OBESITY & SURGERY 1

OBESITY & SURGERY

Dr. PEGBA-OTEMOLU I.L

OBESITY & SURGERY 2

OUTLINE

• Introduction• Definition of terms• Statement of Surgical importance• Prevalence• Associated problems• Pre, Intra & Post-operative considerations• Treatment of Obesity– Operative and Non-Operative

• Conclusion

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INTRODUCTION

• Obesity is an objective measurement assessed as

• Body Mass Index >30kg/m2

• Body weight in excess of 120% of the Ideal Body weight of the individual

• Waist hip ratio >0.85 in females and > 0.90 in males

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STATEMENT OF SURGICAL IMPORTANCE

• Obesity exposes surgical patients to increased morbidity and mortality

• Obesity increases the technical difficulty of surgery to the surgeon and anaesthetist

• Surgery also provides an important treatment option for the correction of obesity

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DEFINITION OF TERMS

• Ideal Body Weight is the believed to be maximally healthful for a person, based chiefly on height but modified by factors such as gender, age, build, and degree of muscular development

• Body mass index: Weight in Kg/ (Height in metres)2

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Body Mass Index in Kg/m2

Underweight Normal Overweight Obese Morbidly Obese*

Super Obese

< 18.5 18.5- 24.9 25 -29.9 >30 >35 or >40 >50

DEFINITION OF TERMS

*Morbid Obesity BMI > 40kg/m2 or >35kg/m2 in the presence of obesity related comorbidity

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• Waist hip ratio: waist circumference at midpoint between lowest rib and iliac crest: widest circumference around the hips

• Lean Body Weight

DEFINITION OF TERMS

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IN CHILDRENAnthropometric Index Percentile Cut-off Values Nutritional Status Indicator

WHO Growth Charts 2nd And 98th Percentiles

Length-for-age < 2nd Short stature

Weight-for-length < 2nd Low weight-for-length

Weight-for-length > 98th High weight-for-length

CDC Growth Charts 5th And 95th Percentile

BMI-for-age ≥ 95th Obesity

BMI-for-age ≥ 85th and < 95th Overweight

BMI-for-age < 5th Underweight

Stature-for-age < 5th Short Stature

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PREVALENCE

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• Obesity is the 2nd most preventable cause of death after cigarette smoking

• It decreases life expectancy (2.4 years)• Predisposes to medical and surgical diseases

in both children and adults

PREVALENCE

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PREVALENCE-MORBIDITY IN OBESE SURGICAL PATIENT

• Wound dehiscence – 30%• Surgical Site Infection – 17% • Incisional Hernia – 30%• Seroma – 19%• Hematoma – 13%• Fat necrosis – 10%• Tenfold increased risk of anastomotic leakage• Increases risk of hernia occurrence and recurrence

after surgery

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PROBLEMS• Central Nervous System (CNS)

– Depression• Cardiovascular Vascular System (CVS)

– Hypertension– Hyperlipidaemia– Ischaemic Heart Disease

• Respiratory System (RS)– Reduced Functional Residual Capacity– Asthma (usually a wheeze due to airway closure)– Sleep disordered breathing– Atelectasis

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• Gastrointestinal system– Dyspepsia– Peptic Ulcer Disease– Reflux– Hernia

• Genitourinary system– Infertility

• Circulatory system– Venous Thrombotic Events– Varicose veins

PROBLEMS

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PROBLEMS

• Musculoskeletal skeletal– Blount’s Disease– Slipped capital femoral epiphyses– Osteoarthritis– Degenerative spine disease

• Endocrine System– Diabetes Mellitus

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PRE-OPERATIVE ASSESSMENT

• During history taking ascertain presence of diagnosed medical conditions

• Ask for symptoms of associated medical conditions

• Past Surgical and anaesthetic history• Medications• Social history of smoking and alcohol or drug

abuse which can compound challenges

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• Examination should reveal comorbidities where present• Record weight, height and BMI• Fat distribution

– Central fat is metabolically active unlike peripheral and contributes significantly to morbidity

• Cardiovascular system– Ensure appropriate cuff size is used for BP measurement

• Respiratory system– Assess cardiopulmonary reserves– Respiratory wheeze at rest

PRE-OPERATIVE ASSESSMENT

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• Investigations should be thorough and seek out undiagnosed or expose severity of diagnosed illnesses– ECG– Arterial saturation < 95% on air– Forced vital capacity < 3L or forced expiratory volume in

1 s < 1.5L– Serum bicarbonate concentration > 27 mmol.l−1

– An arterial PCO2 > 6 kPa– PT/INR

PRE-OPERATIVE ASSESSMENT

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• When possible delay surgery till after patient has lost some weight

• Consent form should include increased risks of surgery attributable to obesity

• Consultant Anaesthetist review prior to surgery for optimal outcomes is important

