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Background: Bariatric surgery in Saudi Arabia has become one of the most performed surgical procedures for weight loss surgery (WLS). The aim of this survey is to highlight the importance of education and training in bariatric anesthesia (BA). Methods: An Internet-based cross-sectional survey was conducted to examine the percentages of general anesthesiologists among respondents who supported the need for formal structured training in BA as the primary outcome. A 41 items questionnaire on different aspects of BA included in this survey. All anesthesiologists in KSA participated in this survey. Results: 42% responded giving anesthesia for bariatric surgery/year between 25 and 50% of cases/year. 22% responded performing 25-50 cases/month, 21% from 10-25 cases, and 14% from 50-100 cases. Compared with how many elective bariatric surgical procedures performed in your center/month revealed significant differences (P < 0.05), 39% responded with no dedicated team in their center, 14% for <10 cases a month, 9% between 25 and 50 cases a month. Compared to the number of cases performed by non-bariatric anesthetists revealed non-significant differences (P > 0.05), upon asking on how many trained/skilled anesthesiologists in bariatric anesthesia in your center, 24% reported none, 4% only one, 21% 2-5 anesthesiologists, 12% 5-10 anesthesiologists, and 19% of the respondents reported more than 10 anesthesiologists specialized in BA. Conclusion: We believe in education and training in bariatric anesthesia. Residents' rotation in BA should be included in their curriculum. A dedicated fellowship program to be developed at a national level as well as courses and workshops.

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BACKGROUND: This survey aimed to explore the availability and accessibility of echocardiography during noncardiac surgery worldwide. METHODS: An internet-based 45-item survey was sent, followed by reminders from August 30, 2021, to August 20, 2022. RESULTS: 1189 responses were received from 62 countries. Nearly seventy-one percent of respondents had intraoperatively used transesophageal or transthoracic echocardiography (TEE and TTE, respectively) for monitoring or examination. The unavailability of echocardiography machines (30.3%), lack of trained personnel (30.2%), and absence of clinical indications (22.6%) were the top 3 reasons for not using intraoperative echocardiography in noncardiac surgery. About 61.5% of participants had access to at least one echocardiography machine. About 41% had access to at least 1 TEE probe, and 62.2% had access to at least 1 TTE probe. Seventy-four percent of centers had a procedure to request intraoperative echocardiography if needed for noncardiac cases. Intraoperative echocardiography service was immediately available in 58% of centers. CONCLUSIONS: Echocardiography machines and skilled echocardiographers are still unavailable at many centers worldwide. National societies should aim to train a critical mass of certified TEE/TTE anesthesiologists and provide all anesthesiologists access to perioperative TEE/TTE machines in anesthesiology departments, considering the increasing number of older and sicker surgical patients scheduled for noncardiac surgery.

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BACKGROUND: This survey aimed to explore the availability and accessibility of echocardiography during noncardiac surgery worldwide. METHODS: An internet-based 45-item survey was sent, followed by reminders from August 30, 2021, to August 20, 2022. RESULTS: 1189 responses were received from 62 countries. Nearly seventy-one percent of respondents had intraoperatively used transesophageal or transthoracic echocardiography (TEE and TTE, respectively) for monitoring or examination. The unavailability of echocardiography machines (30.3%), lack of trained personnel (30.2%), and absence of clinical indications (22.6%) were the top 3 reasons for not using intraoperative echocardiography in noncardiac surgery. About 61.5% of participants had access to at least one echocardiography machine. About 41% had access to at least 1 TEE probe, and 62.2% had access to at least 1 TTE probe. Seventy-four percent of centers had a procedure to request intraoperative echocardiography if needed for noncardiac cases. Intraoperative echocardiography service was immediately available in 58% of centers. CONCLUSIONS: Echocardiography machines and skilled echocardiographers are still unavailable at many centers worldwide. National societies should aim to train a critical mass of certified TEE/TTE anesthesiologists and provide all anesthesiologists access to perioperative TEE/TTE machines in anesthesiology departments, considering the increasing number of older and sicker surgical patients scheduled for noncardiac surgery.

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Left-sided double-lumen tube (LDLT) is commonly used to achieve one lung isolation in most thoracic surgical procedures. Traditionally, the LDLT is blindly placed using direct or video laryngoscopy. In this brief report, we highlight the importance of using our novel insertion depth formula to predict the appropriate LDLT insertion depth and demonstrate the current evidence supporting the efficacy of the formula. Also, we will discuss two relatively new devices of LDLTs: one with an embedded camera at the distal end of the tracheal lumen and the other with a carinal cuff between the bronchial cuff and the tracheal lumen in reducing the incidence of too deep inserted LDLT. We advocate that using our novel formula and these two new devices may reduce but not eliminate the need for FOB to check the insertion depth of LDLT.

