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Morbid Obesity and Gastric Bypass. Diego Gonzalez M.D. Metrohealth Medical Center Cleveland, Ohio November 4, 2002. Fun Facts. 61% of adults in US have BMI >25 in ’99 13% of children 6-11 14% of adolescents aged 12-19 How many deaths in the US are associated with obesity? Economic Cost?

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morbid obesity and gastric bypass

Morbid Obesity and Gastric Bypass

Diego Gonzalez M.D.

Metrohealth Medical Center

Cleveland, Ohio

November 4, 2002

fun facts
Fun Facts
  • 61% of adults in US have BMI >25 in ’99
  • 13% of children 6-11
  • 14% of adolescents aged 12-19
  • 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 non-Hispanic white women(23%) are obese compared to non-Hispanic white men(21%)
  • Most affected-women 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 11-18 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
  • Asthma
  • Decreased FRC
  • Increased risk of aspiration from GERD
  • Difficult airways (ventilate and intubate)
other
Other
  • Arthritis
  • 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 18.5-24.9
  • Overweight 25.0-29.9
  • Obesity
    • Class I 30.0-34.9
    • Class II 35-39.9
    • 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
  • Types
  • Results
  • Complications
indications
Indications
  • Age 18-60
  • BMI > 40
  • BMI > 35 with medical problems
  • Exhausted other venues of weight loss
how do they work
How do they work?
  • Restrictive
  • Malabsorption
  • Behavioral modification
results
Results
  • Weight Loss- 66% at 1 to 2 years after surgery
  • 60% at 5 years
  • 50% at 10 years
  • African-american lose significantly less weight…why?
  • 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
Anesthesia
  • Pre-Op
  • Intra-Op
  • Post-Op
pre op history
Pre-Op/ History
  • History and Physical
  • ROS
  • Airway
  • Heart
  • Lungs
  • 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. 732-736
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 osa27
Lungs/ OSA
  • Risk Factors:
    • Male
    • Middle Age
    • Obesity
    • Alcohol
    • 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 ohs29
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 ohs30
Lungs/OHS
  • Physiologic Changes:
    • Hypersomnolence (also OSA)
    • Arterial Hypoxemia (also OSA)
    • Polycythemia (also OSA)
    • Hypercarbia (also OSA)
    • Respiratory acidosis
    • Pulmonary hypertension (also OSA)
    • RV Failure (also OSA)
lungs ohs31
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, 2001:120:336-339
lungs osa vrs ohs
Lungs/ OSA vrs OHS
  • Chicken or the egg?
  • A spectrum of the same disease?
slide33
Eyes
  • Hypoxia and hypercarbia as a sign of angiogenesis
        • Case Report , Elia J. Duh, AMA-Assn.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….
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 extubation38
Post Op/Extubation

Maximun decrease in PaO2 is 2-3 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 2-3 days post op
post op others
Post Op/ Others
  • Others:
    • DVT early ambulation/ heparin
    • Wound infection is twice as common
    • Guillain-Barre
        • Case Report: Chang; Obes Surg 2002 Aug; 12(4) 592-97
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