BJA Education, 22(6): 231e237 (2022)
doi: 10.1016/j.bjae.2021.12.007
Matrix codes: 1H02,
2A03, 3A13
Anaesthesia for bariatric surgery
K. Reeve and N. Kennedy*
Somerset NHS Foundation Trust, Taunton, UK
*Corresponding author: Nicholas.j.kennedy@gmail.com
Keywords: anaesthesia; bariatric; obesity
Learning objectives
By reading this article, you should be able to:

List the indications for bariatric surgery.

Detail the requirements for bariatric preoperative
assessment.

Describe the different bariatric procedures and
anaesthetic requirements.

Outline common postoperative complications
after bariatric surgery.
The WHO describes being overweight and obese as the
excessive accumulation of fat that presents a risk to health.
Obesity is commonly defined as a BMI >30 kg m2 and being
overweight as a BMI >25 kg m2. According to the WHO, over 2
billion people worldwide were overweight, and of these peo-
ple 650 million were obese in 2016.
Obesity is challenging to treat and involves lifestyle, psy-
chological factors, medical management and surgery. Surgery
for obesity has developed over the past 50 yrs, the first pro-
cedure being a jejunoileal bypass described by Kreman in
1954.1 Surgical techniques have developed significantly over
the years, and today the vast majority of bariatric surgeries are
performed laparoscopically.
This article focuses on providing anaesthesia for patients
undergoing bariatric surgery and details of the procedures
Katherine Reeve BMedSci (Hons) MRCP FRCA is a specialty regis-
trar in anaesthesia at Somerset NHS Foundation Trust.
Nick Kennedy FRCA FFICM is a consultant anaesthetist and inten-
sivist at Somerset NHS Foundation Trust. He founded the UK Society
for Obesity and Bariatric Anaesthesia in 2009 and was its chairman
from 2009 to 2014. He has been lead anaesthetist and involved
with bariatric and obesity anaesthesia for the South West
Regional Bariatric Unit in Somerset since 2004. He has lectured
widely and been involved in many national projects in the
field.
Accepted: 17 December 2021
© 2022 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
For Permissions, please email: permissions@elsevier.com
Advance Access Publication Date: 11 April 2022
Key points

The three main bariatric surgical procedures per-
formed in the UK are all laparoscopic: gastric band,
sleeve gastrectomy and Roux-en-Y gastric bypass.

All patients should undergo effective preoxyge-
nation before induction of anaesthesia with
tracheal intubation and artificial ventilation.

Short-acting drugs should be used and doses
adjusted for appropriate weight.

Early mobilisation and ‘enhanced recovery’
techniques are strongly recommended.

Bariatric surgery is very safe in experienced
hands.
themselves. Anaesthesia for patients with obesity undergoing
non-bariatric surgery has been detailed in a recent article in
this journal.2
Treatment of obesity
Obesity is initially treated with lifestyle modifications,
including education, dietary changes and exercise pro-
grammes. Patients who fail to, or cannot sustain weight loss,
may be referred to a specialist weight management pro-
gramme for medical management.
Medical management
Medications for the treatment of obesity are used as part of a
specialist-led weight management programme and should
never be used as the sole management for patients with obesity.
Orlistat (Xenical) and liraglutide (Saxenda) are the only drugs
licensed for the management of obesity in the UK. These drugs
are licensed as an adjunct to lifestyle measures in patients with
a BMI 30 kg m2 or in individuals with a BMI 28 kg m2 with
other risk factors. Two further drugs are recommended by the
US Food and Drug Administration: bupropionenaltrexone
(Contrave®) and phentermineetopiramate (Qsymia).
231
Anaesthesia for bariatric surgery

