Operative considerations for Obese patients

1. OBESITY & SURGERY
Dr. PEGBA-OTEMOLU I.L
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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
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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
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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
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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
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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
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DEFINITION OF TERMS
*Morbid Obesity BMI > 40kg/m2 or >35kg/m2 in
the presence of obesity related comorbidity

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
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8. IN CHILDREN
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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. PREVALENCE
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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
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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
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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
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13. • Gastrointestinal system
– Dyspepsia
– Peptic Ulcer Disease
– Reflux
– Hernia
• Genitourinary system
– Infertility
• Circulatory system
– Venous Thrombotic Events
– Varicose veins
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PROBLEMS

14. PROBLEMS
• Musculoskeletal skeletal
– Blount’s Disease
– Slipped capital femoral epiphyses
– Osteoarthritis
– Degenerative spine disease
• Endocrine System
– Diabetes Mellitus
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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
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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
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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
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PRE-OPERATIVE ASSESSMENT

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
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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
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20. INTRA-OPERATIVE CONSIDERATIONS
• Anaesthesia
– Positioning for intubation
– Pre-oxygenation
– Airway management
– Vascular access
– Drug dose
– Needle size for regional anaesthesia
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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
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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
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23. COMPLICATIONS OF SURGERY
• Intra-operative
– Hemorrhage
– Development of pressure necrosis
– Respiratory compromise
• Post-operative
– Vide supra
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24. MANAGEMENT OF OBESITY
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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. 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. 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. 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
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29. BARIATRIC SURGERY
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Primarily
restrictive
Malabsorptive
Combination

30. PLASTIC SURGERY
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ABDOMINOPLASTY

31. PLASTIC SURGERY
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BODY CONTOURING

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
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33. QUESTIONS???
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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]
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