R Rodriguez-Roisin, MD

UNIVERSITATDE BARCELONA

OBESIDAD SEVERA Y PULMÓN:EFECTOS DE LA CIRUGÍA

BARIÁTRICA

Why?

Pre-Operative Findings

One Year Later...

Summary

Agenda

Why?

Pre-Operative Findings

One Year Later...

Summary

Agenda

Leptin, IL-6, TNFα, C-RP

Obesity, systemic inflammation & lung

Arismendi E et al. PLoS ONE 2014;9:e107859

Arismendi E et al. PLoS ONE 2014;9:e107859

Beuther D et al. AJRCCM 2006;74:112-9

Severe obesity & lung function

Lung volume reduction in the lower regions due to excessive unopposed intra-abdominal pressure is likely the principal mechanism of arterial blood gases abnormalities induced by ventilation-perfusion (VA/Q) imbalance

Leptin, IL-6, TNFα, CRP

HypothesisThe contention was that very severe obesity:

is associated with impaired pulmonary gas

exchange, more specifically ventilation-

perfusion (VA/Q) ratio and pulmonary

vascular abnormalities.

bariatric surgery reduces body mass index

and systemic inflammation and improves

pulmonary gas exchange defects.

Rivas E et al. Chest 2014 (In Press)

To use the multiple inert gas elimination

technique in morbidly obese individuals,

before and after bariatric surgery.

To characterize pulmonary gas exchange

abnormalities while breathing ambient air

and 100% oxygen.

Objective

Rivas E et al. Chest 2014 (In Press)

Why?

Pre-Operative Findings

One Year Later...

Summary

Agenda

CONTROL OBESE(n, 8) (n, 19)

Age, yrs 50 ± 3 51 ± 2

BMI, kg/m2 25 ± 1 * 45 ± 1 *

Waist Circumference, cm 82 ± 5 * 125 ± 2 *

Waist-to-Hip Ratio 0.83 ± 0.03 0.90 ± 0.01

Former Smokers, n 0 2

Pack-years 0 17 ± 3

AHI, events/h 0 10 ± 2

Metabolic Syndrome, n 0 7

Clinical characteristics

Rivas E et al. Chest 2014 (In Press)

Arterial blood gases (ambient air)

mm

Hg

0

50

100

87±1

76±3

37±139±1

18±1

27±2

PaO2AaPO2 PaCO2

< 0.001

< 0.001

NS

CONTROLOBESE

Rivas E et al. Chest 2014 (In Press)

PaO2 PaCO2

Arterial blood gases (air vs 100% O2)

0

50

100

150

450

650m

mH

g

76±3

39±1 39±1

519

21% 100%

PaO2 PaCO2

*

*

Rivas E et al. Chest 2014 (In Press)

100%21%

Blo

od F

low

Dis

pers

ion

(Lo

g S

DQ

)

Shunt & VA/Q mismatching

Shu

nt, %

QT

21% 100%

< 0.01

0

5

10

15

0.00

0.50

1.00 NS

Rivas E et al. Chest 2014 (In Press)

r, – 0.63p < 0.05

Response to 100% oxygen

Change in Log SDQ

Ch

an

ge

in S

hu

nt,

%Q

T

-1.00 0.00 1.00-5.0

0.0

5.0

10.0

15.0

Rivas E et al. Chest 2014 (In Press)

Aghamohammadzadeh R et al. JACC 2013;62:128–35

Obesity & perivascular adipose tissue

Why?

Pre-Operative Findings

One Year Later...

Summary

Agenda

BMI decreased from 45 to 31 kg/m2

Excess Weight Loss: 79 %

ERV & serum biomarkers

Rivas E et al. Chest 2014 (In Press)

Arterial blood gases (ambient air)m

mH

g

100

0

50

89±2

27±2

40±1

15±2

76±3

39±1

PaCO2AaPO2PaO2

BEFOREAFTER

< 0.001

< 0.001NS

Rivas E et al. Chest 2014 (In Press)

Arterial blood gases (air vs 100% O2)

0

50

100150

450

650A

rter

ial P

O2,

mm

Hg

76±3

39±1

< 0.001

< 0.001

†

21% 100%

*

*

†

89±276±3

519

583BEFOREAFTER

Rivas E et al. Chest 2014 (In Press)

*

21%Blo

od F

low

Dis

pers

ion

(Lo

g S

DQ

)S

hunt

, %Q

T

< 0.01

*

21%

Shunt & VA/Q mismatching

< 0.01

†

100%

100%0

5

10

15

0.00

0.50

1.00

†

BEFOREAFTER

Rivas E et al. Chest 2014 (In Press)

r, – 0.63p < 0.05

BEFORE

Change in Log SDQ

15.0

Ch

ang

e in

Sh

un

t ,%

QT

-1.00 0.00 1.00-5.0

0.0

5.0

10.0

AFTER

r, – 0.45p, NS

Ch

ang

e in

Sh

un

t ,%

QT

Change in Log SDQ

-1.00 0.00 1.00-5.0

0.0

5.0

10.0

15.0

Response to 100% oxygen

Rivas E et al. Chest 2014 (In Press)

Aghamohammadzadeh R et al. JACC 2013;62:128–35

Obesity & perivascular adipose tissue

Why?

Pre-Operative Findings

One Year Later...

Summary

Agenda

Summary (1)

Morbidly obese subjects have mild-

to-moderate arterial hypoxemia

induced by mild-to-moderate shunt

and mildly broadened pulmonary

blood flow dispersion

Rivas E et al. Chest 2014 (In Press)

Summary (2)

Functional reabsorption atelectasis, without reversion of hypoxic pulmonary vasoconstriction is induced by oxygen breathing. This is consistent with alveolar denitrogenation and weaker pulmonary vessels possibly related to endothelial dysfunction

Rivas E et al. Chest 2014 (In Press)

Summary (3)

These gas exchange disturbances appear to be related to underlying excess body weight, reduced expiratory reserve volume and chronic systemic inflammation

Rivas E et al. Chest 2014 (In Press)

Summary (4)

After bariatric surgery, pulmonary gas exchange defects are considerably improved but not completely restored. These abnormalities concur with residual obesity and systemic inflammation

Rivas E et al. Chest 2014 (In Press)

Muchas Gracias !!!!