Morbid Obesity and Gastric Bypass

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Morbid Obesity and Gastric Bypass

• Courtesy of
• Diego Gonzalez M.D.
• Metrohealth Medical Center
• Cleveland, Ohio

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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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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
• BMIweight (kg) / height (m2)
• BMIpounds/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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Types of Surgery
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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
  weightwhy?
• 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
• Predictability 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, Hypertriglyceridimi
  a

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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
• 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, 2001120336-339

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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 vs 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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• UNKNOWN

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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 an exquisite 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
• Higher Incidence of Guillain-Barre
• Case Report Chang Obes Surg 2002 Aug 12(4)
  592-97