Table 1 NICE clinical guideline 189: indications for bariatric surgery (2014).4

Bariatric surgery is a treatment option for people with obesity if all of the following criteria are fulfilled:
(i) They have a BMI 40 kg m2, or between 35 and 40 kg m2 and other significant disease (e.g. Type 2 diabetes or high blood pressure)
that could be improved if they lost weight.
(ii) All appropriate non-surgical measures have been tried, but the person has not achieved or maintained adequate, clinically
beneficial weight loss.
(iii) The person has been receiving or will receive intensive management in a Tier 3 service (see reference for further details).
(iv) The person is generally fit for anaesthesia and surgery.
(v) The person commits to the need for long-term follow-up.
In addition, in 2014, NICE published specific points relating to bariatric surgery for people with recent-onset Type 2 diabetes:
(i) Offer an expedited assessment for bariatric surgery to people with a BMI 35 kg m2 who have recent-onset Type 2 diabetes as
long as they are also receiving or will receive assessment in a Tier 3 service (or equivalent).
(ii) Assessment for bariatric surgery should be considered in people with a BMI between 30 and 34.9 kg m2 or people of Asian family
origin at a lower BMI who have recent-onset Type 2 diabetes.

In December 2020, the National Institute for Health and
Care Excellence (NICE) recommended liraglutide, the first new
drug for obesity in over a decade.3 Liraglutide binds to and
activates the glucagon-like peptide-1 receptor and increases
insulin secretion, decreasing glucagon secretion and slows
gastric emptying.
Centrally-acting appetite suppressants used previously in
the management of obesity, including fenfluramine and
sibutramine, have been withdrawn because of serious con-
cerns over safety.
Surgical management
Patients in the UK can generally only be referred for NHS-
funded bariatric surgery after assessment by a specialist
weight management service. Bariatric surgery is considered in
people who have severe obesity and with associated comor-
bidities. The National Institute for Health and Care Excellence
has published guidelines on indications for bariatric surgery
(Table 1).4 Weight reduction is achieved by different surgical
procedures, including gastric banding, sleeve gastrectomy
and Roux-en-Y gastric bypass.
Preoperative care
Patients undergoing bariatric surgery should be preopera-
tively assessed in a multidisciplinary team (MDT) setting. The
MDT should include a bariatric surgeon, nurse specialist,
dietician, psychologist, anaesthetist experienced in managing
patients for bariatric surgery and a physician.
A thorough preoperative assessment is needed to evaluate
common systemic effects of obesity, including diabetes mel-
litus, hypertension and ischaemic heart disease. ECG evalua-
tion is important; further cardiac testing, such as
echocardiography and cardiopulmonary exercise testing, may
be required depending on the patient’s symptoms, investiga-
tion findings and available facilities. Potentially high-risk pa-
tients should be identified. Relying solely on BMI is
unsatisfactory; assessing whether a patient has central
obesity and metabolic syndrome is a useful way to identify
high-risk patients. As bariatric surgery is an elective proced-
ure, any comorbidities should be optimised before surgery.
The obesity surgery mortality risk score (OS-MRS) is a vali-
dated preoperative screening tool for bariatric surgery, used to
predict patients at risk of postoperative complications who
may benefit from care in high-dependency care unit (HDU) or
ICU.5 Patients scoring 4e5 points on the OS-MRS should be
considered for postoperative admission to HDU or ICU bed.
Risk assessment of other comorbidities should be along
standard lines for all patients.
Obstructive sleep apnoea (OSA) is common in patients with
obesity. Patients should be screened for OSA using one of the
screening tools (e.g. STOP-Bang). Patients who present for
surgery with treated sleep apnoea (established on CPAP for a
minimum of 6 weeks) should bring in their own CPAP ma-
chines to use postoperatively. Patients with sleep apnoea who
are unable to tolerate CPAP should be admitted to an HDU
setting postoperatively.
The airway should be assessed thoroughly to predict
difficult ventilation or tracheal intubation. Fat distribution
should be evaluated, as patients with centralised obesity tend
to have less favourable airway anatomy. The UK National
Audit Project 4 (NAP4) service evaluation found that patients
with obesity were at high risk of airway obstruction, hypo-
ventilation and regurgitation at extubation. Emergence
should be recognised as a period of increased risk.6
Whilst the evidence suggests that obesity, assessed by BMI
alone, adds only a small additional risk for difficulty of intu-
bation and ventilation, using features, such as increased neck
circumference and Mallampati score, will identify patients
with a higher risk of airway difficulties. Obesity is associated
with difficulty in maintaining an airway and oxygenation
before intubation and also of rapid oxygen desaturation.
Thorough planning for airway management and effective
preoxygenation are critical.
Patients often undergo a preoperative weight loss regimen
for 2e4 weeks before bariatric surgery. This regimen involves
a low-calorie diet (800 kcal day1) and has been shown to
reduce liver volume by 16e20%, hence being called the ‘liver
shrinkage diet’. Low-calorie diets may affect fluid distribution
and enzymes responsible for drug metabolism. However,
these effects have not been extensively studied and no major
changes are appreciable in clinical practice. Preoperative
weight loss has been shown to reduce postoperative compli-
cations and improve surgical access.7
During surgery
Safety briefings are especially important in bariatric cases
before starting each operating list and each case. Confirma-
tion of the patient’s BMI, anticipated anaesthetic complica-
tions, adequate operating table size, staffing and appropriate
equipment should be discussed and made available.

