1. Morbid Obesity and Gastric Bypass

2. 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

3. 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

4. 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
50% are more likely to be obese

5.                                           
                                          
Taco Bell?
Mexican american boys tend to have higher prevalence of overweight.
National Institute of Health. Call to Action Report 1998

7. Heart Disease Hypertension twice as common
Increased risk: MI, CHF, Sudden Death, Arrythmias.
BMI greater than 25.

8. Diabetes
A gain of 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

9. Respiratory Sleep Apnea Obesity Hypoventilation Syndrome Asthma
Decreased FRC
Increased risk of aspiration from GERD
Difficult airways (ventilate and intubate)
Decreased FRC translates into quicker desaturation

10. Other Arthritis Reproductive complications Gallbladder disease.
Depression, Social Discrimination

11. What is BMI? Body Mass Index BMI=weight (kg) / height (m2)
BMI=pounds/inches 2 x 703
Why BMI?
A panel convened by the NIH in 1998recommended that BMI be used to classify overweight and obesity. Simple rapid and cheap

12. Classification Healthy Weight 18.5-24.9 Overweight 25.0-29.9 Obesity
Class II
Class III >40

13. 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

14. Surgery Aspect
Indications
Types
Results
Complications

15. Indications Age 18-60 BMI > 40 BMI > 35 with medical problems
Exhausted other venues of weight loss
For example this beautifiul girls have NOT exhausted their venus to loss weight e.i. Excersice, diet, medications

16. Types of Surgery

17. How do they work?
Restrictive
Malabsorption
Behavioral modification

19. Results Weight Loss- 66% at 1 to 2 years after surgery 60% at 5 years
African-american lose significantly less weight…why?
Improvement in comorbities

20. 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

21. Anesthesia
Pre-Op
Intra-Op
Post-Op

22. Pre-Op/ History History and Physical ROS Airway Heart Lungs
Eyes… eyes?… yes eyes
Previous anesthesia

23. Airway
Mallampati, mouth opening, tongue size, thyromental distance, sternomental distance, neck circumference
Predictibility 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

24. Cardiovascular HTN: multiple medications difficult to control
Cardiomyopathy, CHF, Ischemia, CVA, Pulmonary HT, DVT, PE, Hypercholesterolemia, Hypertriglyceridimia

25. 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

26. Lungs/ OSA
OSA- hypersomnolence, loud snoring, apnea and hypopnea during sleep
Physiologic changes:
Arterial hypoxemia
Polycythemia
Arterial Hypercarbia
HTN
Pulmonary hypertension

27. Lungs/ OSA Risk Factors: Male Middle Age Obesity Alcohol
Drug Induced Sleep

28. Lungs/OHS Obesity Hypoventilation Syndrome is defined as: PaO2 < 70
PaCO2 > 45
BMI > 30 kg/m2
No other respiratory disease of explaining the gas anomaly

29. 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

30. 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)

31. 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, 2001:120:

32. Lungs/ OSA vrs OHS
Chicken or the egg?
A spectrum of the same disease?

33. Eyes Hypoxia and hypercarbia as a sign of angiogenesis
Case Report , Elia J. Duh, AMA-Assn.org

34. Intra Operative GA vrs 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….

35. NOT KNOWN

36. Post Op
Extubation
Post Op Pain
OSA and OHS
Cardiac

37. Post Op/Extubation Fully awake Recover in head up positioning
Monitoring very important if OSA or OHS

38. 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

39. Pain Control and OSA
Pt with OSA have a exquist sensibility to narcotics, even when used in regional techniques.
Narcotics can have depressive effects up to 2-3 days post op

40. Post Op/ Others Others: DVT early ambulation/ heparin
Wound infection is twice as common
Guillain-Barre
Case Report: Chang; Obes Surg 2002 Aug; 12(4)