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Year : 2022  |  Volume : 16  |  Issue : 4  |  Page : 444-451

Pediatric obesity and anesthetic challenges of metabolic surgery

1 Department of Anesthesia, Critical Care, and Pain Management, Faculty of Medicine, Ain Shams University (ASU), Cairo, Egypt
2 Department of Surgery King, Salman International University, Mostafa, El Tor, South Sinai, Egypt
3 Dow Medical College, Karachi, Pakistan
4 Department of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University Health Sciences Center, Shreveport, LA, United States

Correspondence Address:
Ahmed Hashim
Faculty of Medicine, Ain Shams University (ASU), Cairo
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sja.sja_469_22

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Date of Submission27-Jun-2022
Date of Decision20-Jul-2022
Date of Acceptance27-Aug-2022
Date of Web Publication03-Sep-2022


Obesity in the pediatric population is considered a growing problem. It is likely that there will be a significant impact related to obesity on the health of future generations. Obesity has increased the incidence of a spectrum of diseases ranging from microvascular complications over the retina and peripheral nerves to an increased incidence of cancer. We have conducted an electronic search in MEDLINE, PubMed, ISI Web of Science, and Scopus scientific databases targeting studies published between 2000 till 2019. Several modalities have shown a wide spectrum of the effectiveness of weight control among adolescents. Despite achieving short-term success among obese adolescents, maintaining such change is challenging. The emergence of metabolic or bariatric surgeries has opened the door for long-term control over weight gain with considerable remission of unfavorable metabolic mediated or modulated effects associated with obesity such as diabetes mellitus and hypertension. The most commonly practiced metabolic surgery among adolescents is sleeve gastrectomy which is associated with comparable weight and metabolic control and a lesser risk of complication. Anesthesia is considered a major challenge among the pediatric population, especially those with significant obesity. Preoperative evaluation is always warranted to exclude and manage different associated comorbidities. The anesthetic challenges associated with pediatric obesity begin with intubation. Maintenance and emergence from anesthesia along with postoperative antiemetics and analgesia can pose additional challenges. Managing the postoperative period is considered a cornerstone in the early detection and management of any postoperative complication. Especially those complications related to the metabolic and nutritional aspects of the bariatric surgery. Finally, despite being a valuable option in managing obesity, bariatric surgery in adolescents comes with significant anesthetic challenges that need to be consistently evaluated and managed.

Keywords: Pediatric anesthesia, pediatric diabetes, pediatric obesity

How to cite this article:
Hashim A, Sedky MK, Masood W, Shehata IM, Kaye AD. Pediatric obesity and anesthetic challenges of metabolic surgery. Saudi J Anaesth 2022;16:444-51

How to cite this URL:
Hashim A, Sedky MK, Masood W, Shehata IM, Kaye AD. Pediatric obesity and anesthetic challenges of metabolic surgery. Saudi J Anaesth [serial online] 2022 [cited 2022 Dec 1];16:444-51. Available from:

  Introduction Top

Obesity is a multifactorial disease with multiple interconnections with many other prevalent conditions.[1] Since 1980, the prevalence of obesity has doubled, with about one-third of the world population now classified as obese or overweight.[2] Obesity has been connected to multiple health-related conditions, including cardiovascular incidents, diabetes mellitus, cancer, and many other pathophysiological processes.[3],[4] Additionally, obesity carries a significant economic burden on afflicted families. In the US, it has been estimated that health costs incurred by a single obese individual are US$1,901 per annum in 2014.[5] Besides affecting adults, obesity is a growing problem in the pediatric population.[6] A recent National Health and Nutrition Examination Survey revealed the prevalence of obesity among the pediatric population is about 18%.[7] In this regard, Ahmad et al.[8] have demonstrated that most adolescents aged (10 to 14 years) are at risk of remaining obese as adults.

The emergence of metabolic surgeries has led to both enhancing and accelerating weight and breaking the endocrinal vicious circle of obesity.[9] Currently, bariatric or metabolic surgery (BS) is considered the most effective long-term therapy for severely obese patients (grade II) with associated metabolic diseases and for morbidly and super morbidly obese patients (grades III-IV).[10] Despite being an effective approach to treating obesity and its metabolic complications, BS remains a significant challenge among pediatric populations.[11] In the following review, therefore, we describe anesthetic considerations raised in the context of metabolic surgeries among the pediatric population.

  Material and Methods Top

Literature search

Relevant literature reporting the interventions for controlling excess weight in children and adolescents was identified through an electronic search of papers published from 2000 to 2019 in MEDLINE, PubMed, ISI Web of Science, and Scopus. Keywords such as “childhood obesity”, “overweight,” “weight disorder,” “intervention,” “treatment,” “management,” “nutrition,” “behavior therapy,” and “diet therapy” were used.

Study selection

Having removed duplicates, the relevant papers were selected in three phases. In the first and second phases, titles and abstracts of papers were screened and irrelevant papers were excluded. In the last phase, the full text of recruited papers was explored deeply to select only relevant papers. Discrepancies were resolved by consultation and consensus.

  Bariatric Surgery Options in Pediatrics Top

Bariatric procedures are divided into two broad categories, Restrictive (e.g., laparoscopic adjustable gastric band, LAGB, and Sleeve gastrectomy, SG) and Malabsorptive procedures, or a combination of both (e.g., Roux-en-Y gastric bypass, RYGB).[12] SG, RYGB, and LAGB are the most common operations among adolescents seeking metabolic surgery options. However, the Food and Drug Administration has concluded that adjustable bands should not be used as a surgical option in obese patients below the age of 18 years.[13]

SG is considered one of the commonest, if not the commonest, bariatric surgery for adults or adolescents nowadays.[14] It entails the removal of most (80–90%) of the greater curvature of the stomach, which leaves a tubular remnant stomach about 10 to 15% of its original size.[15] The SG has gained popularity as one of the safest options among different bariatric procedures related to its technical simplicity and a lesser spectrum of complications compared to RYGB. Additionally, it has near-equivalent weight loss and efficiency regarding comorbidities to RYGB, with fewer revision surgeries and better nutrient absorption.[16] Alqahtani et al.[17] have demonstrated no major complications and a low rate of minor complications (4.3%) in both short- and middle-term outcomes.