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The purpose of research is to seek answers and new knowledge. When conducted properly and systematically, research adds to humanity's corpus of knowledge and hence to our general advancement. However, this is only possible if reported research is accurate and transparent. Guidelines for all the major types of studies (STROBE, CONSORT, PRISMA, MOOSE, STARD, and SPIRIT) have been developed and refined over the years, and their inception, development, and application are briefly discussed in this paper. Indeed, there are currently over 250 of these guidelines for various types of medical research, and these are published by the EQUATOR network. This paper will also briefly review progress in acceptance and adoption of these guidelines.

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Background: The geo-strategic position of Pakistan on the world map is incredibly important and idyllic as the country is considered the gateway to central Asia. Pakistan has faced political instability for the last three decades, causing a brain drain and adversely affecting socioeconomic growth. This study aims to investigate the impact of an unstable environment on the brain drain of highly skilled professionals, healthcare workers, researchers, and research productivity in Pakistan from January 2000 to December 2022. Material and Methods: The data were recorded from the World Bank, the Higher Education Commission (HEC) Pakistan, the Pakistan Medical and Dental Council (PMDC), the Bureau of Emigration and Overseas Employment (BEOS), Pakistan, Academic Ranking of World Universities (ARWU), and Web of Science Clarivate Analytics. Initially, 32 documents were selected in this study, and finally, eight fact sheets, official government websites, and international organizations were included. Results: The result revealed that due to political instability, in 2022 about 832,339 highly qualified and accomplished experts headed abroad, among them 17976 (2.15%) were highly qualified and 20865 (2.50%) were highly competent professionals. These include accountants 7197 (0.86%), engineers 6,093 (0.73%), agricultural experts 3,110 (0.37%), doctors 2,464 (0.29%), computer experts 2,147 (0.25%), nurses and paramedics 1768 (0.21%), technicians 23347 (2.80%), electricians 20322 (2.44%), and schools and university faculty 1004 (0.12%). Pakistan has a total of 380 Higher Education Commission-indexed academic journals, among them 11 (2.89%) academic journals were indexed in the Web of Science and 23 journals were placed in the Web of Science emerging indexing. Among these journals, only one journal surpassed the impact factor of more than 2.0. The quartile ranking of Pakistani journals is 01 journal in Q2; 02 in Q3; and the remaining 08 journals in Q4. From August 1947 to December 2022, Pakistan produced a total of 259249 research articles, and from January 2000 to December 2022, the number of articles published was 248457 (95.83%). Since the last 22 years, the trend of research publications was continuously increased; however, the rising trend decreased in 2022 with a declined rate of 1263 (3.42%). Conclusion: The unstable sociopolitical environment in Pakistan caused a brain drain of highly qualified and skilled professionals and impaired the global standing of universities, academic journals, and research productivity in Pakistan. Pakistan must resolve the instability and establish sustainable policies to minimize the brain drain of highly qualified and skilled experts and convalesce their academic institutes and their research productivity for the development of the nation.

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Background: Anesthesia with deep neuromuscular block for laparoscopic surgery may result in less postoperative pain with lower intra-abdominal pressure. However, the results in the existing literature are controversial. This study aimed to evaluate the effect of deep versus moderate neuromuscular block (NMB) on the postoperative recovery characteristics after laparoscopic sleeve gastrectomy (LSG) for weight loss surgery. Methods: This is parallel-group, randomized clinical trial. The study was conducted at a tertiary care center. Patients undergoing LSG were included. Patients were randomly assigned to either deep (post-tetanic count 1-2) or moderate (train-of-four 1-2) NMB group. The primary outcomes were numeric rating scale scores of the postoperative pain at rest and postoperative shoulder pain. The secondary outcomes were the length of hospital stay (LOS) and postoperative complications. The statistics were performed using StatsDirect statistical software (Version 2.7.9). Results: Two groups were identified: Group D (deep NMB), 29 patients, and Group M (moderate NMB), 28 patients. The BMI mean values for groups D and M were 44 and 45 kg/m2 respectively (P > 0.05). The mean durations of surgery for were 46.7 min and 44.1 min for groups M and D, respectively (P > 0.05). The mean train-of-four (TOF) counts were 0.3 and 0 for groups M and D, respectively (P < 0.05). The mean times from giving reversal agent to tracheal extubation (minutes) were 6.5 and 6.58 min for groups M and D, respectively (P > 0.05). In the recovery room, the means of pain scores were 3 and 4 for groups M and D, respectively (P > 0.05). Upon admission to the surgical ward, the median values of the pain score were non-significant (P > 0.05) (95% CI: 0.4-0.7). The opioid consumption in the recovery room was non-significant between both groups (P > 0.05) (95% CI: 0.3-0.6). Postoperative shoulder pain was non-significant between both groups (P > 0.05) (95% CI: 0.4-0.7). The median values of surgeon opinion of both groups were non-significant (P > 0.05). Regarding the LOS, the mean values of groups D and M were 1.20 and 1.21 days, respectively (P > 0.05). Conclusions: There was no significant difference between moderate and deep NMB techniques in terms of duration of the surgical procedure, postoperative pain, shoulder pain, and length of hospital stay. Further studies on a larger sample size are required to investigate the long-term recovery characteristics of patients with obesity undergoing LSG.

