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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 l.jpg

Morbid Obesity and Gastric Bypass

Diego Gonzalez M.D.

Metrohealth Medical Center

Cleveland, Ohio

November 4, 2002


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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


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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


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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


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Taco Bell?

  • Mexican american boys tend to have higher prevalence of overweight.

  • National Institute of Health. Call to Action Report 1998


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Heart Disease

  • Hypertension twice as common

  • Increased risk: MI, CHF, Sudden Death, Arrythmias.


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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


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Respiratory

  • Sleep Apnea

  • Obesity Hypoventilation Syndrome

  • Asthma

  • Decreased FRC

  • Increased risk of aspiration from GERD

  • Difficult airways (ventilate and intubate)


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Other

  • Arthritis

  • Reproductive complications

  • Gallbladder disease.

  • Depression, Social Discrimination


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What is BMI?

  • Body Mass Index

  • BMI=weight (kg) / height (m2)

  • BMI=pounds/inches 2 x 703

  • Why BMI?


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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


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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


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Surgery Aspect

  • Indications

  • Types

  • Results

  • Complications


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Indications

  • Age 18-60

  • BMI > 40

  • BMI > 35 with medical problems

  • Exhausted other venues of weight loss



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How do they work?

  • Restrictive

  • Malabsorption

  • Behavioral modification


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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


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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


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Anesthesia

  • Pre-Op

  • Intra-Op

  • Post-Op


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Pre-Op/ History

  • History and Physical

  • ROS

  • Airway

  • Heart

  • Lungs

  • Eyes… eyes?… yes eyes

  • Previous anesthesia


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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


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Cardiovascular

  • HTN: multiple medications difficult to control

  • Cardiomyopathy, CHF, Ischemia, CVA, Pulmonary HT, DVT, PE, Hypercholesterolemia, Hypertriglyceridimia


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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


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Lungs/ OSA

  • OSA- hypersomnolence, loud snoring, apnea and hypopnea during sleep

    • Physiologic changes:

      • Arterial hypoxemia

      • Polycythemia

      • Arterial Hypercarbia

      • HTN

      • Pulmonary hypertension


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Lungs/ OSA

  • Risk Factors:

    • Male

    • Middle Age

    • Obesity

    • Alcohol

    • Drug Induced Sleep


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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


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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


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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)


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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


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Lungs/ OSA vrs OHS

  • Chicken or the egg?

  • A spectrum of the same disease?


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Eyes

  • Hypoxia and hypercarbia as a sign of angiogenesis

    • Case Report , Elia J. Duh, AMA-Assn.org


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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….



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Post Op

  • Extubation

  • Post Op Pain

  • OSA and OHS

  • Cardiac


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Post Op/Extubation

  • Fully awake

  • Recover in head up positioning

  • Monitoring very important if OSA or OHS


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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


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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


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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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