In comparison to SG, RYGB is considered a valid alternative to SG in adolescent and pediatric populations. Inge et al.[18] have demonstrated that adolescents have remission of diabetes and hypertension more often than adults on a five-year follow-up period. In a Swedish national analysis, Olbers et al.[19] have demonstrated a significant decrease in cardiovascular complications of adolescent participants; however, increasing costs on the rate of additional surgical interventions and nutritional deficiencies.

  Comorbidities of Pediatric Obesity Top

Obesity has always been marked by a higher incidence of multiple underline organ dysfunction. Similarly, pediatric obesity brings significant consequences. Childhood obesity is potentially associated with devastating comorbidities, including diabetes mellitus type 2 (DM 2), coronary artery diseases (CADs), hypertension, obstructive sleep apnea (OSA), nonalcoholic fatty liver disease (NAFLD), and metabolic syndrome that may progress later in life.[20],[21] Certain correlated diseases such as OSA, respiratory, and cardiovascular disorders in obese pediatric patients represent the most difficulties associated with anesthetic and surgical procedures.

Obstructive sleep apnea (OSA)

OSA is a sleep disorder characterized by a degree of respiratory cessation, which is usually accompanied by sleep disruption, hypoxemia, arrhythmias, and arterial oxygen desaturation.[22],[23] OSA prevalence ranges from around 35-75% in obese children.[24] Although the exact cause is unknown, studies have shown that obesity contributes to OSA by anatomical narrowing by redundant soft tissues, including the tongue, soft palate, and pharyngeal wall. OSA may also be caused by abnormal neuromuscular tone.[25],[26] These anatomical changes represent a substantial difficulty for any anesthesiologist during endotracheal intubation.[27]

Respiratory intricacies of pediatric obesity

Pediatric obesity has long been recognized as having substantial consequences on the respiratory system secondary to an alteration in the metabolic rate proportional to body mass index.[28] Adiposity also precipitates changes in both lungs and chest wall secondary to the fat deposition that will eventually lead to a picture similar to restrictive lung diseases.[29] Thus, altering the effectiveness of apneic oxygenation (AO) and increasing respiratory impedance during tracheal intubation.[30]

Cardiovascular complications

The global prevalence of cardiovascular system complications among the pediatric age group has been potentially linked to obesity.[31] Increased cardiac output and blood volume secondary to increased bodily demand causes a persistent increase in heart workload, eventually leading to left ventricular hypertrophy (LVH).[32],[33] The long-living LVH, together with chronically high vascular resistance, maybe later be complicated by cor-pulmonale, magnifying the cardiovascular-associated adverse events within any anesthetic protocol. Moreover, metabolic syndrome has been thoroughly linked to cardiovascular events in the obese pediatric population. The metabolic syndrome includes insulin resistance, dyslipidemia, hypertension, nonalcoholic fatty liver disease, and proinflammatory syndrome.[34]

  Preoperative Assessment of the Pediatric Population Top

It is important to consider the ethics related to bariatric surgery in the pediatric population.[34] The managing team must ensure that no other acceptable medical intervention can treat or reverse the patient's obesity-related medical condition, except for the surgical interference.[35] The medical team should treat patients based on beneficence, no maleficence, autonomy, and justice.[36]

Besides ethical concerns, many associated medical considerations may change or halt any bariatric procedure. Meticulous preoperative assessment of the adolescent is essential to ensure effective and safe bariatric intervention.[37] Pratt et al.[37] have addressed multiple parameters to be examined before arranging a bariatric intervention, including Laboratory studies, Cardiac, Pulmonary, and Gastrointestinal function, and the ability of postoperative compliance and psychological status. Moreover, the nutritional assessment is important to detect the baseline micronutrient deficiency, which is common in the pediatric population and may have an adverse consequence on the composite outcome.[38] An extension of the nutritional panel has been recommended to include thiamin (B1), vitamin B12, and B6, calcium, parathyroid hormone (PTH), alkaline phosphatase, vitamins A, D, E, and K, phosphorus, magnesium, copper, and zinc.[16],[39]

Besides the basic metabolic pattern, cardiac function should be thoroughly examined before the bariatric procedure. Many obese children suffer from a wide spectrum of cardiovascular comorbidities ranging from hypertension (HTN) to arrhythmia.[38] Schlottmann et al.[40] have demonstrated that properly controlling the associated cardiac comorbidities is essential for proper postoperative outcomes. The proper cardiac evaluation may include medical history, physical examination, and a 12-lead electrocardiogram. Together with preoperative cardiac concerns, OSA is associated with increased mortality and postoperative adverse outcomes following bariatric procedures.[41] Preoperative detection of OSA is crucial before any surgical procedures requiring general anesthesia or even sedation. OSA can increase the risk of intraoperative hypoxemia, hypercapnia, atelectasis, laryngospasm, and the need for reintubation.[42]

Interestingly, one of the essential preoperative steps is the assessment of the feasibility of the patient and family compliance with the postoperative follow-up. The postoperative follow-up aims to monitor weight loss and any remission of the associated metabolic comorbidities.[43] Additionally, the preoperative dedication to compliance with the follow-up is essential for the early detection and management of any micro- or micronutrient deficiency.[44]

  Anesthetic Challenges Top

Despite recent advances in anesthesiology, pediatric obesity is still a signicant challenge facing anesthesiologists. Pediatric anesthesia is associated with a significant risk of morbidity and mortality because obese children are more difficult to ventilate, to intubate, and to cannulate. Futher, pediatric obesity also complicates anesthesic drug dosage calculations. Anatomical and pharmacological issues are caused by a short neck, increased subcutaneous fat, and unpredictable pharmacokinetics of drugs. Moreover, the pediatric populations are at high risk of developing laryngospasm on extubation and morbidly obese patients are liable to obstruction.[30],[45],[46]

Obtaining vascular access and fluid management

Recent research has shown that obese children often require multiple attempts to obtain successful venous access.[47] A high-frequency linear ultrasound probe has also been tried for obtaining venous and arterial access and showed a significant increase in the success rates of the first cannulation attempt to 85.78%.[48] Invasive arterial blood pressure monitoring is only needed in pediatric bariatric surgery in case of significant hemodynamic instability or inaccurate measurement of non-invasive blood pressure monitor due to patient position.[49] Alimian et al.[50] have compared liberal vs. restrictive fluid management in bariatric surgeries and showed no difference in the effect of both kinds of fluid management. Still, only one study proved that liberal fluids administration is associated with a lower risk of acute kidney injury.

