Unformatted text preview: Morbid Obesity and Gastric Morbid Obesity and Gastric Bypass
Diego Gonzalez M.D.
Metrohealth Medical Center
November 4, 2002 Fun Facts
Fun Facts 61% of adults in US have BMI >25 in ’99
13% of children 611
14% of adolescents aged 1219
How many deaths in the US are associated with obesity?
Economic Cost? National Institute of Health. Call to Action Report Deaths and Cost
Deaths and Cost 300,000 deaths per year
BMI >30 have a 50%100% increased risk of premature death.
117 BILLION dollars in 2000 National Institute of Health. Call to Action Report More Fun Facts
More Fun Facts More nonHispanic white women(23%) are obese compared to nonHispanic white men(21%)
Most affectedwomen are of low socioeconomic. National Institute of Health. Call to Action Report Taco Bell?
Taco Bell? Mexican american boys tend to have higher prevalence of overweight. National Institute of Health. Call to Action Report 1998 Heart Disease
Heart Disease Hypertension twice as common
Increased risk: MI, CHF, Sudden Death, Arrythmias. Diabetes
Diabetes A gain of 1118 lbs increases the risk of developing Type 2 to twice that of normal individuals
Over 80% of people with DM type 2 are overweight or obese Respiratory Respiratory Sleep Apnea
Obesity Hypoventilation Syndrome
Increased risk of aspiration from GERD
Difficult airways (ventilate and intubate) Other
Reproductive complications Gallbladder disease.
Depression, Social Discrimination What is BMI?
What is BMI? Body Mass Index
BMI=weight (kg) / height (m2)
BMI=pounds/inches 2 x 703
Why BMI? Classification Classification Healthy Weight 18.5
Obesity Class I 30.034.9
Class II 3539.9
Class III >40 Limitations to BMI….really?
Limitations to BMI….really? Overestimate body fat in persons who are very muscular i.e. body builders
Underestimate body fat in persons who have lost muscle mass i.e. elderly Surgery Aspect
Surgery Aspect Indications
Indications Age 1860
BMI > 40
BMI > 35 with medical problems
Exhausted other venues of weight loss Types of Surgery
Types of Surgery How do they work?
How do they work? Restrictive
Behavioral modification Results
Results Weight Loss 66% at 1 to 2 years after surgery
60% at 5 years
50% at 10 years
Africanamerican lose significantly less weight…
Improvement in comorbities Complications
Complications Akin to any surgery i.e. infection, DVT, wound deshicense, anastomotic leaks, etc.
Death 1%2% after surgery, but higher with other comorbities.
Irritable bowel syndrome ….can lead to rectal problems Anesthesia
PostOp PreOp/ History
PreOp/ History History and Physical
Eyes… eyes?… yes eyes
Previous anesthesia Airway
Airway Mallampati, mouth opening, tongue size, thyromental distance, sternomental distance, neck circumference
Predictibility of difficult intubation: neither obesity or BMI predicted problems with tracheal intubation… BUT HIGH MALLAMPATI SCORE >3 and LARGE NECK CIRCUMFERENCE MAY INCREASE THE POTENTIAL FOR DIFFICULT LARYNGOSCOPY AND INTUBATION Anesthesia and Analgesia, Mar 2002. 732736 Cardiovascular
Cardiovascular HTN: multiple medications difficult to control
Cardiomyopathy, CHF, Ischemia, CVA, Pulmonary HT, DVT, PE, Hypercholesterolemia
, Hypertriglyceridimia Obesity Cardiomyopathy
Obesity Cardiomyopathy Patients with severe and long standing obesity
LVH, left ventricle dilation and LV diastolic dysfunction.
Left Ventricle Failure and Right Ventricle Failure = Obesity Cardiomyopathy
Causes of death are CHF and sudden cardiac death Lungs/ OSA
Lungs/ OSA OSA hypersomnolence, loud snoring, apnea and hypopnea during sleep Physiologic changes: Arterial hypoxemia Polycythemia Arterial Hypercarbia HTN Pulmonary hypertension Lungs/ OSA
Lungs/ OSA Risk Factors: Male
Drug Induced Sleep Lungs/OHS
Lungs/OHS Obesity Hypoventilation Syndrome is defined as: PaO2 < 70 PaCO2 > 45 BMI > 30 kg/m2
No other respiratory disease of explaining the gas anomaly Lungs/OHS
Lungs/OHS Why is there hypoventilation?
1. High cost of work of respiration
2. Dysfunction of the respiratory center
3. Repeated episodes of nocturnal obstructive apnea Lungs/OHS
Lungs/OHS Physiologic Changes: Hypersomnolence (also OSA)
Arterial Hypoxemia (also OSA)
Polycythemia (also OSA)
Hypercarbia (also OSA)
Pulmonary hypertension (also OSA)
RV Failure (also OSA) Lungs/OHS
Lungs/OHS Some say that OHS progress into OSA
Some say that they are different entities.
Who is right?
OHS are usually: Older, more obese, more deranged daytime ABG values, more restricted lung volume, more severe desaturation during sleep. Chest, 2001:120:336339 Lungs/ OSA vrs OHS
Lungs/ OSA vrs OHS Chicken or the egg?
A spectrum of the same disease? Eyes
Eyes Hypoxia and hypercarbia as a sign of angiogenesis Case Report , Elia J. Duh, AMAAssn.org Intra Operative
Intra Operative GA vrs TIVA GA supplemented with regional
Fast onset and fast offset medication
Good muscle paralysis
Calculate drug doses according to IBW
Best choice of maintenance is…. NOT KNOWN
NOT KNOWN Post Op
Post Op Extubation
Post Op Pain
OSA and OHS
Cardiac Post Op/Extubation
Post Op/Extubation Fully awake
Recover in head up positioning
Monitoring very important if OSA or OHS Post Op/Extubation
Maximun decrease in PaO2 is 23 days post op.
Mechanical weaning can be difficult b/c:
1. Increased work of breathing
2. Decresed lung volumes
3. V/Q mismatch Pain Control and OSA
Pain Control and OSA Pt with OSA have a exquist sensibility to narcotics, even when used in regional techniques.
Narcotics can have depressive effects up to 23 days post op Post Op/ Others
Post Op/ Others Others: DVT early ambulation/ heparin
Wound infection is twice as common
GuillainBarre Case Report: Chang; Obes Surg 2002 Aug; 12(4) 59297 Daddies little girl…Ana Isabel
Daddies little girl…Ana Isabel ...
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- Anatomy, morbid obesity, Lungs/ OSA, Lungs/ OSA vrs