232 BJA Education - Volume 22, Number 6, 2022

 Anaesthesia for bariatric surgery

Table 2 Suggested dosing for anaesthetic drugs. Adapted from the SOBA single sheet guideline.9 Permission for table use has been
granted by SOBA.

Lean body weight (males maximum 100 kg; Adjusted body weight Total body weight
females maximum 70 kg) (IBWþ40% excess)

Propofol induction Propofol infusion Suxamethonium

Fentanyl and alfentanil Neostigmine (maximum 5 mg) Low-molecular-weight heparins
Morphine Sugammadex
Non-depolarising neuromuscular blocking agents Antibiotics
Paracetamol
Local anaesthetics

In many centres, anaesthesia is induced in the operating
theatre, with the patient self-positioning onto the operating
table. This avoids excessive manual handling and may help
avoid pressure injuries. An inflatable ‘hover mattress’ is
commonly used to move the patient after the procedure. The
operating table must take extremes of body weight and have
appropriate leg and arm board attachments.
The reverse Trendelenburg position is usually required for
surgery. The patient’s legs may be placed in gutters with a foot
support to stop slippage and arms placed out on boards. The
patient is in a ‘ramped’ position to assist airway management,
and this is the preferred position for surgical access and
laparoscopic viewing. Invasive arterial pressure monitoring is
rarely required, and non-invasive arterial pressure can often
be measured successfully on the forearm if the upper arm is
too large or conical in shape. We advise the placement of two
venous cannulae.
A nasogastric tube (NGT) may be requested by the surgical
team to decompress the stomach during surgery. If so, insert
the tube via the orogastric route and remove as soon as the
stomach has been decompressed. If left in situ, there is the risk
of the NGT being accidently stapled into the pouch.
Airway
Preoxygenation of the lungs is vital, as patients with obesity
desaturate rapidly during induction of anaesthesia. The key
technique to reduce desaturation is good-quality preoxyge-
nation with a tight-fitting mask with the patient in a ramped
position to achieve an end-tidal O2 concentration of 90%. CPAP
or high-flow oxygen techniques can also be used.
Tracheal intubation should be used for all patients un-
dergoing laparoscopic bariatric surgery. The choice of lar-
yngoscopic device depends on the anaesthetist’s personal
preference. However, it is advisable that a video laryngoscope
is available.
Drugs
The pharmacokinetics of drugs in patients with obesity has
been reviewed recently in this journal.8 Lean body mass is
often used in obesity for drug dosing, defined as the mass of
non-adipose tissues (maximum 100 kg in males and 70 kg in
females). It is useful for calculating doses of polar drugs with a
small volume of distribution, such as non-depolarising
neuromuscular blocking agents (NMBAs) and bolus doses for
target-controlled infusion systems, to avoid overdose
(Table 2). Ideal body weight (IBW) is the predicted weight of a
person from the person’s height and a predicted normal BMI
of 22. ‘Adjusted’ body weight uses a correction factor for the
distribution of the drug. The suggested adjusted weight
(IBWþ40% excess weight) is a commonly used formula, where
excess weight¼(actual body weighteIBW). Table 2 highlights
some of the commonly used drugs and the preferred weight to
calculate individual patient doses.9 The Society for Obesity
and Bariatric Anaesthesia (SOBA) UK has an app available for
dose calculations.
The drugs commonly used in anaesthesia for patients with
obesity have been detailed in a recent article in this journal on
anaesthesia for the patient with obesity.2 Anaesthesia for
patients undergoing bariatric surgery uses many of the tech-
niques described, with the use of short-acting drugs being key.
Neuromuscular block
Tracheal intubation should be performed in all patients un-
dergoing laparoscopic bariatric surgery. We recommend
rocuronium as the NMBA of choice because of its speed of
onset and reversibility. Neuromuscular block should be
maintained during the operation, continuous neuromuscular
monitoring used and quantitative monitoring is recom-
mended. Neuromuscular block must be reversed fully at the
end of surgery before extubation. Sugammadex may be useful
for complete antagonism of the effects of rocuronium. Some
centres advocate using ‘deep neuromuscular block’ to facili-
tate laparoscopic surgical conditions. Adequate reversal of
neuromuscular block is particularly important when this
technique is used.
Ventilation
Artificial ventilation should be used for all patients, using a
tidal volume 6e8 ml kg1 based on IBW, and a sufficient level
of PEEP should be applied (5e10 cmH2O). In laparoscopic bar-
iatric surgery, body habitus and a pneumoperitoneum can
result in high peak airway pressures, although the reverse
Trendelenburg position can mitigate this to some extent and
peak airway pressures usually remain below 30 cmH2O. In
some very large patients, especially with central obesity,
pressures up to 36e40 cmH2O may be accepted. It is important
to address and treat any reversible causes of high pressures in
the usual way.
Analgesia and antiemetics
The majority of procedures are performed laparoscopically;
thus, techniques, such as epidural analgesia, are rarely used.
We recommend using a multimodal opioid-sparing analgesic

