabolic complications such as diabetes
mellitus, hypertension and dyslipidemia can pose tremendous burden to the healthcare system. Lifestyle modification and
medications are the usual measures to deal with these chronic illnesses, but a considerable proportion of patients need more
aggressive interventions, such as bariatric/metabolic surgery, to achieve more sustainable control.
There is an increasing trend in the need of bariatric surgical service in Hospital Authority (HA) hospitals. These operations
are technically challenging because of the patients’ body appeal. Morbidities can be difficult to diagnose and manage, and
some may end up as mortality. The resulting medico-legal litigation can be detrimental to both professionals and institutes.
Based on experience in the West, accreditation and credentialing are proven effective approaches to reducing death and
complications of bariatric procedures.

As a core feature of quality in surgery, accreditation must address three aspects: structure, processes, and outcomes. In
the US, accredited centres must report their outcomes to a centralised database. They also need to meet core standard
requirements depending on the level of the centre. Low-acuity centres must perform a minimum of 25 procedures every
year in order to be accredited to perform bariatric surgery. Revisional procedures or high-risk patients are reserved for
comprehensive centres, which need to perform a minimum of 50 cases annually to be accredited. Apart from case volume,
there are other standards for accreditation: commitment to quality care, 24/7 critical care support, appropriate equipment
and instruments, data collection, and continuous quality improvement process. Credentialing of individual surgeon should
also be a key component in accreditation.
It is a high time for HA to review its stance in the development of bariatric/metabolic surgical services. A structured and well-
defined accreditation programme is highly recommended. It is of mutual benefit with enhanced patient safety and lower risk
of medico-legal litigation.

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