  Airway Management Top

Proper airway assessment to predict difficulty in intubation and/or ventilation is an essential step in preparation for such a challenging case in anesthesia. Mallampati score has always been the cornerstone in predicting difficult ventilation or intubation. It has a sensitivity of 53% to predict difficult intubation and 17% to detect difficult ventilation.[51] However, it is difficult to properly assess the pediatric population due to a lack of cooperation.

The role of ultrasound

Studies conducting the role of ultrasound to predict difficult ventilation or difficult intubation have shown some contradicting results. One study showed that measuring the distance between the skin and the vocal cords or the suprasternal notch is highly predictive of difficult intubation.[52] Another study showed that the distance between the skin and the thyrohyoid membrane is also predictive of difficult intubation.[53] On the other side of the coin, Alessandri et al.[54] could not find a statistically significant difference between measuring the distance between skin and hyoid or skin and epiglottis in predicting difficult intubation. Furthermore, ultra-sound can be used to confirm the size of ETT required for intubation by the accuracy of 88 to 100% compared to 35% for age-based formula (i.e., age/4 + 4) in non-cuffed ETT, or 60% in case of cuffed ETT.[55] Other studies found that the overall accuracy of the age-based formula is as low as 27%.[56] Moreover, distance from the skin to the epiglottis can successfully predict difficult bag-mask ventilation.[54]

Confirmation of intubation

Anesthesiologists use several methods to confirm endotracheal intubation.[57] Auscultation of bilateral air entry in lungs,[58],[59] tube misting,[60] or self-inflating tube bulbs[61] proved to be unreliable.[62] Therefore, more objective methods like capnography[63] and ultrasound to confirm intubation should decrease the adverse events.

The anesthesiologist can use the ultrasound either with a static method by injecting the tube cuff with saline for visualization or by the dynamic method using an ultrasound scan during the intubation procedure with a sensitivity reaching 100%.[64],[65],[66],[67] Depth of intubation is essential as misplacement can lead to either barotrauma or dislodgement of the tube. Traditionally, Borselow tape equation was used in pediatric patients to verify the depth of intubation followed by lung auscultation.[68] The pitfall in Borselow is that the anatomy is not typical in all individuals, and x-ray can be time-consuming.[69] Recent studies showed that ultrasound is a more sensitive and specific way to evaluate intubation depth.[70]

Difficult intubation

The difficult airway society produced a stepwise algorithm for managing difficult pediatric airways.[71] In contrast to difficult adult intubation, where awake intubation is the gold standard, the pediatric population does not show cooperation for such a technique. However, modified awake intubation with topicalization of the airway and insertion of the supraglottic device may help in cases like the Pierre Robin sequence.[72] Video laryngoscopy or flexible bronchoscopy shall be ready for use in anticipated difficult cases.[73]


When it comes to ventilation, Sevdi et al.[74] showed no statistical difference in efficacy between pressure-controlled ventilation and volume-controlled ventilation in pediatric bariatric surgery regarding acid-base status, respiratory function tests, post-op, fluid intake, urine output, pain score, and rate of complications.

Anesthesia regimen

Calculating the doses of anesthetic drugs in obese children is still a dilemma.

Lean body mass is commonly used for dose calculation, as in propofol.[75] The intubation dose of succinylcholine is calculated based on the total body weight.[76] However, normal fat mass (based on allometric theory and partition of body mass into fat and fat-free components) may provide a better relationship between the size and body composition effects on the pharmacokinetics of all drugs.[77] Many smartphone applications are implemented in pediatric anesthesia to help in dose calculation and distraction of the patients on induction.[78]

Regarding anesthesia maintenance, sevoflurane and desflurane have comparable efficacy, but both have higher efficacy and faster emergence than isoflurane. Moreover, desflurane has more rapid emergence and return to normal recognition reducing the risk of undesirable postoperative delirium.[79] Due to the unpredictable pharmacokinetics of drugs in pediatric obese patients, total intravenous anesthesia TIVA was not the method of choice.[80] However, with EEG-based monitoring, the proper understanding of pharmacology, and the availability of advances in equipment, TIVA has become an attractive option.[81]

Anesthetic adjuvant as alpha 2 agonist dexmedetomidine reduces the risk for postoperative delirium.[80] The The ED95 values of dexmedetomidine for pediatric sedation infused over 10 min are 0.75 and 0.74 μg kg−1 with and without obesity, respectively, based on total body weight.[82]


Opioid-sparing analgesia is the most appropriate approach for performing bariatric surgery on obese children as they have increased opioid sensitivity, increased risk of obstructive sleep apnea syndrome, and decreased bowel function in the immediate postoperative period. Epidural catheters devoid of opioids can relieve pain postoperatively.[83],[84] Although transverses abdominal plane block is commonly used post-laparoscopic surgeries, Albrecht et al.[85] showed that it does not improve pain scores or reduce opioid consumption. Non-steroidal anti-inflammatory drugs (NSAID) are another opioid-sparing plan used to relieve visceral and inflammatory effects.[86],[87],[88],[89] Further research needs to be done on the pharmacokinetics of NSAIDs in obese pediatric patients due to the lack of information.[90] The most commonly prescribed analgesia in the pediatric population is acetaminophen. Research on pediatric obese patients with NAFLD showed upregulation of cp450 – 2E1 with an increased risk of increased production of hepatotoxic metabolites.[91] Pediatric bariatric surgery patients are at increased risk of postoperative nausea and vomiting, which may require multimodal antiemesis.[80]