BJA Education - Volume 22, Number 6, 2022 233

Anaesthesia for bariatric surgery
Fig 1 Anatomy of bariatric surgical procedures: (a) Gastric band, (b) Sleeve gastrectomy, (c) Roux-en-Y gastric bypass.
regimen with local anaesthetic wound infiltration and ad-
juncts, such as ketamine, clonidine and NSAIDs, where no
contraindications exist. Anti-emetic prophylaxis is recom-
mended, as nausea and vomiting are highly undesirable.
Types of surgery
Numerous surgical procedures have been developed since the
mid-20th century. The main procedures from 2000 to 2010
were gastric bypass and gastric banding. In the past decade,
sleeve gastrectomy has become increasingly popular. All
these procedures can give significant weight loss, and the
decision of which is the most suitable for an individual is
multifactorial. The most commonly performed bariatric sur-
gical procedures are described as follows.
Gastric banding
In this procedure, an adjustable gastric band is inserted lap-
aroscopically and placed around the proximal stomach
(Fig. 1A). Gastric banding is a short procedure that requires
minimal analgesia. It also involves placement of a subcu-
taneous injection port, often over the xiphisternum. The aim
of the procedure is to decrease the gastric capacity and lead to
early satiety. The size of the restriction into the stomach can
be altered by inflating or deflating the band with saline via its
subcutaneous port. A complication of a gastric band is band
slippage, in which the band is not effective and pain can
result.
Sleeve gastrectomy
Sleeve gastrectomy is a permanent method of reducing the
size of the stomach. It is performed laparoscopically and
takes 1e2 h. A bougie is placed trans-orally and placed
against the lesser curvature of the stomach. The stomach is
then stapled into a banana shape aiming lateral to the
bougie (Fig. 1B). Sleeve gastrectomy confers effective weight
loss and improvement in comorbid conditions, such as Type
2 diabetes, similar to a Roux-en-Y gastric bypass but with
lower morbidity and mortality rates.10 Human ghrelin
234 BJA Education - Volume 22, Number 6, 2022
concentrations decrease after sleeve gastrectomy.11 This
may explain the loss of hunger and rapid weight loss in
some individuals. The procedure is simpler than the gastric
bypass.
The most feared complication of a sleeve gastrectomy is a
gastric leak, which typically occurs in the first few days after
surgery and commonly near the gastro-oesophageal junction.
Roux-en-Y gastric bypass
Gastric bypass is performed laparoscopically, takes 1e3 h and
is the most complex bariatric procedure performed
commonly. The small bowel is divided and a ‘Roux loop’ is
brought up towards the stomach. The stomach is divided into
two, the upper small pouch to receive a small amount of food
from the oesophagus. The pouch is anastomosed to the Roux
limb so that food passes directly into the distal small bowel,
bypassing the distal stomach, duodenum and jejunum. A
distal end-to-side small bowel anastomosis is made to deliver
digestive fluids to the bowel (Fig. 1C).
A multimodal analgesic technique is required, as this is the
most painful bariatric procedure.
Postoperatively, there is the risk of anastomotic leaks.
There are also longer-term issues with vitamin and mineral
deficiencies, and patients may require lifelong supplementa-
tion. Weight loss is most pronounced in the 2 yrs after the
procedure. Typically, some weight is regained over time,
although most patients maintain a 25% weight loss at 10 yrs.12
Both gastric bypass and sleeve gastrectomy procedures
may require placement by the anaesthetist of a large-bore
(typically 34 Fr) bougie to enable the surgeon to clearly delin-
eate the anatomy to separate and anastomose the stomach. In
addition, to test for anastomotic leaks, at the surgeon’s
discretion, water containing methylene blue 60e180 ml is
injected into the stomach remnant via a large-bore orogastric
tube passed by the anaesthetist. Any spillage of methylene
blue will cause skin and hair discoloration, and patients
should be warned of this before surgery. It is strongly rec-
ommended that inexperienced anaesthetists have seen these
manoeuvres before undertaking them, as there are potentially
serious risks of mediastinal and stomach perforation.

