title: Minimally invasive gastric bypass in a morbidly obese patient with myasthenia gravis.
abstract: Associated or rare diseases, such as myasthenia gravis, introduce a challenge to the perioperative management of severely obese patients undergoing bariatric surgery. We report the surgical management and unique anesthetic approach to a 55-year-old morbidly obese woman with a complex past medical history that included myasthenia gravis, who underwent laparoscopic gastric bypass. Her myasthenia was controlled on pyridostigmine and her greatest concern was the potential need for postoperative mechanical ventilation. While the laparoscopic surgical approach was ideal to reduce pain and the adverse effects on ventilatory mechanics associated with open upper abdominal surgery, a combined inhalational and intravenous anesthetic without muscle relaxants resulted in satisfactory surgical conditions, and allowed for immediate postoperative extubation followed by an uneventful postoperative course. Continued perioperative anticholinesterase administration may have facilitated this successful outcome. We conclude that a diagnosis of myasthenia gravis does not mandate postoperative mechanical ventilation following laparoscopic gastric bypass.
authors.affiliation: Department of Anesthesia, Tufts-New England Medical Center and Tufts University School of Medicine, 750 Washington Street, Boston, MA 02111, USA. Rschumann@tufts-nemc.org
authors.forename: Roman
authors.initials: R
authors.lastname: Schumann
authors.forename: Michael
authors.initials: M
authors.lastname: Tarnoff
authors.forename: Zafar I
authors.initials: ZI
authors.lastname: Siddiqui
mesh_terms: D000769:Anesthesia, Inhalation; D000779:Anesthetics, Local; D002800:Cholinesterase Inhibitors / Q000008:administration & dosage / Q000627:therapeutic use; D015897:Comorbidity; D005260:Female; D015390:Gastric Bypass / Q000379:methods*; D006801:Humans; D010535:Laparoscopy; D008875:Middle Aged; D009157:Myasthenia Gravis / Q000188:drug therapy / Q000453:epidemiology*; D009388:Neostigmine / Q000008:administration & dosage / Q000627:therapeutic use; D009767:Obesity, Morbid / Q000453:epidemiology* / Q000601:surgery; D011729:Pyridostigmine Bromide / Q000008:administration & dosage / Q000627:therapeutic use
chemical_list: D000779:Anesthetics, Local; D002800:Cholinesterase Inhibitors; D009388:Neostigmine; D011729:Pyridostigmine Bromide