  Postoperative Considerations in Pediatric Bariatric Surgery Top

Bariatric surgery, considered among the most life-modifying surgeries, requires adequate postoperative care for long-lasting and enduring outcomes. Postoperative care involves active monitoring and bodily inspection to prevent post-surgical stress response of organs and ensure a thorough amelioration of health.[92] Like any other medical intervention, pain management in pediatric bariatric surgery needs the earliest supervision.[93] The medical team needs to perform adequate measures to scale pain intensity and restrain it by properly administering analgesics.[94] Besides this, the medical team should be attentive to the early postoperative period's comprehensive metabolic panel (CMP).[95] The multidisciplinary team may order CMP under preoperative comorbidities to diagnose any irregularities in basic blood tests following the bariatric surgery.[96]

Respiratory problems are early postoperative complications following bariatric surgery.[96] Gupta et al.[97] evaluated the prevalence of postoperative pneumonia (PP) and respiratory failure (PRF) following bariatric surgery. They found that they account for one-fifth of complications accompanied by the delay in the discharge of patients and eventually death. Pulmonary complications resulting from pneumoperitoneum and inappropriate patient positioning require proper consideration by a multidisciplinary team.[98],[99] Using non-invasive positive-pressure ventilation (NIPPV) preoperatively can subsequently reduce the risk of postoperative hypoxemia by preoxygenation delaying the desaturation.[100] Apart from this, research has shown that prompt ambulation in a postoperative intensive care unit can cause a significant reduction in complications and reduce the length of hospitalization.[101]

Besides the pulmonary complications, dumping syndrome is a frequent complication of bariatric surgery.[102] Dumping syndrome typically occurs after one hour of the meal and involves gastrointestinal disturbances that include nausea, vomiting, abdominal pain, and bloating associated with tachycardia, hypoglycemia, and diaphoresis.[96],[102] Dumping syndrome in adolescents following bariatric surgery can make them more susceptible to frustration and post-surgery depression, impacting their quality of life.[103] However, the symptoms can be effectively managed by pharmaceutical formulations and proper guidance on meal proportions.[96]

It has been reported in various research studies that bariatric surgery in adolescents makes them highly vulnerable to nutritional deficiencies in the future as compared to adults.[104],[105] Bariatric surgeries accelerate gastric pouch emptying and reduce gastric secretions and intestinal absorption, thus interrupting the nutritional status.[106] Olber et al.[19] assessed the long-term nutritional complication in adolescents and found that 32-46% of patients predominantly suffered from iron deficiency anemia within five years. Other nutritional deficiencies include 16-22% for vitamin B12 and around 3-78% for vitamin D. Thus, it is crucially important for the multidisciplinary team to monitor nutritional profiles annually and prescribe suitable supplements to cater to any nutritional deficiencies in the future.[104]

