In morbidly obese patients, the 30 degrees Reverse Trendelenburg position provided the longest SAP when compared to the 30 degrees Back Up Fowler and Horizontal-Supine positions. Since on induction of general anesthesia morbidly obese patients may be difficult to mask ventilate and/or intubate, this extra time may preclude adverse sequelae resulting from hypoxemia. Therefore, Reverse Trendelenburg is recommended as the optimal position for induction.

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Alcoholic liver disease is characterized by the accumulation of fat and inflammatory changes in the liver. Because free fatty acids, the precursors of triglycerides, can damage biological membranes, accumulation of free fatty acids in the liver might be in part responsible for the functional and morphological changes seen in alcoholic liver disease. We, therefore, determined the hepatic lipid composition in biopsies from 31 patients with alcoholic liver disease, 18 patients with morbid obesity, and 5 patients without evidence of liver disease. Free fatty acids were found in all liver biopsies. Patients with morbid obesity or alcoholic liver disease had significantly higher fatty acid and triglyceride levels than did controls (p <, 0.01). Patients with alcoholic liver disease had significantly higher fatty acid levels than did patients with morbid obesity (p < 0.05), while there was no difference in the triglyceride concentrations between these two groups. The distribution of the fatty acids in the free fatty acid fraction differed significantly from that in the triglyceride fraction indicating a preferential incorporation of unsaturated fatty acids into triglycerides. This difference in the distribution pattern was lost in patients with the most severe forms of alcoholic liver disease. The data are consistent with the hypothesis that accumulation of free fatty acids in patients with alcoholic liver disease may be responsible for or contribute to the observed functional and morphological damages.

Extraperitoneal mesh reinforcement avoids intestinal complications and subsequent operations to remove mesh. Recurrence is more frequent after onlay mesh reinforcement and usually occurs at the cranial or caudal edge of the mesh within the first 2 years after hernia repair. Retrorectus repair is the preferred open surgical treatment of incisional hernia, but it has not been universally applicable. Hernias developing 6 to 7 years after surgery are not the result of failed earlier repairs.

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To define frequency of lipid abnormalities and to monitor improvement or correction of those abnormalities postoperatively, 66 patients with chronic morbid obesity had total cholesterol, high-density-lipoprotein (HDL) cholesterol, and triglyceride determinations preoperatively and at staged intervals up to 5-7 y after Roux-Y gastric bypass. Preoperative abnormal HDL-cholesterol and triglyceride concentrations were frequent. Major improvements occurred in these lipid concentrations by 6 mo postoperatively, and some further improvements occurred with additional weight loss at 1 y. At 5-7 y, among 33 patients, raised concentrations of HDL cholesterol were upheld in women (P less than 0.01); reductions in triglycerides were maintained in men (P less than 0.025); and reduced total cholesterol:HDL-cholesterol, which was achieved by 6 mo, was sustained in both men and women (P less than 0.01). In comparing lipid profiles of gastric surgery through 5 y with recent data from the surgical arm of the Program on Surgical Control of the Hyperlipidemias (POSCH), postulates are made of anticipated reduction in morbid, and even fatal, cardiac events in the operated morbidly obese population.

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