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Elderly patients are perceived as a high-risk group for procedural sedation. Procedural sedation analgesia (PSA) is generally safe in older adults. What is not acceptable is undertreating pain or inadequately sedating a stable patient. All the usual precautions should be taken. One should consider any comorbidities that could make the patient more at risk of adverse reactions or complications. Older patients may be at higher risk for oxygen desaturation, but they usually respond quickly to supplemental oxygen. Geriatric patients usually require lower doses of medications. They tend to be more sensitive to medications, with slower metabolism, less physiologic reserve to handle side effects, and a smaller volume of distribution. The use of drugs for sedation in elderly patients requires careful consideration of their age-related changes in physiology and pharmacokinetics. The choice of drug should be based on the patient's medical condition, comorbidities, and potential adverse effects. Moreover, the administration should be done by trained personnel with close monitoring of vital signs and level of consciousness to prevent complications such as respiratory depression.

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Artificial intelligence (AI) broadly refers to machines that simulate intelligent human behavior, and research into this field is exponential and worldwide, with global players such as Microsoft battling with Google for supremacy and market share. This paper reviews the "good" aspects of AI in medicine for individuals who embrace the 4P model of medicine (Predictive, Preventive, Personalized, and Participatory) to medical assistants in diagnostics, surgery, and research. The "bad" aspects relate to the potential for errors, culpability, ethics, data loss and data breaches, and so on. The "ugly" aspects are deliberate personal malfeasances and outright scientific misconduct including the ease of plagiarism and fabrication, with particular reference to the novel ChatGPT as well as AI software that can also fabricate graphs and images. The issues pertaining to the potential dangers of creating rogue, super-intelligent AI systems that lead to a technological singularity and the ensuing perceived existential threat to mankind by leading AI researchers are also briefly discussed.

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Background: Publish or perish is a cliched mantra but publishing requires the acquisition of a wide set of disparate skills that are typically learned in a completely ad-hoc manner in an early period of one's career. The Write a Scientific Paper (WASP) course is delivered online by an experienced, international faculty of academics, including several medical journal editors. This study retrospectively analyzed the attendees' perceptions of the usefulness and the utility of WASP. Methods: An email questionnaire of 11 questions was sent to all previous WASP attendees, 370 subjects, in May 2022. The questions included the geographical locations of the subjects as well as the number of published articles before and since WASP course. Besides a couple of questions on rating and recommending the WASP course, some other related questions were also asked. Results: There were 68 responses (18%) with high agreement (Cronbach α = 0.92). The WASP course fared well across the different research-oriented dimensions and expectations and is mostly welcomed by young career professionals. Following WASP, a 9% increase in scientific writing and published articles engagement was reported. Discussion: WASP is an international and unique course that emphasises presentation skills using newspaper media theory. It highlights to the delegates the importance of understanding the conflicting tripod of forces that govern publishing. Authors wish to publish more; readers are inundated, wishing to read less, whereas journal editors' primary aims are to elevate their journals' impact factors. WASP endorsements and the testimonials are invariably positive. The transition to online barely affected satisfaction rates with WASP while permitting the enrolment of a more international faculty that includes even more journal editors. WASP's ultimate objective is to impart the faculty's collective experience to the delegates in this crucial, early aspect of career progress.