PRE-OPERATIVE ASSESSMENT

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PRE-OPERATIVE PREPARATION

• Appropriate sized gowns• Adequate number of theatre staff• Appropriate monitoring equipment• Notify theatre staff of patient and needs for

adequate preparation• DVT Prophylaxis

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INTRA-OPERATIVE CONSIDERATIONS

• Anaesthesia– Positioning for intubation– Pre-oxygenation– Airway management – Vascular access– Drug dose– Needle size for regional anaesthesia

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• Transferring patient to operating table• Positioning on table• Operating table size/maximum weight• Tourniquet use• Cleaning and draping• Electrocautery• Access to operative site• Wound closure

INTRA-OPERATIVE CONSIDERATIONS

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POST-OPERATIVE CONSIDERATIONS

• Increased risk of Venous thrombotic events• Look out for early signs of surgical site

infection • Positioning to prevent aspiration• Prevention of bedsores

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COMPLICATIONS OF SURGERY

• Intra-operative– Hemorrhage– Development of pressure necrosis– Respiratory compromise

• Post-operative– Vide supra

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MANAGEMENT OF OBESITY

TREATMENT OPTIONS

• Medicine 18% vs Surgery 30% to 80%• J Am Coll Surg. 2003 Mar;196(3):379-84.

– A comparison of diet and exercise therapy versus laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity: a decision analysis model.

Patterson EJ, Urbach DR, Swanstrom LL.

Department of Minimally Invasive Surgery, Legacy Health System, Portland, OR, USA.

CONCLUSIONS: In a decision analysis model, laparoscopic gastric bypass surgery for morbid obesity was associated with a substantially longer survival than diet and exercise therapy. Copyright 2003 by the American College of Surgeons

NON-OPERATIVE

Food Addiction– Psychological Component– Physical Component– Group Therapy & Support

Behavior Modification– Eat 3 times per day– No Snacking Between Meals (Water Only)– No Eating after 7:00 pm

Lifestyle Changes– Walk one half hour per day (Continuous)

ELIGIBILITY CRITERIA FOR SURGERY

• Acceptable Medical Risk for Surgery• Failed attempts @ non-surgical weight

reductions (Diet & Exercise)• BMI>40; • BMI> 35 with obesity related comorbidities• No Psychiatric Contraindications• Realistic Commitment and Expectations

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WORLDWIDE

• 468,609 Bariatric Surgeries performed worldwide (2013)

• 95.7% carried out laparoscopically• 32.9% in the USA• 45% Roux-en-Y • 37 % Sleeve Gastrectomy• 10% Adjustable Gastric Banding

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BARIATRIC SURGERYPrimarily restrictive

Malabsorptive

Combination

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PLASTIC SURGERYABDOMINOPLASTY

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PLASTIC SURGERYBODY CONTOURING

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CONCLUSION

• Obesity has inherent medical risks which increase morbidity and mortality in surgery

• Obesity poses mechanical and technical challenges that must also be anticipated and planned for

• Obesity often requires multi-disciplinary management

• Operative options are available and have better outcomes for the treatment of the morbidly obese

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QUESTIONS???

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REFERENCES• F. Charles Brunicardi, MD, FACS Ed. 2015. The surgical Management of Obesity In: Schwartz’s Principles

of Surgery 10th Edition. New York, McGraw Hill Medical pp. 1099-1125• Leonard L., & Barton S. J. (2008) Preoperative Preparation In:Norman Williams Ed. Bailey and Love’s

Short Practice of Surgery 25th Edition. Great Britain, Edward Arnold Publishers pp. 188-189• Principles and Practice of Surgery Including Pathology in the Tropics Chapter 63 Minimally Invasive

Surgery• Ducheine Y., (2010) Morbid Obesity [Presentation] Chateau Montebello• Chambers W.A (2007) Peri-operative management of the morbidly obese patient. The Association of

Anaesthetists of Great Britain and Ireland Available from: http://www.aagbi.org/sites/default/files/Obesity07.pdf [Accessed 10th May, 2015]

• Grifiths R.,(2015) Peri-operative management of the obese surgical patient. The Association of Anaesthetists of Great Britain and Ireland. Available from: http://onlinelibrary.wiley.com/doi/10.1111/anae.13101/full# [Accessed 11th May, 2015]

• Centers for Disease Control & Prevention (2013) Use and Interpretation of the WHO and CDC Growth Charts for Children from Birth to 20 Years in the United States. Available from: http://www.cdc.gov/nccdphp/dnpao/growthcharts/resources/growthchart.pdf [Accessed 11th May, 2015]

• Angrisani L1, Santonicola A, Iovino P, Formisano G, Buchwald H, Scopinaro N. (2015) Bariatric Surgery Worldwide 2013. Obesity Surgery. 2015 Oct;25(10):1822-32. Available from: doi: 10.1007/s11695-015-1657-z [Accessed 11th May, 2015]