Intragastric balloon
This procedure is not laparoscopic. An inflatable silicon
intragastric balloon is inserted endoscopically via the mouth.
Once in the stomach, the balloon is inflated with saline. The
aim of the procedure is to decrease gastric capacity and lead to
early satiety. It is a short procedure, usually carried out under
i.v. sedation and local anaesthesia. The durability of intra-
gastric balloons is typically 6e12 months, but it varies be-
tween manufacturers. Balloon removal is also performed
endoscopically.
An intragastric balloon is sometimes used as an adjunct for
weight loss in patients with a BMI 25e35 who do not qualify
for bariatric surgery. It is also used in patients with very high
BMIs (>60e70) in whom a surgical procedure is deemed too
challenging and the risks too high. In such patients, the pro-
cedure can be hazardous and should not be managed by
inexperienced anaesthetists. Either topical anaesthesia only
or general anaesthesia with tracheal intubation is recom-
mended, rather than sedation.
Postoperative care
Early complications include nausea and vomiting, leaks,
bleeding and venous thromboembolic events (VTEs).
Nausea and vomiting
The phenotype of patients undergoing bariatric surgery,
typically female and aged <50 yrs, and the surgery itself put
patients at a high risk of postoperative nausea and vomiting.
The use of multiple anti-emetics and opioid-free total i.v.
anaesthesia is beneficial. The optimum combination of
antiemetics is uncertain. A combination of dexamethasone,
cyclizine and prochlorperazine is effective, although the
benefit of triple therapy over dual therapy remains
unproved.13
Thromboembolism
Venous thromboembolism is a major cause of mortality in
patients undergoing bariatric surgery. The risk is increased
because of common risk factors for thromboembolism (pre-
vious history of thromboembolism, increased age, smoking,
OSA and the oestrogen contraceptive pill). Mechanical
compression devices are recommended unless contra-
indicated, along with pharmacological prevention. Evidence
surrounding the best pharmacological methods and lengths of
therapy is lacking.14 Protocols vary in different surgical cen-
tres, and further prospective evidence is required.
Anastomotic leak
Anastomotic leak is a feared complication of any bariatric
surgical procedure (prevalence 0.8e1.5%).15 A leak increases
overall morbidity to 61% and mortality to 15%.16 Patients at
higher risk from a leak include those patients undergoing
revision bariatric surgery, with a BMI >50 kg m2 and with
metabolic syndrome X.17,18 Commonly, a leak presents from
24 h to a few days after surgery, usually with a persistent
tachycardia. Patients may also have an associated pyrexia and
abdominal pain. Alternative diagnoses, such as VTE, should
be explored. However, a persistent tachycardia should be
assumed to be a leak until proved otherwise. Radiological
Anaesthesia for bariatric surgery
imaging is helpful, but it is often sensible to proceed directly to
laparoscopy if a leak is suspected.
Bleeding
Postoperative bleeding is a relatively common complication
and occurs after 0.5e4% of bariatric surgeries (not including
gastric bands).19 Bleeding presents often as melaena, occa-
sionally haematemesis and a decrease in postoperative hae-
moglobin concentration. It rarely causes hypovolaemia, and
supportive management is nearly always adequate. Endo-
scopic evaluation may be useful and surgical intervention is
rarely required. The staple line of a sleeve gastrectomy and
the anastomoses in the gastric bypass are the usual sites of
bleeding.
Postoperative pulmonary complications
Patients with obesity are at higher risk of postoperative pul-