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Background: The increasing prevalence of obesity is a significant concern worldwide. Laparoscopic sleeve gastrectomy (LSG) is an effective and standard procedure for sustained weight loss. However, optimal pain control is essential for enhanced recovery after surgery. The aim of this randomized controlled study was to investigate the efficacy of a pre-incisional laparoscopic preperitoneal local anesthetic technique (PLPLAT) on recovery characteristics following LSG. Methods: A total of 120 obese patients scheduled to undergo LSG were randomized into the PLPLAT or placebo group (n = 60 patients in both groups). All patients received conventional intravenous or other analgesics postoperatively, as required. The primary outcome was the postoperative pain score. The secondary outcomes included morphine consumption, other analgesics, length of stay in the postanesthesia care unit (PACU), hemodynamic changes, postoperative nausea and vomiting (PONV), early mobilization, and length of hospital stay. Results: Pain scores in the PACU and at 12 hours after surgery in the ward were significantly lower in the PLPLAT group than in the placebo group (P < 0.05). The morphine consumption was significantly less in PLPLAT group with mean dosage of 2.95 mg (± 0.39) compared to 6.0 mg (± 0.4) in placebo group. PONV, mean arterial pressure, and PACU stay were significantly higher in the placebo group than in the PLPLAT group (P < 0.05). Conclusion: Intraoperative PLPLAT provide effective postoperative pain relief for patients undergoing LSG. The findings indicated the efficacy of PLPLAT in reducing postoperative pain, enhancing recovery, and facilitating early discharge.

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The dream is now real! We had started thinking of establishing "Bariatric Anesthesia Fellowship" (BAF) program in our setting since 2012. The reason was the increasing number of bariatric surgical cases for weight loss under general anesthesia (GA). The journey till establishing the BAF program consisted of two phases. Phase I started in 2012 to establish clinical practice guidelines (CPG) in "Anesthesia for Patients with Morbid Obesity undergoing weight loss surgery". Phase II started in 2015 to establish BAF program. In 2021 the first draft of BAF program was submitted to the medical education for approval. In March 2022, we got the interim approval of the program. Though the journey took sometime but ultimately it ended with success and achieving the dream. In this review, we are going to discuss a roadmap consisted of two phases in an attempt to reach our goal of establishing the BAF program.

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In 2016, the Enhanced Recovery After Bariatric Surgery guidelines (G16) was published, and in 2022, an update to it was released (G22). Grading of recommendations, assessment, development, and evaluations (GRADE), emphasizing the level of evidence (LoE) of both the guidelines, was performed. An overview of methodology was also performed, considering the following questions: how can research be improved, what can be done in the future using data, and how to collaborate more? Both guidelines did not explain how the LoE conclusions were derived regarding the risk of bias. There is also potential for forming a global consortium that deals with bariatric research, which can serve as a repository for all relevant data. Ensuring that this data is FAIR (findability, accessibility, interoperability, reusability) compliant and using this data to formulate future guidelines will benefit clinicians and patients alike.

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Background and Objectives: Peritoneal dialysis is an excellent treatment for end-stage renal disease. Peritoneal dialysis is more advantageous if the catheter is positioned laparoscopically with omentopexy. General anesthesia is required for laparoscopic peritoneal dialysis catheter placement. General anesthesia is associated with increased postoperative morbidity and mortality in high-risk patients. In this retrospective study, the results of laparoscopic placement of peritoneal dialysis catheter under preperitoneal local anesthesia technique and sedation are presented for end-stage renal disease patients not fit for general anesthesia. Methods: We recruited 13 patients for laparoscopic placement of peritoneal dialysis catheter out of 99 end-stage renal disease patients who presented at a local tertiary hospital. The selection criteria were based on the American Society of Anesthesiologists classification III or above and patients unfit for general anesthesia. Results: Laparoscopic placement of peritoneal dialysis catheter was performed on 99 patients, and 13 patients were unfit for general anesthesia. Laparoscopic placement of peritoneal dialysis catheter and omentopexy were performed on these 13 patients together with capnoperitoneum, under preperitoneal local anesthesia technique and sedation. Three catheters were removed due to exit-site infection. One patient died after 2 years due to cardiac disease. The remaining patients continued with peritoneal dialysis. No omental entrapment, catheter migration, or other complications were encountered. Conclusion: Laparoscopic placement of peritoneal dialysis catheter under preperitoneal local anesthesia technique and sedation was successful for high-risk patients unfit for general anesthesia. This technique can be expanded for healthy patients to avoid general anesthesia complications, reduce costs, and speed recovery.

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Seizure and anesthesia is a topic necessitating more studies to understand its mechanism. Some anesthetic agents triggers seizures, while others can control it. We are here reporting a case of apparently healthy young adult patient who underwent diagnostic cystoscopy and urethral dilatation under general anesthesia and who developed seizure immediately after admission to the postanaesthetic care unit.