R Rodriguez-Roisin, MD UNIVERSITAT DE 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

BODE MASS INDEX (BMI) = WEIGHT/HEIGHT – – – – 39.9 ≥ 40 NORMALOVERWEIGHTOBESITY IOBESITY IIOBESITY III Obesity: Definition (BMI) & prevalence Yanovski SZ & Yanovski JA. NEJM 2011;364:987-9

Leptin, IL-6, TNFα, C-RP Obesity, systemic inflammation & lung

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

Vanfleteren LEGW et al. AJRCCM 2013;187:728-35

Obesity treatment Eckel RH. NEJM 2007;356:

Bariatric surgery for severe obesity DeMaria EJ. NEJM 2008;358:

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 (V A /Q) imbalance

Leptin, IL-6, TNFα, CRP Hypothesis The contention was that very severe obesity:  is associated with impaired pulmonary gas exchange, more specifically ventilation- perfusion (V A /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

CONTROLOBESE (n, 8)(n, 19) Age, yrs50±351±2 BMI, kg/m 2 25±1 *45±1 * Waist Circumference, cm82±5 *125±2 * Waist-to-Hip Ratio0.83± ±0.01 Former Smokers, n02 Pack-years017±3 AHI, events/h010±2 Metabolic Syndrome, n07 Clinical characteristics Rivas E et al. Chest 2014 (In Press)

ERV & serum biomarkers Leptin, ng/mL < CONTROLOBESE CRP, mg/L < CONTROLOBESE Adiponectin, μg/mL CONTROLOBESE ERV, % pred CONTROLOBESE <

Arterial blood gases (ambient air) mmHg ±1 76±3 37±1 39±1 18±1 27±2 PaO 2 AaPO 2 PaCO 2 < NS CONTROL OBESE Rivas E et al. Chest 2014 (In Press)

PaO 2 PaCO 2 Arterial blood gases (air vs 100% O 2 ) mmHg 76±3 39± %100% PaO 2 PaCO 2 * * Rivas E et al. Chest 2014 (In Press)

100%21% Blood Flow Dispersion (Log SDQ) Shunt & V A /Q mismatching Shunt, %Q T  21% 100% < NS Rivas E et al. Chest 2014 (In Press)

r, – 0.63 p < 0.05 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

BMI decreased from 45 to 31 kg/m 2 Excess Weight Loss: 79 % ERV & serum biomarkers Rivas E et al. Chest 2014 (In Press)

BMI decreased from 45 to 31 kg/m 2 Excess Weight Loss: 79 % ERV & serum biomarkers 125 < ERV, % pred BEFOREAFTER CRP, mg/L BEFOREAFTER < Leptin, ng/mL BEFOREAFTER < Adiponectin, μg/mL < BEFORE AFTER

Arterial blood gases (ambient air) mmHg ±2 27±2 40±1 15±2 76±3 39±1 PaCO 2 AaPO 2 PaO 2 BEFORE AFTER < NS Rivas E et al. Chest 2014 (In Press)

Arterial blood gases (air vs 100% O 2 ) Arterial PO 2, mmHg 76±3 39±1 < † 21%100% * * † 89±2 76± BEFORE AFTER Rivas E et al. Chest 2014 (In Press)

* 21% Blood Flow Dispersion (Log SDQ) Shunt, %Q T  < 0.01 * 21% Shunt & V A /Q mismatching < 0.01 † 100% † BEFORE AFTER Rivas E et al. Chest 2014 (In Press)

 r, – 0.63 p < 0.05 BEFORE Change in Log SDQ 15.0 Change in Shunt,%Q T  AFTER r, – 0.45 p, NS Change in Shunt,%Q T Change in Log SDQ Response to 100% oxygen Rivas E et al. Chest 2014 (In Press)

Δ BMI, Kg/m 2 Rho, – 0.72 p < 0.01 Δ FRC, L Δ BMI, Kg/m 2 Δ Log SDQ Rho, 0.54 p < Pre- & post-operative correlations

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 !!!!