Pathophysiology of obesitas impact on laparoscopy j p mulier md phd mercedes garcia md
This presentation is the property of its rightful owner.
Sponsored Links
1 / 29

Pathophysiology of obesitas, impact on laparoscopy J P Mulier MD PhD Mercedes Garcia MD PowerPoint PPT Presentation


  • 92 Views
  • Uploaded on
  • Presentation posted in: General

“The sea” from Georges Gerard Better known as “fat Mathilde of Ostend”. Pathophysiology of obesitas, impact on laparoscopy J P Mulier MD PhD Mercedes Garcia MD. Sint Jan Brugge-Oostende www.publicationslist.org/jan.mulier. Classification of body weight:. Body Mass Index (BMI):

Download Presentation

Pathophysiology of obesitas, impact on laparoscopy J P Mulier MD PhD Mercedes Garcia MD

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Pathophysiology of obesitas impact on laparoscopy j p mulier md phd mercedes garcia md

“The sea” from Georges Gerard

Better known as

“fat Mathilde of Ostend”

Pathophysiology of obesitas, impact on laparoscopy J P Mulier MD PhDMercedes Garcia MD

Sint Jan Brugge-Oostende

www.publicationslist.org/jan.mulier

ESPCOP 14 nov 2009 Ostend JPM


Classification of body weight

Classification of body weight:

  • Body Mass Index (BMI):

    • TBW/Length 2 (Kg/m2 )

      Overweight: BMI 25 – 30

      Obese: BMI  30

  • Moderate obese: BMI 30-34,9

  • Severe obese : BMI 35-39,9

  • Morbid obese: BMI  40

  • Super obese : BMI  50

  • Super super obese: BMI  60

ESPCOP 14 nov 2009 Ostend JPM


Body fat weight formula

Body fat weight formula

  • Women

    • Factor 1 (Total body weight x 0.732) + 8.987

    • Factor 2 Wrist measurement (at fullest point) / 3.140

    • Factor 3 Waist measurement (at naval) x 0.157

    • Factor 4 Hip measurement (at fullest point) x 0.249

    • Factor 5 Forearm measurement (at fullest point) x 0.434

  • Lean Body Mass

    • Factor 1 + Factor 2 - Factor 3 - Factor 4 + Factor 5

  • Men

    • Factor 1(Total body weight x 1.082) + 94.42

    • Factor 2 Waist measurement x 4.15

  • Lean Body Mass:

    • Factor 1 - Factor 2

  • Body Fat Weight: Total body weight - Lean Body Mass

ESPCOP 14 nov 2009 Ostend JPM


Waist to hip ratio whr

Waist to Hip ratio (WHR)

  • Man normal WHR: 0,9

  • Woman normal WHR: 0,7

  • Android fat distribution

    • WHR > 0,8

  • Gynoid fat distribution

    • WHR < 0,8

ESPCOP 14 nov 2009 Ostend JPM


Whr vs bmi

WHR vs BMI

ESPCOP 14 nov 2009 Ostend JPM


Obesity type

Obesity type

  • Android vsGynoid

ESPCOP 14 nov 2009 Ostend JPM


Attractiveness in whr from 4000 bc until 2000 ac

Attractiveness in WHR from 4000 BC until 2000 AC

1,5 1,1 1,5 0,5 0,7

ESPCOP 14 nov 2009 Ostend JPM


Metabolic syndrome 3 of the 4

Metabolic syndrome: 3 of the 4

Diabetus

Hypertension

Dyslipidemia

Visceral obesity

ESPCOP 14 nov 2009 Ostend JPM


Negative feedback loop

Negative feedback loop

  • Obesity: high leptin but

    • BBB transport insufficient; hypothal leptin resistance

      • Evolution: resistance when oversupply to allow storage, no mechanism for continuous oversupply

Slow reaction over days

Resistance problem

fast reaction in hours

Insufficiency problem

ESPCOP 14 nov 2009 Ostend JPM


Hypoxia hypothesis

Hypoxia hypothesis

  • If angiogenesis, hypoxia improves

  • If fibrosis, hypoxia stays stimulating further inflammatory reactions and adipokines secretion

    • Dyslipidemia, hypertension, glucose intolerance

ESPCOP 14 nov 2009 Ostend JPM


Changes in the respiratory system

Changes in the respiratory system

  • Fat intercostal, diaphragm, intra visceral

    • decreased chest wall compliance

    • impaired lung expansion

    • permanent hypoventilation and atelectasis.

  • Reduction in 1 sec V, RV, FRC and TLC

    • dyspnea

    • need CPAP, PEEP and recruitment

  • Increased pulmonary blood flow

    • Lung compliance decreased

ESPCOP 14 nov 2009 Ostend JPM


Result respiratory distress

Result: Respiratory distress

  • increased work of breathing,

  • increased oxygen consumption,

  • no reserve capacity

  • ventilation perfusion mismatch

    • mean AaDO2 is 4 times higher

  • impaired gas exchange

    • PaO2 is lower

  • Every 5 kg reduction in weight increases the PaO2 and decreases the AaDO2 by 1 mmHg

ESPCOP 14 nov 2009 Ostend JPM


Osa ohs pickwick syndrome

OSA -> OHS -> Pickwick syndrome

  • 5% of morbid obese persons have obstructive sleep apnoea (OSA): pharyngeal collapse

    • daytime somnolence, snoring, awaken from sleep choking, morning headaches.

