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Obesity & Surgery

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Operative considerations for Obese patients

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Obesity & Surgery

  1. 1. OBESITY & SURGERY Dr. PEGBA-OTEMOLU I.L OBESITY & SURGERY 1
  2. 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 OBESITY & SURGERY 2
  3. 3. 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 OBESITY & SURGERY 3
  4. 4. 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 OBESITY & SURGERY 4
  5. 5. 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 OBESITY & SURGERY 5
  6. 6. 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 OBESITY & SURGERY 6 DEFINITION OF TERMS *Morbid Obesity BMI > 40kg/m2 or >35kg/m2 in the presence of obesity related comorbidity
  7. 7. • Waist hip ratio: waist circumference at midpoint between lowest rib and iliac crest: widest circumference around the hips • Lean Body Weight DEFINITION OF TERMS OBESITY & SURGERY 7
  8. 8. IN CHILDREN OBESITY & SURGERY 8 Anthropometric 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
  9. 9. PREVALENCE OBESITY & SURGERY 9
  10. 10. • 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 OBESITY & SURGERY 10
  11. 11. 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 OBESITY & SURGERY 11
  12. 12. 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 OBESITY & SURGERY 12
  13. 13. • Gastrointestinal system – Dyspepsia – Peptic Ulcer Disease – Reflux – Hernia • Genitourinary system – Infertility • Circulatory system – Venous Thrombotic Events – Varicose veins OBESITY & SURGERY 13 PROBLEMS
  14. 14. PROBLEMS • Musculoskeletal skeletal – Blount’s Disease – Slipped capital femoral epiphyses – Osteoarthritis – Degenerative spine disease • Endocrine System – Diabetes Mellitus OBESITY & SURGERY 14
  15. 15. 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 OBESITY & SURGERY 15
  16. 16. • 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 OBESITY & SURGERY 16
  17. 17. • 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 OBESITY & SURGERY 17 PRE-OPERATIVE ASSESSMENT
  18. 18. • 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 OBESITY & SURGERY 18
  19. 19. 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 OBESITY & SURGERY 19
  20. 20. INTRA-OPERATIVE CONSIDERATIONS • Anaesthesia – Positioning for intubation – Pre-oxygenation – Airway management – Vascular access – Drug dose – Needle size for regional anaesthesia OBESITY & SURGERY 20
  21. 21. • 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 OBESITY & SURGERY 21
  22. 22. 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 OBESITY & SURGERY 22
  23. 23. COMPLICATIONS OF SURGERY • Intra-operative – Hemorrhage – Development of pressure necrosis – Respiratory compromise • Post-operative – Vide supra OBESITY & SURGERY 23
  24. 24. MANAGEMENT OF OBESITY OBESITY & SURGERY 24
  25. 25. 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
  26. 26. 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)
  27. 27. 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
  28. 28. 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 OBESITY & SURGERY 28
  29. 29. BARIATRIC SURGERY OBESITY & SURGERY 29 Primarily restrictive Malabsorptive Combination
  30. 30. PLASTIC SURGERY OBESITY & SURGERY 30 ABDOMINOPLASTY
  31. 31. PLASTIC SURGERY OBESITY & SURGERY 31 BODY CONTOURING
  32. 32. 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 OBESITY & SURGERY 32
  33. 33. QUESTIONS??? OBESITY & SURGERY 33
  34. 34. 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] OBESITY & SURGERY 34

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