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Pathophysiology of obesitas, impact on laparoscopy J P Mulier MD PhD Mercedes Garcia MD

“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. Sint Jan Brugge-Oostende www.publicationslist.org/jan.mulier. Classification of body weight:. Body Mass Index (BMI):

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Pathophysiology of obesitas, impact on laparoscopy J P Mulier MD PhD Mercedes Garcia MD

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

  2. Classification of body weight: • Body Mass Index (BMI): • TBW/Length 2 (Kg/m2 ) Overweight: BMI 25 – 30 Obese: BMI  30 • Moderate obese: BMI 30-34,9 • Severe obese : BMI 35-39,9 • Morbid obese: BMI  40 • Super obese : BMI  50 • Super super obese: BMI  60 ESPCOP 14 nov 2009 Ostend JPM

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

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

  5. WHR vs BMI ESPCOP 14 nov 2009 Ostend JPM

  6. Obesity type • Android vs Gynoid ESPCOP 14 nov 2009 Ostend JPM

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

  8. Metabolic syndrome: 3 of the 4 Diabetus Hypertension Dyslipidemia Visceral obesity ESPCOP 14 nov 2009 Ostend JPM

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

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

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

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

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

  14. Pulmonary disorders ESPCOP 14 nov 2009 Ostend JPM

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

  16. 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 ESPCOP 14 nov 2009 Ostend JPM

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

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

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

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

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

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

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

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

  25. Lapararoscopy lowers E • Mean IAP: 15,4 +/- 1,5 mmHg • Mean pneumoperitoneum time: 59 +/- 19 minutes • J Mulier PGA 2009 ESPCOP 14 nov 2009 Ostend JPM

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

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

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

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

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