  Conclusion Top

Childhood obesity is a prevailing condition associated with multiple comorbidities. Bariatric surgery is one of the therapeutic protocols for childhood obesity. One of the most challenging aspects of pediatric bariatric surgery is the anesthesia. Ultrasound can be of great value in predicting difficult intubation, confirming endotracheal tube placement, and obtaining vascular access. There is no significant difference in efficacy between volume-controlled ventilation and pressure-controlled ventilation. Liberal fluid therapy may be preferred over restrictive fluid therapy to prevent acute kidney injury. Opioid-sparing analgesia shall be used, including epidural catheters devoid of opioids. NSAID can be used in analgesia, but further research must be done on the drug's pharmacokinetics in obese children due to a lack of information. Meticulous preanesthetic evaluation and careful airway management plan are crucial to providing safe pediatric anesthesia.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Chooi YC, Ding C, Magkos F. The epidemiology of obesity. Metabolism 2019;92:6-10.  Back to cited text no. 1
GBD 2015 Obesity Collaborators, Afshin A, Forouzanfar MH, Reitsma MB, Sur P, Estep K, et al. Health effects of overweight and obesity in 195 countries over 25 years. N Engl J Med 2017;377:13-27.  Back to cited text no. 2
Singh GM, Danaei G, Farzadfar F, Stevens GA, Woodward M, Wormser D, et al. The age-specific quantitative effects of metabolic risk factors on cardiovascular diseases and diabetes: A pooled analysis. PLoS One 2013;8:e65174.  Back to cited text no. 3
Lauby-Secretan B, Scoccianti C, Loomis D, Grosse Y, Bianchini F, Straif K, et al. Body fatness and cancer--viewpoint of the IARC working group. N Engl J Med 2016;375:794-8.  Back to cited text no. 4
Kim DD, Basu A. Estimating the medical care costs of obesity in the United States: Systematic review, meta-analysis, and empirical analysis. Value Health 2016;19:602-13.  Back to cited text no. 5
Kumar S, Kelly AS. Review of childhood obesity: From epidemiology, etiology, and comorbidities to clinical assessment and treatment. Mayo Clin Proc 2017;92:251-65.  Back to cited text no. 6
Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of Obesity Among Adults and Youth: United States, 2015–2016. NCHS data brief, no 288. Hyattsville, MD: National Center for Health Statistics. NCHS Data Brief [Internet] 2017;(288):1–8. Available from: [Lat accessed on 2022 Jun 25].  Back to cited text no. 7
Ahmad QI, Ahmad CB, Ahmad SM. Childhood obesity. Indian J Endocrinol Metab 2010;14:19-25.  Back to cited text no. 8
Cornejo-Pareja I, Clemente-Postigo M, Tinahones FJ. Metabolic and endocrine consequences of bariatric surgery. Front Endocrinol (Lausanne) 2019;10:626. doi: 10.3389/fendo. 2019.00626.  Back to cited text no. 9
Salas-Salvadó J, Rubio MA, Barbany M, Moreno B, Grupo Colaborativo de la SEEDO. [SEEDO 2007 Consensus for the evaluation of overweight and obesity and the establishment of therapeutic intervention criteria]. Med Clin (Barc) 2007;128:184-96; quiz 1 P following 200.  Back to cited text no. 10
Brenn BR. Anesthesia for pediatric obesity. Anesthesiol Clin North Am 2005;23:745-64.  Back to cited text no. 11
Kang JH, Le QA. Effectiveness of bariatric surgical procedures: A systematic review and network meta-analysis of randomized controlled trials. Medicine (Baltimore) 2017;96:e8632. doi: 10.1097/MD.0000000000008632.  Back to cited text no. 12
Thenappan A, Nadler E. Bariatric surgery in children: Indications, types, and outcomes. Curr Gastroenterol Rep 2019;21:24.  Back to cited text no. 13
Koh CY, Inaba CS, Sujatha-Bhaskar S, Hohmann S, Ponce J, Nguyen NT. Laparoscopic adjustable gastric band explantation and implantation at academic centers. J Am Coll Surg 2017;225:532-7.  Back to cited text no. 14
Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013;23:427-36.  Back to cited text no. 15
Pratt JSA, Browne A, Browne NT, Bruzoni M, Cohen M, Desai A, et al. ASMBS pediatric metabolic and bariatric surgery guidelines, 2018. Surg Obes Relat Dis 2018;14:882-901.  Back to cited text no. 16
Alqahtani A, Elahmedi M, Alqahtani YA, Al-Darwish A. Endoscopic sleeve gastroplasty in 109 consecutive children and adolescents with obesity: Two-year outcomes of a new modality. Am J Gastroenterol 2019;114:1857-62.  Back to cited text no. 17
Inge TH, Courcoulas AP, Jenkins TM, Michalsky MP, Brandt ML, Xanthakos SA, et al. Five-year outcomes of gastric bypass in adolescents as compared with adults. N Engl J Med 2019;380:2136-45.  Back to cited text no. 18
Olbers T, Beamish AJ, Gronowitz E, Flodmark C-E, Dahlgren J, Bruze G, et al. Laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity (AMOS): A prospective, 5-year, Swedish nationwide study. Lancet Diabetes Endocrinol 2017;5:174-83.  Back to cited text no. 19
Mărginean CO, Meliţ LE, Ghiga DV, Mărginean MO. Early inflammatory status related to pediatric obesity. Front Pediatr 2019;7:241. doi: 10.3389/fped. 2019.00241.  Back to cited text no. 20
Malhotra S, Sivasubramanian R, Singhal V. Adult obesity and its complications: A pediatric disease? Curr Opin Endocrinol Diabetes Obes 2021;28:46-54.  Back to cited text no. 21
Working Group of Chinese Guideline for the Diagnosis and Treatment of Childhood OSA, Subspecialty Group of Pediatrics, Society of Otorhinolaryngology Head and Neck Surgery, Chinese Medical Association, Subspecialty Group of Respiratory Diseases, Society of Pediatrics, Chinese Medical Association, Society of Pediatric Surgery, Chinese Medical Association, Editorial Board of Chinese Journal of Otorhinolaryngology Head and Neck Surgery. [Chinese guideline for the diagnosis and treatment of childhood obstructive sleep apnea (2020)]. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2020;55:729-47.  Back to cited text no. 22
