1. ESPCOP 14 nov 2009 Ostend JPM Sint Jan Brugge-Oostende www.publicationslist.org/jan.mulier “The sea” from Georges Gerard Better known as “fat Mathilde of Ostend” Pathophysiology of obesitas, impact on laparoscopy J P Mulier MD PhD Mercedes Garcia MD

2. ESPCOP 14 nov 2009 Ostend JPM Classification of body weight: Body Mass Index (BMI): Body Mass Index (BMI): TBW/Length 2 ( Kg/m 2 ) TBW/Length 2 ( Kg/m 2 ) Overweight: BMI 25 – 30 Obese: BMI  30 Moderate obese: BMI 30-34,9 Moderate obese: BMI 30-34,9 Severe obese : BMI 35-39,9 Severe obese : BMI 35-39,9 Morbid obese: BMI  40 Morbid obese: BMI  40 Super obese : BMI  50 Super obese : BMI  50 Super super obese: BMI  60 Super super obese: BMI  60

3. ESPCOP 14 nov 2009 Ostend JPM Body fat weight formula Women Women Factor 1 (Total body weight x 0.732) + 8.987 Factor 1 (Total body weight x 0.732) + 8.987 Factor 2 Wrist measurement (at fullest point) / 3.140 Factor 2 Wrist measurement (at fullest point) / 3.140 Factor 3 Waist measurement (at naval) x 0.157 Factor 3 Waist measurement (at naval) x 0.157 Factor 4 Hip measurement (at fullest point) x 0.249 Factor 4 Hip measurement (at fullest point) x 0.249 Factor 5 Forearm measurement (at fullest point) x 0.434 Factor 5 Forearm measurement (at fullest point) x 0.434 Lean Body Mass Lean Body Mass Factor 1 + Factor 2 - Factor 3 - Factor 4 + Factor 5 Factor 1 + Factor 2 - Factor 3 - Factor 4 + Factor 5 Men Men Factor 1(Total body weight x 1.082) + 94.42 Factor 1(Total body weight x 1.082) + 94.42 Factor 2 Waist measurement x 4.15 Factor 2 Waist measurement x 4.15 Lean Body Mass: Lean Body Mass: Factor 1 - Factor 2 Factor 1 - Factor 2 Body Fat Weight: Total body weight - Lean Body Mass Body Fat Weight: Total body weight - Lean Body Mass

4. ESPCOP 14 nov 2009 Ostend JPM Waist to Hip ratio (WHR) Man normal WHR: 0,9 Man normal WHR: 0,9 Woman normal WHR: 0,7 Woman normal WHR: 0,7 Android fat distribution Android fat distribution WHR > 0,8 WHR > 0,8 Gynoid fat distribution Gynoid fat distribution WHR < 0,8 WHR < 0,8

5. ESPCOP 14 nov 2009 Ostend JPM WHR vs BMI

6. ESPCOP 14 nov 2009 Ostend JPM Obesity type Android vsGynoid Android vsGynoid

7. ESPCOP 14 nov 2009 Ostend JPM Attractiveness in WHR from 4000 BC until 2000 AC 1,5 1,1 1,5 0,5 0,7

8. ESPCOP 14 nov 2009 Ostend JPM Metabolic syndrome: 3 of the 4 HypertensionDiabetus Visceral obesityDyslipidemia

9. ESPCOP 14 nov 2009 Ostend JPM Negative feedback loop Obesity: high leptin but Obesity: high leptin but BBB transport insufficient; hypothal leptin resistance BBB transport insufficient; hypothal leptin resistance Evolution: resistance when oversupply to allow storage, no mechanism for continuous oversupply Evolution: resistance when oversupply to allow storage, no mechanism for continuous oversupply Slow reaction over days Resistance problem fast reaction in hours Insufficiency problem

10. ESPCOP 14 nov 2009 Ostend JPM Hypoxia hypothesis If angiogenesis, hypoxia improves If angiogenesis, hypoxia improves If fibrosis, hypoxia stays stimulating further inflammatory reactions and adipokines secretion If fibrosis, hypoxia stays stimulating further inflammatory reactions and adipokines secretion  Dyslipidemia, hypertension, glucose intolerance

11. ESPCOP 14 nov 2009 Ostend JPM Changes in the respiratory system Fat intercostal, diaphragm, intra visceral Fat intercostal, diaphragm, intra visceral decreased chest wall compliance decreased chest wall compliance impaired lung expansion impaired lung expansion permanent hypoventilation and atelectasis. permanent hypoventilation and atelectasis. Reduction in 1 sec V, RV, FRC and TLC Reduction in 1 sec V, RV, FRC and TLC dyspnea dyspnea need CPAP, PEEP and recruitment need CPAP, PEEP and recruitment Increased pulmonary blood flow Increased pulmonary blood flow Lung compliance decreased Lung compliance decreased

12. ESPCOP 14 nov 2009 Ostend JPM Result: Respiratory distress increased work of breathing, increased work of breathing, increased oxygen consumption, increased oxygen consumption, no reserve capacity no reserve capacity ventilation perfusion mismatch ventilation perfusion mismatch mean AaDO2 is 4 times higher mean AaDO2 is 4 times higher impaired gas exchange impaired gas exchange PaO2 is lower PaO2 is lower Every 5 kg reduction in weight increases the PaO2 and decreases the AaDO2 by 1 mmHg Every 5 kg reduction in weight increases the PaO2 and decreases the AaDO2 by 1 mmHg