monary complications (PPCs), including atelectasis, aspiration
and hypoventilation. Several factors are involved, and no
single intervention, including preoperative incentive spirom-
etry, has been shown to have a dramatic effect on reducing
the incidence of PPCs.
Nutritional deficiencies
Early postoperative nutritional care is extremely important
and should involve a dietician with a protocol-driven staged-
meal plan. In the longer term, patients are at risk from
nutritional deficiencies.
Psychological impact
Generally, bariatric surgery leads to a positive effect on pa-
tients’ mental health through weight loss and improved self-
esteem. However, with the potential for slow weight loss or
issues with weight regain, low mood can occur. Patients un-
dergoing bariatric surgery have a higher rate of suicide than
the general population.20
Dumping syndrome
Dumping syndrome is a chronic complication of the mal-
absorptive surgical procedures. It describes a group of symp-
toms, including abdominal pain, nausea, vomiting, flushing
and diarrhoea.
Outcomes
In the SLEEVEPASS (2018) and SM-BOSS trials (2018), there
were no significant differences in weight loss between pa-
tients undergoing sleeve gastrectomy or gastric bypass.21,22
Conversely, in a recent large multicentre study, patients
who had a gastric bypass had greater weight loss, a marginally
higher Type 2 diabetes mellitus remission rate and better
long-term glycaemic control compared with patients who had
sleeve gastrectomy.23 The gastric bypass tends to improve
symptoms of gastro-oesophageal reflux, whereas the sleeve
has been shown to worsen it in some patients. Therefore,
individual patients need to consider their weight loss aims,
concurrent disease, risk of complications and reflux symp-
toms in choosing the type of surgery to undergo.
BJA Education - Volume 22, Number 6, 2022 235
Anaesthesia for bariatric surgery
Enhanced recovery
The international Enhanced Recovery After Surgery Society
compiled an expert consensus guideline in 2016 for enhanced
recovery after bariatric surgery.24 The guidance outlines
comprehensive evidence-based interventions for both the
peri- and postoperative periods and is recommended reading.
Special considerations
In patients presenting with an acute abdomen with a history
of bariatric surgery, the following unique diagnoses should be
considered:
(i) In gastric band slippage, patients often report vomiting,
fullness and pain.
(ii) Adjustable gastric band erosion is a rare surgical emer-
gency. Symptom onset is commonly non-specific and
insidious.
(iii) Internal hernia is a late complication that is difficult to
diagnose. It can occur at the anastomotic site or through
defects in the bowel mesentery.
Reversibility
Bariatric procedures can lead to unwanted consequences that
lead a patient to seek reversal. Gastric bands are the most
easily reversed. Gastric bypass reversal is a complex proced-
ure with numerous potential complications. The sleeve gas-
trectomy is considered irreversible, as a large portion of the
stomach is removed.
Conclusions
Bariatric surgery in the UK is safe. All the common surgical
procedures are highly effective in experienced hands and
deliver life-changing benefits for patients. Comprehensive
medical management and MDT assessment before referral for
surgery are very important. Patients undergoing bariatric
surgery can be challenging, and there are specific risks that
anaesthetists need to understand.
Declaration of interests
The authors declare that they have no conflicts of interest.
MCQs
The associated MCQs (to support CME/CPD activity) will be
accessible at www.bjaed.org/cme/home by subscribers to BJA
Education.
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