Andersen IG, Holm J-C, Homøe P. Obstructive sleep apnea in obese children and adolescents, treatment methods and outcome of treatment - A systematic review. Int J Pediatr Otorhinolaryngol 2016;87:190-7.  Back to cited text no. 23
Bin-Hasan S, Katz S, Nugent Z, Nehme J, Lu Z, Khayat A, et al. Prevalence of obstructive sleep apnea among obese toddlers and preschool children. Sleep Breath 2018;22:511-5.  Back to cited text no. 24
Roche J, Gillet V, Perret F, Mougin F. Obstructive sleep apnea and sleep architecture in adolescents with severe obesity: Effects of a 9-month lifestyle modification program based on regular exercise and a balanced diet. J Clin Sleep Med 2018;14:967-76.  Back to cited text no. 25
Timmerman M, Basille D, Basille-Fantinato A, Baud ME, Rebibo L, Andrejak C, et al. Short-term assessment of obstructive sleep apnea syndrome remission rate after sleeve gastrectomy: A cohort study. Obes Surg 2019;29:3690-7.  Back to cited text no. 26
Rudra A, Chatterjee S, Das T, Sengupta S, Maitra G, Kumar P. Obstructive sleep apnoea and anaesthesia. Indian J Crit Care Med 2008;12:116-23.  Back to cited text no. 27
[PUBMED]  [Full text]  
Mafort TT, Rufino R, Costa CH, Lopes AJ. Obesity: Systemic and pulmonary complications, biochemical abnormalities, and impairment of lung function. Multidiscip Respir Med 2016;11:28.  Back to cited text no. 28
di Palmo E, Filice E, Cavallo A, Caffarelli C, Maltoni G, Miniaci A, et al. Childhood obesity and respiratory diseases: Which link? Children (Basel) 2021;8:177. doi: 10.3390/children8030177.  Back to cited text no. 29
Tait AR, Voepel-Lewis T, Burke C, Kostrzewa A, Lewis I. Incidence and risk factors for perioperative adverse respiratory events in children who are obese. Anesthesiology 2008;108:375-80.  Back to cited text no. 30
Ho TF. Cardiovascular risks associated with obesity in children and adolescents. Ann Acad Med Singap 2009;38:48-9.  Back to cited text no. 31
Murphy MO, Huang H, Bauer JA, Schadler A, Makhoul M, Clasey JL, et al. Impact of pediatric obesity on diurnal blood pressure assessment and cardiovascular risk markers. Front Pediatr 2021;9:596142. doi: 10.3389/fped. 2021.596142.  Back to cited text no. 32
Genoni G, Menegon V, Secco GG, Sonzini M, Martelli M, Castagno M, et al. Insulin resistance, serum uric acid and metabolic syndrome are linked to cardiovascular dysfunction in pediatric obesity. Int J Cardiol 2017;249:366-71.  Back to cited text no. 33
Boudreaux AM, Tilden SJ. Ethical dilemmas for pediatric surgical patients. Anesthesiol Clin North Am 2002;20:227-40.  Back to cited text no. 34
Caniano DA. Ethical issues in pediatric bariatric surgery. Semin Pediatr Surg 2009;18:186-92.  Back to cited text no. 35
Boles RE, Moore JM, Glover JJ. The role of ethics consultation in decision making for bariatric surgery in pediatrics. Semin Pediatr Surg 2020;29:150884. doi: 10.1016/j.sempedsurg. 2020.150884.  Back to cited text no. 36
Pratt JSA, Roque SS, Valera R, Czepiel KS, Tsao DD, Stanford FC. Preoperative considerations for the pediatric patient undergoing metabolic and bariatric surgery. Semin Pediatr Surg 2020;29:150890. doi: 10.1016/j.sempedsurg. 2020.150890.  Back to cited text no. 37
Mirensky TL. Bariatric surgery in youth. Endocrinol Metab Clin North Am 2016;45:419-31.  Back to cited text no. 38
Fullmer MA, Abrams SH, Hrovat K, Mooney L, Scheimann AO, Hillman JB, et al. Nutritional strategy for adolescents undergoing bariatric surgery: Report of a working group of the Nutrition Committee of NASPGHAN/NACHRI. J Pediatr Gastroenterol Nutr 2012;54:125-35.  Back to cited text no. 39
Schlottmann F, Nayyar A, Herbella FAM, Patti MG. Preoperative Evaluation in Bariatric Surgery. J Laparoendosc Adv Surg Tech A 2018;28:925-9.  Back to cited text no. 40
De Jong A, Verzilli D, Geniez M, Chanques G, Nocca D, Jaber S. [Why is the morbidly obese patient at high risk of anesthetic complications?]. Presse Med 2018;47:453-63.  Back to cited text no. 41
Koeck ES, Barefoot LC, Hamrick M, Owens JA, Qureshi FG, Nadler EP. Predicting sleep apnea in morbidly obese adolescents undergoing bariatric surgery. Surg Endosc 2014;28:1146-52.  Back to cited text no. 42
Inge TH, Krebs NF, Garcia VF, Skelton JA, Guice KS, Strauss RS, et al. Bariatric surgery for severely overweight adolescents: Concerns and recommendations. Pediatrics 2004;114:217-23.  Back to cited text no. 43
Kim HJ, Madan A, Fenton-Lee D. Does patient compliance with follow-up influence weight loss after gastric bypass surgery? A systematic review and meta-analysis. Obes Surg 2014;24:647-51.  Back to cited text no. 44
Samuels PJ. Anesthesia for adolescent bariatric surgery. Int Anesthesiol Clin 2006;44:17-31.  Back to cited text no. 45
Maxwell BG, Ingrande J, Rosenthal DN, Ramamoorthy C. Perioperative management of the morbidly obese adolescent with heart failure undergoing bariatric surgery. Paediatr Anaesth 2012;22:476-82.  Back to cited text no. 46
Nafiu OO, Burke C, Cowan A, Tutuo N, Maclean S, Tremper KK. Comparing peripheral venous access between obese and normal weight children. Paediatr Anaesth 2010;20:172-6.  Back to cited text no. 47
Samoya SW. Real-time ultrasound-guided peripheral vascular access in pediatric patients. Anesth Analg 2010;111:823-5.  Back to cited text no. 48
Hsia DS, Fallon SC, Brandt ML. Adolescent bariatric surgery. Arch Pediatr Adolesc Med 2012;166:757-66.  Back to cited text no. 49
Alimian M, Mohseni M, Moradi Moghadam O, Seyed Siamdoust SA, Moazzami J. Effects of liberal versus restrictive fluid therapy on renal function indices in laparoscopic bariatric surgery. Anesth Pain Med 2020;10:e95378.  Back to cited text no. 50
Bair AE, Caravelli R, Tyler K, Laurin EG. Feasibility of the preoperative Mallampati airway assessment in emergency department patients. J Emerg Med 2010;38:677-80.  Back to cited text no. 51