13. ESPCOP 14 nov 2009 Ostend JPM OSA -> OHS -> Pickwick syndrome 5% of morbid obese persons have obstructive sleep apnoea (OSA): pharyngeal collapse 5% of morbid obese persons have obstructive sleep apnoea (OSA): pharyngeal collapse daytime somnolence, snoring, awaken from sleep choking, morning headaches. daytime somnolence, snoring, awaken from sleep choking, morning headaches. hypoxemia and desaturation during night. hypoxemia and desaturation during night. it progresses sometimes to obesity hypoventilation syndrome (OHS). it progresses sometimes to obesity hypoventilation syndrome (OHS). + Hypoxemia and hypercapnea during day + Hypoxemia and hypercapnea during day Further progress to Pickwick syndrome Further progress to Pickwick syndrome + policytemia and right heart failure + policytemia and right heart failure

14. ESPCOP 14 nov 2009 Ostend JPM Pulmonary disorders

15. ESPCOP 14 nov 2009 Ostend JPM Disorders in the cardiovascular system

16. ESPCOP 14 nov 2009 Ostend JPM CT scan Mulier J.P., Coenegrachts CT analysis of the elastic deformation and elongation of the abdominal wall during colon inflation for virtual coloscopy Eur J Anesthesia 2008 Suppl

17. ESPCOP 14 nov 2009 Ostend JPM BMI effect on abdominal P/V relation J Mulier ISPUB 2009 J Mulier ISPUB 2009 Pressure volume relation is linear Pressure volume relation is linear PV0 and E define each patient PV0 and E define each patient J Mulier IFSO 2007 J Mulier IFSO 2007

18. ESPCOP 14 nov 2009 Ostend JPM Android versus Gynoid fat distribution has a different Elastance

19. ESPCOP 14 nov 2009 Ostend JPM Two types of android obesity Intra visceral adiposity Extra visceral adiposity Intra visceral adiposity Extra visceral adiposity Subcutaneus fat is scant and Subcutaneus fat is thick and Subcutaneus fat is scant and Subcutaneus fat is thick and intra abdominal fat is thick and intra abdominal fat is scant. intra abdominal fat is thick and intra abdominal fat is scant. Subcutaneus Fat Visceral fat

20. ESPCOP 14 nov 2009 Ostend JPM Large intra visceral fat volume, or liver steatosis makes the relation non linear ! If the abdominal fascia is already circular instead of elliptic If the abdominal fascia is already circular instead of elliptic No deformation possible No deformation possible No radius decrease with increasing volume No radius decrease with increasing volume

21. ESPCOP 14 nov 2009 Ostend JPM What can we do to improve the abdominal physiology? Improve surgical workspace Improve surgical workspace Facilitate ventilation Facilitate ventilation Reduce mortality Reduce mortality Methods available ? Methods available ?

22. ESPCOP 14 nov 2009 Ostend JPM Muscle relaxation effect on PV0 E or Compliance no change E or Compliance no change E is by fascia, size en shape determined E is by fascia, size en shape determined PV0 lower PV0 lower Relaxants identical to 2 MAC Sevo or Desflu Relaxants identical to 2 MAC Sevo or Desflu J Mulier B dillemans EJA 2006, IFSO 2008 J Mulier B dillemans EJA 2006, IFSO 2008

23. ESPCOP 14 nov 2009 Ostend JPM Table inclination changes PVO J Mulier, B Dillemans Ifso 2009 J Mulier, B Dillemans Ifso 2009

24. ESPCOP 14 nov 2009 Ostend JPM Leg flexion lowers E J Mulier B Dillemans IFSO 2009 J Mulier B Dillemans IFSO 2009

25. ESPCOP 14 nov 2009 Ostend JPM Lapararoscopy lowers E Begin lap End lap IAV at 15 2.85 +/- 0.46 4.83 +/- 0.78 * Elastance 3.32 +/- 0.48 2.17 +/- 0.5 * PV0 5.7 +/- 0.88 4.89 +/- 1.0 Mean IAP: 15,4 +/- 1,5 mmHg Mean IAP: 15,4 +/- 1,5 mmHg Mean pneumoperitoneum time: 59 +/- 19 minutes Mean pneumoperitoneum time: 59 +/- 19 minutes J Mulier PGA 2009 J Mulier PGA 2009

26. ESPCOP 14 nov 2009 Ostend JPM What can we do to improve the abdominal physiology? Improve surgical workspace Improve surgical workspace Facilitate ventilation Facilitate ventilation Reduce mortality Reduce mortality Weigth reduction pre op lowers the PV0 Weigth reduction pre op lowers the PV0 Muscle relaxation lowers the PV0 Muscle relaxation lowers the PV0 Trendelenburg lowers the PV0 Trendelenburg lowers the PV0 Beach chair position lowers the E Beach chair position lowers the E Prolonged pneumoperitoneum lowers the E Prolonged pneumoperitoneum lowers the E Gravidity lowers E Gravidity lowers E

27. ESPCOP 14 nov 2009 Ostend JPM Conclusion Android vs gyneoid fat distribution Android vs gyneoid fat distribution Intra visceral vs extra visceral fat accumulation Intra visceral vs extra visceral fat accumulation Metabolic syndrome with cardiovascular risk and diabetes Metabolic syndrome with cardiovascular risk and diabetes Higher intra abdominal pressures PV0 Higher intra abdominal pressures PV0 Lower Elastance E Lower Elastance E Higher mortality Higher mortality Respiratory function is decreased Respiratory function is decreased Higher cardiac output with possible obesity cardiomyopathy and pulmonary hypertension Higher cardiac output with possible obesity cardiomyopathy and pulmonary hypertension Muscle relaxation, beach chair, weight reduction Muscle relaxation, beach chair, weight reduction

28. ESPCOP 14 nov 2009 Ostend JPM The obese patient is a challenge for anaesthesia if android shape with intra visceral fat.

29. ESPCOP 14 nov 2009 Ostend JPM Become member of ESPCOP today everyone has obese patients in the future