    • hypoxemia and desaturation during night.

  • it progresses sometimes to obesity hypoventilation syndrome (OHS).

    • + Hypoxemia and hypercapnea during day

  • Further progress to Pickwick syndrome

    • + policytemia and right heart failure

ESPCOP 14 nov 2009 Ostend JPM


Pulmonary disorders

Pulmonary disorders

ESPCOP 14 nov 2009 Ostend JPM


Disorders in the cardiovascular system

Disorders in the cardiovascular system

ESPCOP 14 nov 2009 Ostend JPM


Ct scan

CT scan

  • Mulier J.P., Coenegrachts CT analysis of the elastic deformation and elongation of the abdominal

  • wall during colon inflation for virtual coloscopy

  • Eur J Anesthesia 2008 Suppl

ESPCOP 14 nov 2009 Ostend JPM


Bmi effect on abdominal p v relation

J Mulier ISPUB 2009

Pressure volume relation is linear

PV0 and E define each patient

J Mulier IFSO 2007

BMI effect on abdominal P/V relation

ESPCOP 14 nov 2009 Ostend JPM


Android versus gynoid fat distribution has a different elastance

Android versus Gynoid fat distribution has a different Elastance

ESPCOP 14 nov 2009 Ostend JPM


Two types of android obesity

Two types of android obesity

Subcutaneus FatVisceral fat

Intra visceral adiposity Extra visceral adiposity

Subcutaneus fat is scant and Subcutaneus fat is thick and

intra abdominal fat is thick and intra abdominal fat is scant.

ESPCOP 14 nov 2009 Ostend JPM


Large intra visceral fat volume or liver steatosis makes the relation non linear

If the abdominal fascia is already circular instead of elliptic

No deformation possible

No radius decrease with increasing volume

Large intra visceral fat volume, or liver steatosis makes the relation non linear !

ESPCOP 14 nov 2009 Ostend JPM


What can we do to improve the abdominal physiology

What can we do to improve the abdominal physiology?

  • Improve surgical workspace

  • Facilitate ventilation

  • Reduce mortality

    • Methods available ?

ESPCOP 14 nov 2009 Ostend JPM


Muscle relaxation effect on pv0

Muscle relaxation effect on PV0

  • E or Compliance no change

    • E is by fascia, size en shape determined

  • PV0 lower

    • Relaxants identical to 2 MAC Sevo or Desflu

      • J Mulier B dillemans EJA 2006, IFSO 2008

ESPCOP 14 nov 2009 Ostend JPM


Table inclination changes pvo

Table inclination changes PVO

  • J Mulier, B Dillemans Ifso 2009

ESPCOP 14 nov 2009 Ostend JPM


Leg flexion lowers e

Leg flexion lowers E

  • J Mulier B Dillemans IFSO 2009

ESPCOP 14 nov 2009 Ostend JPM


Lapararoscopy lowers e

Lapararoscopy lowers E

  • Mean IAP: 15,4 +/- 1,5 mmHg

  • Mean pneumoperitoneum time: 59 +/- 19 minutes

    • J Mulier PGA 2009

ESPCOP 14 nov 2009 Ostend JPM


What can we do to improve the abdominal physiology1

What can we do to improve the abdominal physiology?

  • Improve surgical workspace

  • Facilitate ventilation

  • Reduce mortality

    • Weigth reduction pre op lowers the PV0

    • Muscle relaxation lowers the PV0

    • Trendelenburg lowers the PV0

    • Beach chair position lowers the E

    • Prolonged pneumoperitoneum lowers the E

      • Gravidity lowers E

ESPCOP 14 nov 2009 Ostend JPM


Conclusion

Conclusion

  • Android vs gyneoid fat distribution

  • Intra visceral vs extra visceral fat accumulation

    • Metabolic syndrome with cardiovascular risk and diabetes

    • Higher intra abdominal pressures PV0

    • Lower Elastance E

    • Higher mortality

  • Respiratory function is decreased

  • Higher cardiac output with possible obesity cardiomyopathy and pulmonary hypertension

  • Muscle relaxation, beach chair, weight reduction

ESPCOP 14 nov 2009 Ostend JPM


The obese patient is a challenge for anaesthesia if android shape with intra visceral fat

The obese patient is a challenge for anaesthesia if android shape with intra visceral fat.

ESPCOP 14 nov 2009 Ostend JPM


Become member of espcop today everyone has obese patients in the future

Become member of ESPCOP today everyone has obese patients in the future

ESPCOP 14 nov 2009 Ostend JPM


  • Login