Ezri T, Gewürtz G, Sessler DI, Medalion B, Szmuk P, Hagberg C, et al. Prediction of difficult laryngoscopy in obese patients by ultrasound quantification of anterior neck soft tissue. Anaesthesia 2003;58:1111-4.  Back to cited text no. 52
Adhikari S, Zeger W, Schmier C, Crum T, Craven A, Frrokaj I, et al. Pilot study to determine the utility of point-of-care ultrasound in the assessment of difficult laryngoscopy. Acad Emerg Med 2011;18:754-8.  Back to cited text no. 53
Alessandri F, Antenucci G, Piervincenzi E, Buonopane C, Bellucci R, Andreoli C, et al. Ultrasound as a new tool in the assessment of airway difficulties: An observational study. Eur J Anaesthesiol 2019;36:509-15.  Back to cited text no. 54
Shibasaki M, Nakajima Y, Ishii S, Shimizu F, Shime N, Sessler DI. Prediction of pediatric endotracheal tube size by ultrasonography. Anesthesiology 2010;113:819-24.  Back to cited text no. 55
Pillai R, Kumaran S, Jeyaseelan L, George SP, Sahajanandan R. Usefulness of ultrasound-guided measurement of minimal transverse diameter of subglottic airway in determining the endotracheal tube size in children with congenital heart disease: A prospective observational study. Ann Card Anaesth 2018;21:382-7.  Back to cited text no. 56
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Clyburn P, Rosen M. Accidental oesophageal intubation. Br J Anaesth 1994;73:55-63.  Back to cited text no. 57
Ramsingh D, Frank E, Haughton R, Schilling J, Gimenez KM, Banh E, et al. Auscultation versus point-of-care ultrasound to determine endotracheal versus bronchial intubation: A diagnostic accuracy study. Anesthesiology 2016;124:1012-20.  Back to cited text no. 58
Callaway CW, Soar J, Aibiki M, Böttiger BW, Brooks SC, Deakin CD, et al. Part 4: Advanced life support: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation 2015;132 (16 Suppl 1):S84-145.  Back to cited text no. 59
Kelly JJ, Eynon CA, Kaplan JL, de Garavilla L, Dalsey WC. Use of tube condensation as an indicator of endotracheal tube placement. Ann Emerg Med 1998;31:575-8.  Back to cited text no. 60
Tanigawa K, Takeda T, Goto E, Tanaka K. Accuracy and reliability of the self-inflating bulb to verify tracheal intubation in out-of-hospital cardiac arrest patients. Anesthesiology 2000;93:1432-6.  Back to cited text no. 61
Li J. Capnography alone is imperfect for endotracheal tube placement confirmation during emergency intubation. J Emerg Med 2001;20:223-9.  Back to cited text no. 62
MacLeod BA, Heller MB, Gerard J, Yealy DM, Menegazzi JJ. Verification of endotracheal tube placement with colorimetric end-tidal CO2 detection. Ann Emerg Med 1991;20:267-70.  Back to cited text no. 63
Gottlieb M, Nakitende D, Sundaram T, Serici A, Shah S, Bailitz J. Comparison of static versus dynamic ultrasound for the detection of endotracheal intubation. West J Emerg Med 2018;19:412-6.  Back to cited text no. 64
Long B, Koyfman A, Gottlieb M. Diagnostic accuracy of ultrasound for confirmation of endotracheal tube placement. Acad Emerg Med 2019;26:1096-8.  Back to cited text no. 65
Das SK, Choupoo NS, Haldar R, Lahkar A. Transtracheal ultrasound for verification of endotracheal tube placement: A systematic review and meta-analysis. Can J Anaesth 2015;62:413-23.  Back to cited text no. 66
Gottlieb M, Bailitz J. Can transtracheal ultrasonography be used to verify endotracheal tube placement? Ann Emerg Med 2015;66:394-5.  Back to cited text no. 67
Mori T, Nomura O, Hagiwara Y, Inoue N. Diagnostic accuracy of a 3-point ultrasound protocol to detect esophageal or endobronchial mainstem intubation in a pediatric emergency department. J Ultrasound Med 2019;38:2945-54.  Back to cited text no. 68
Rice PF, Crosby TLD, Roberts SA. Variability of the carina-incisor distance as assessed by endoscopic ultrasound. Clin Oncol (R Coll Radiol) 2003;15:383-5.  Back to cited text no. 69
Bissinger U, Lenz G, Kuhn W. Unrecognized endobronchial intubation of emergency patients. Ann Emerg Med 1989;18:853-5.  Back to cited text no. 70
Weiss M, Engelhardt T. Proposal for the management of the unexpected difficult pediatric airway. Paediatr Anaesth 2010;20:454-64.  Back to cited text no. 71
Engelhardt T, Fiadjoe JE, Weiss M, Baker P, Bew S, Echeverry Marín P, et al. A framework for the management of the pediatric airway. Paediatr Anaesth 2019;29:985-92.  Back to cited text no. 72
Ovassapian A. The flexible bronchoscope. A tool for anesthesiologists. Clin Chest Med 2001;22:281-99.  Back to cited text no. 73
Sevdi MS, Demirgan S, Erkalp K, Erol MK, Ozalp A, Altinel Y, et al. Comparison of intra-operative pressure-controlled ventilation and volume-controlled ventilation in bariatric surgery: A prospective randomized study. Cureus 2021;13:e17567.  Back to cited text no. 74
Olutoye OA, Yu X, Govindan K, Tjia IM, East DL, Spearman R, et al. The effect of obesity on the ED (95) of propofol for loss of consciousness in children and adolescents. Anesth Analg 2012;115:147-53.  Back to cited text no. 75
Lemmens HJM, Brodsky JB. The dose of succinylcholine in morbid obesity. Anesth Analg 2006;102:438-42.  Back to cited text no. 76
Anderson BJ, Holford NH. What is the best size predictor for dose in the obese child? Paediatr Anaesth 2017;27:1176-84.  Back to cited text no. 77
Thomairy NA, Mummaneni M, Alsalamah S, Moussa N, Coustasse A. Use of smartphones in hospitals. Health Care Manag (Frederick) 2015;34:297-307.  Back to cited text no. 78
Juvin P, Vadam C, Malek L, Dupont H, Marmuse JP, Desmonts JM. Postoperative recovery after desflurane, propofol, or isoflurane anesthesia among morbidly obese patients: A prospective, randomized study. Anesth Analg 2000;91:714-9.  Back to cited text no. 79
