Obesity Part 4

Obesity Part 4: 

Obesity Part 4

Obesity-related Surgical procedures: 

Obesity-related Surgical procedures Neoplastic : Cancer Endometrial, breast, prostate, colorectal, renal Fibroadenoma of the breast Gynecologic: Uterine fibroma Ovarian cysts Cesarean section Stress urinary incontinence

Common surgical procedures associated with obesity: 

Common surgical procedures associated with obesity Tonsillectomy and Adenoidectomy Adenotonsillar hypertrophy is most effective treatment for OSA OSA may persist May be from increased visceral fat having an effect on decreasing airway tone  airway collapse May be from increased fat in the neck decreases caliber of airway Hold off on opioids until extubated

Orthopedic procedures: 

Orthopedic procedures Slipped capital femoral epiphysis (SCFE) Occurs when proximal femoral epiphysis separates from the femoral neck through growth plate Considered orthopedic emergency (urgency)  risk of avascular necrosis of femoral head Seen in up to 30% of obese children High incidence of premature degenerative joint disease General +/- regional anesthesia: Femoral sciatic block or epidural

SCFE: 

SCFE

Orthopedic procedures: 

Orthopedic procedures Blount’s disease (tibia vara) Caused by excessive weight on growth plate Knee pain Characterized by bowing of knees medially Tibial osteotomy and lengthening General +/- regional anesthesia Femoral block or epidural

Bariatric surgery : 

Bariatric surgery Goal is to reduce morbidity and mortality and improve metabolic and organ function Meta-analyses show that: Evidence supporting a benefit of bariatric surgery was strongest in patients with a BMI of >40, while the benefits in those with BMI of 35 to 39 were less clear Diabetes completely resolved in 77 percent and resolved or improved in 86 percent Hyperlipidemia improved in 70 percent or more of patients Hypertension resolved in 62 percent and resolved or improved in 79 percent Obstructive sleep apnea resolved in 86 percent and resolved or improved in 84 percent GERD improved in most patients Urinary stress incontinence decreased by 47%

Bariatric surgery: 

Bariatric surgery Indications: Be well-informed and motivated Have a BMI >40 Have acceptable risk for surgery Have failed previous nonsurgical weight loss Adults with BMI > 35 kg/m2 who have serious comorbidities such as diabetes, OSA, OICD, or severe joint disease Contraindications Untreated major depression or psychosis Binge eating disorders Current drug and alcohol abuse Severe cardiac disease Severe coagulopathy Inability to comply with nutritional requirements Controversial: Age > 65 or < 18; may be considered

Bariatric surgery: 

Bariatric surgery Malabsorptive : rarely performed at this time Jejunoileal bypass Biliopancreatic bypass Biliopancreatic diversion with duodenal switch Restrictive Vertical banded gastroplasty (VBG) Laparascopic adjustable gastric banding (LAGB) Second most commonly performed bariatric procedure in US but is becoming more popular due to simplicity in technique, adjustability, reversibility, and relatively low perioperative mortality; less weight loss compared to LRYGB Sleeve gastrectomy Malabsorptive and restrictive Laparascopic Roux-en-Y gastric bypass (LRYGB) Combines gastric restriction with minimal degree of malabsorption Most commonly performed bariatric procedure in US Can have significant metabolic complications

Gastric banding: 

Gastric banding Restrictive procedure Compartmentalizes the upper stomach by placing a tight, adjustable prosthetic band around the entrance to the stomach The gastric band consists of a soft, locking silicone ring connected to an infusion port placed in the subcutaneous tissue Injection of saline into the port leads to reduction in the band diameter, resulting in an increased degree of restriction

Roux-en-y gastric bypass: 

Roux-en-y gastric bypass Anastomosis of proximal gastric pouch to a segment of proximal jejunum Bypasses most of stomach and entire duodenum Roux limb (or alimentary limb) is anastomosed to the new gastric pouch and functions to drain consumed food

Future areas of investigation: 

Future areas of investigation Infectobesity Refers to obesity of infectious origin and the emerging field of medical research that studies the relationship between pathogens (disease-causing organisms, such as viruses and bacteria) and weight gain Term was coined in 2001

Future areas of investigation: 

Future areas of investigation Capascin (University of Toronto) Injected in diabetic mice and killed vascularization; Studies shown to prevent fat cells, or adipocytes, from growing into mature cells ?“antiobesity” properties; ?anticancer properties Sertraline-1 Role in anti-aging and DM with metformin

“Master Switch” gene for obesity: 

“Master Switch” gene for obesity Recent study published in journal Nature Genetics (May 2011) Since fat plays important role in metabolic disease, regulating gene could be target for drugs Found a link between KLF14 gene, which is linked to Type 2 DM and cholesterol, and other genes found in fat tissue Seems to act as master switch in controlling processes that connect changes in SQ fat to disturbances in muscle and liver that contribute to other metabolic conditions Nature Genetics Volume: 43, Pages: 561–564 Year published: (2011)

Ethical Issues in the OR: 

Ethical Issues in the OR Does obesity qualify as child abuse? http://www.latimes.com/health/la-he-childhood-obesity-custody-20110829,0,3696579.story http://jama.ama-assn.org/content/306/2/206.short How young is too young to perform bariatric surgery? http://onlinelibrary.wiley.com/doi/10.1111/j.1758-8111.2010.00003.x/full http://journals.lww.com/jpgn/pages/articleviewer.aspx?year=2004&issue=07000&article=00002&type=fulltext Are anesthesia providers cognizant of the increased risk with the obese pediatric patient? http://journals.lww.com/anesthesiology/pages/articleviewer.aspx?year=2008&issue=03000&article=00009&type=fulltext http://bja.oxfordjournals.org/content/106/3/359.full

References : 

References American Academy of Pediatrics. Prevention of Pediatric Overweight and Obesity. Pediatrics 2003; 112 (2): 424 – 430. Anderson PM, Butcher KF. Childhood Obesity: Trends and Potential Causes. The Future of Children 2006; 16 (1): 19 – 45. Caprio S. Treating Childhood Obesity and Associated Medical Conditions 2006; 16 (1): 209 – 227. CDC, BMI – Body Mass Index for children and teens. Available at www.cdc.gov/nccdphp/dnpa/bmi/childrens . Accessed September 5, 2011. CDC, Childhood Overweight and Obesity. Available at www.cdc.gov/obesity/childhood/ . Accessed September 7, 2011. CDC, Healthy Youth. Available at www.cdc.gov/healthyyouth/obesity/facts.htm. Accessed September 7, 2011. Choudhary AK, Donnelly LF, Racadio JM, Strife JL. Diseases Associated with Childhood Obesity. American Journal of Roentgenology 2007; 118 : 1118 – 1130.

References: 

References Daniels SR. The Consequences of Childhood Overweight and Obesity. The Future of Children 2006; 16 (1): 47 – 67. Matricardi PM, Gruber C, Wahn U, Lau S. The asthma-obesity link in childhood: open questions, complex evidence, a few answers only. Clinical and Experimental Allergy 2007; 37 (4): 476 - 484 Miller JL, Goldstone AP, Couch JA, Shuster J, He G, Driscoll DJ, Liu Y, Schmalfuss IM. Pituitary abnormalities in Prader-Willi syndrome and early onset morbid obesity. American Journal of Medical Genetics Part A 2007 Mullen, M. (2009). The obesity-ethnicity link. The Ohio State University Alumni Magazine, p.30 National Institutes of Health (2009). Retrieved October 13, 2010, from http://obesityresearch.nih.gov/About/about.htm Noller DT, Paulk DP. Childhood obesity: Curbing an American epidemic. Journal of the American Academy of Physician Assistants 2005

References: 

References Sakurai K, M Kawazuma , T Adachi, T Harigaya , Y Saito, N Hashimoto, and C Mori. 2004. Bisphenol A affects glucose transport in mouse 3T3-F442A adipocytes. Brit. J. Pharm. 141:209-214 Setzer N, Saade E. Childhood obesity and anesthetic morbidity. Pediatric Anesthesia 2007; 17 (4): 321 – 327 McAuliffe, M.S., Gambrell , P.G., & Edge, M.J. Obesity and Anesthesia Practice. In: Nagelhout JJ, Plaus , KL, eds. Nurse Anesthesia , 4 th edition. St. Louis: Elsevier Saunders; 2010: 1024 – 1044.