Mecoli M, Kandil A, Campion M, Samuels P. Pediatric obesity: Anesthetic implications and perioperative considerations for weight loss surgery. Curr Anesthesiol Rep 2017;7:125-34.  Back to cited text no. 80
Mani V, Morton NS. Overview of total intravenous anesthesia in children. Paediatr Anaesth 2010;20:211-22.  Back to cited text no. 81
Wu B, Shan J, Zhou Q, Wang L. Determination of the ED95 of a single bolus dose of dexmedetomidine for adequate sedation in obese or nonobese children and adolescents. Br J Anaesth 2021;126:684-91.  Back to cited text no. 82
Alvarez A, Singh PM, Sinha AC. Postoperative analgesia in morbid obesity. Obes Surg 2014;24:652-9.  Back to cited text no. 83
Zotou A, Siampalioti A, Tagari P, Paridis L, Kalfarentzos F, Filos KS. Does epidural morphine loading in addition to thoracic epidural analgesia benefit the postoperative management of morbidly obese patients undergoing open bariatric surgery? A pilot study. Obes Surg 2014;24:2099-108.  Back to cited text no. 84
Albrecht E, Kirkham KR, Endersby RVW, Chan VWS, Jackson T, Okrainec A, et al. Ultrasound-guided transversus abdominis plane (TAP) block for laparoscopic gastric-bypass surgery: A prospective randomized controlled double-blinded trial. Obes Surg 2013;23:1309-14.  Back to cited text no. 85
Caesar Y, Sidlovskaja I, Lindqvist A, Gislason H, Hedenbro JL. Intraabdominal pressure and postoperative discomfort in laparoscopic Roux-en-Y gastric bypass (RYGB) surgery: A randomized study. Obes Surg 2016;26:2168-72.  Back to cited text no. 86
Saurabh S, Smith JK, Pedersen M, Jose P, Nau P, Samuel I. Scheduled intravenous acetaminophen reduces postoperative narcotic analgesic demand and requirement after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2015;11:424-30.  Back to cited text no. 87
Ziemann-Gimmel P, Hensel P, Koppman J, Marema R. Multimodal analgesia reduces narcotic requirements and antiemetic rescue medication in laparoscopic Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis 2013;9:975-80.  Back to cited text no. 88
Andersen LPH, Werner MU, Rosenberg J, Gögenur I. Analgesic treatment in laparoscopic gastric bypass surgery: A systematic review of randomized trials. Obes Surg 2014;24:462-70.  Back to cited text no. 89
Ameer B, Weintraub MA. Pediatric obesity: Influence on drug dosing and therapeutics. J Clin Pharmacol 2018;58 Suppl 10:S94-107.  Back to cited text no. 90
van Rongen A, Välitalo PAJ, Peeters MYM, Boerma D, Huisman FW, van Ramshorst B, et al. Morbidly obese patients exhibit increased CYP2E1-mediated oxidation of acetaminophen. Clin Pharmacokinet 2016;55:833-47.  Back to cited text no. 91
Akhtar A, MacFarlane RJ, Waseem M. Pre-operative assessment and post-operative care in elective shoulder surgery. Open Orthop J 2013;7:316-22.  Back to cited text no. 92
Gamboa JSB. Pain management in weight loss surgery: Aiming for multimodal approach. AOWMC 2016;5. Available from:  Back to cited text no. 93
Tashlizky Madar R, Zion Yohay N, Grinstein Cohen O, Cohen L, Newman-Heiman N, Dvori Y. Post-bariatric surgery care in Israeli adolescents: A qualitative study. Clin Nurs Res 2021;30:1281-9.  Back to cited text no. 94
Kim TY, Kim S, Schafer AL. Medical management of the postoperative bariatric surgery patient. In: Feingold KR, Anawalt B, Boyce A, Chrousos G, de Herder WW, Dhatariya K, et al., editors. Endotext. South Dartmouth (MA):, Inc.; 2000. Availablefrom: [Last accessed on 2021 Nov 28].  Back to cited text no. 95
Elrazek AEMAA, Elbanna AEM, Bilasy SE. Medical management of patients after bariatric surgery: Principles and guidelines. World J Gastrointest Surg 2014;6:220-8.  Back to cited text no. 96
Gupta PK, Gupta H, Kaushik M, Fang X, Miller WJ, Morrow LE, et al. Predictors of pulmonary complications after bariatric surgery. Surg Obes Relat Dis 2012;8:574-81.  Back to cited text no. 97
Loring SH, Behazin N, Novero A, Novack V, Jones SB, O'Donnell CR, et al. Respiratory mechanical effects of surgical pneumoperitoneum in humans. J Appl Physiol (1985) 2014;117:1074-9.  Back to cited text no. 98
Pantel H, Hwang J, Brams D, Schnelldorfer T, Nepomnayshy D. Effect of incentive spirometry on postoperative hypoxemia and pulmonary complications after bariatric surgery: A randomized clinical trial. JAMA Surg 2017;152:422-8.  Back to cited text no. 99
Landoni G, Likhvantsev V, Kuzovlev A, Cabrini L. Perioperative noninvasive ventilation after adult or pediatric surgery: A comprehensive review. J Cardiothorac Vasc Anesth 2022;36:785-93.  Back to cited text no. 100
Małczak P. One hundred seventy-nine consecutive bariatric operations after introduction of protocol inspired by the principles of enhanced recovery after surgery (ERAS®) in bariatric surgery. Med Sci Monit 2015;21:791-7.  Back to cited text no. 101
Scarpellini E, Arts J, Karamanolis G, Laurenius A, Siquini W, Suzuki H, et al. International consensus on the diagnosis and management of dumping syndrome. Nat Rev Endocrinol 2020;16:448-66.  Back to cited text no. 102
Emous M, Wolffenbuttel BHR, Totté E, van Beek AP. The short- to mid-term symptom prevalence of dumping syndrome after primary gastric-bypass surgery and its impact on health-related quality of life. Surg Obes Relat Dis 2017;13:1489-500.  Back to cited text no. 103
Menser T, Muniz Castro J, Lopez A, Jones SL, Kash BA, Sherman V, et al. Post-bariatric surgery lab tests: Are they excessive and redundant? Surg Endosc 2020;34:4626-31.  Back to cited text no. 104
Durkin N, Desai AP. What is the evidence for paediatric/adolescent bariatric surgery? Curr Obes Rep 2017;6:278-85.  Back to cited text no. 105
Gehrer S, Kern B, Peters T, Christoffel-Courtin C, Peterli R. Fewer nutrient deficiencies after laparoscopic sleeve gastrectomy (LSG) than after laparoscopic Roux-Y-Gastric bypass (LRYGB)—A prospective study. Obes Surg 2010;20:447-53.  Back to cited text no. 106


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