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

ESPCOP 14 nov 2009 Ostend JPM

Sint Jan Brugge-OostendeSint Jan Brugge-Oostendewww.publicationslist.org/jan.mulier www.publicationslist.org/jan.mulier

““The sea” from Georges GerardThe sea” from Georges Gerard

Better known as Better known as

““fat Mathilde of Ostend”fat Mathilde of Ostend”

Pathophysiology of obesitas, Pathophysiology of obesitas, impact on laparoscopy impact on laparoscopy

J P Mulier MD PhDJ P Mulier MD PhDMercedes Garcia MDMercedes Garcia MD


Classification of body Classification of body weight:weight:

Body Mass Index (BMI):Body Mass Index (BMI): TBW/Length TBW/Length 2 2 (( Kg/Kg/mm2 2 ))

Overweight: Overweight: BMI 25 – 30 BMI 25 – 30 Obese: Obese: BMI BMI 30 30• Moderate obese: Moderate obese: BMI 30-34,9BMI 30-34,9• Severe obese : Severe obese : BMI 35-39,9BMI 35-39,9• Morbid obese: Morbid obese: BMI BMI 40 40 • Super obese : Super obese : BMI BMI 50 50 • Super super obese: Super super obese: BMI BMI 60 60


Body fat weight formulaBody fat weight formula WomenWomen

Factor 1 (Total body weight x 0.732) + 8.987Factor 1 (Total body weight x 0.732) + 8.987 Factor 2 Wrist measurement (at fullest point) / 3.140Factor 2 Wrist measurement (at fullest point) / 3.140 Factor 3 Waist measurement (at naval) x 0.157Factor 3 Waist measurement (at naval) x 0.157 Factor 4 Hip measurement (at fullest point) x 0.249Factor 4 Hip measurement (at fullest point) x 0.249 Factor 5 Forearm measurement (at fullest point) x 0.434Factor 5 Forearm measurement (at fullest point) x 0.434

Lean Body MassLean Body Mass Factor 1 + Factor 2 - Factor 3 - Factor 4 + Factor 5Factor 1 + Factor 2 - Factor 3 - Factor 4 + Factor 5

Men Men

Factor 1(Total body weight x 1.082) + 94.42Factor 1(Total body weight x 1.082) + 94.42 Factor 2 Waist measurement x 4.15Factor 2 Waist measurement x 4.15

Lean Body Mass: Lean Body Mass: Factor 1 - Factor 2Factor 1 - Factor 2

Body Fat Weight: Total body weight - Lean Body Body Fat Weight: Total body weight - Lean Body MassMass


Waist to Hip ratio Waist to Hip ratio (WHR)(WHR)

Man normal WHR: 0,9Man normal WHR: 0,9 Woman normal WHR: 0,7Woman normal WHR: 0,7

Android fat distributionAndroid fat distribution WHR > 0,8WHR > 0,8

Gynoid fat distributionGynoid fat distribution WHR < 0,8WHR < 0,8


WHR vs BMIWHR vs BMI


Obesity typeObesity type

Android Android vsvs GynoidGynoid


Attractiveness in WHR from 4000 BC until 2000 Attractiveness in WHR from 4000 BC until 2000 ACAC

1,5 1,1 1,5 0,5 0,7 1,5 1,1 1,5 0,5 0,7


Metabolic syndrome: Metabolic syndrome: 3 of the 43 of the 4

HypertensionDiabetus

Visceral obesityDyslipidemia


Negative feedback loopNegative feedback loop Obesity: high leptin butObesity: high leptin but

BBB transport insufficient; hypothal leptin BBB transport insufficient; hypothal leptin resistanceresistance Evolution: resistance when oversupply to Evolution: resistance when oversupply to

allow storage, no mechanism for continuous allow storage, no mechanism for continuous oversupplyoversupply

Slow reaction over daysResistance problem

fast reaction in hoursInsufficiency problem


Hypoxia hypothesisHypoxia hypothesis

If angiogenesis, hypoxia improvesIf angiogenesis, hypoxia improves If fibrosis, hypoxia stays stimulating further If fibrosis, hypoxia stays stimulating further

inflammatory reactions and adipokines inflammatory reactions and adipokines secretionsecretion Dyslipidemia, hypertension, glucose intoleranceDyslipidemia, hypertension, glucose intolerance


Changes in the respiratory Changes in the respiratory systemsystem

Fat intercostal, diaphragm, intra Fat intercostal, diaphragm, intra visceral visceral decreased chest wall compliance decreased chest wall compliance impaired lung expansion impaired lung expansion permanent hypoventilation and permanent hypoventilation and

atelectasis. atelectasis. Reduction in 1 sec V, RV, FRC and TLCReduction in 1 sec V, RV, FRC and TLC

dyspneadyspnea need CPAP, PEEP and recruitment need CPAP, PEEP and recruitment

Increased pulmonary blood flowIncreased pulmonary blood flow Lung compliance decreasedLung compliance decreased


Result: Respiratory Result: Respiratory distressdistress

increased work of breathing,increased work of breathing, increased oxygen consumption, increased oxygen consumption, no reserve capacityno reserve capacity ventilation perfusion mismatch ventilation perfusion mismatch

mean AaDO2 is 4 times higher mean AaDO2 is 4 times higher impaired gas exchange impaired gas exchange

PaO2 is lowerPaO2 is lower Every 5 kg reduction in weight increases Every 5 kg reduction in weight increases

the PaO2 and decreases the AaDO2 by 1 the PaO2 and decreases the AaDO2 by 1 mmHgmmHg


OSA -> OHS -> Pickwick OSA -> OHS -> Pickwick syndromesyndrome

5% of morbid obese persons have 5% of morbid obese persons have obstructive sleep apnoea (OSA): obstructive sleep apnoea (OSA): pharyngeal collapsepharyngeal collapse daytime somnolence, snoring, awaken from daytime somnolence, snoring, awaken from

sleep choking, morning headaches. sleep choking, morning headaches. hypoxemia and desaturation during night. hypoxemia and desaturation during night.

it progresses sometimes to obesity it progresses sometimes to obesity hypoventilation syndrome (OHS).hypoventilation syndrome (OHS). + Hypoxemia and hypercapnea during day+ Hypoxemia and hypercapnea during day

Further progress to Pickwick syndromeFurther progress to Pickwick syndrome + policytemia and right heart failure + policytemia and right heart failure


Pulmonary disordersPulmonary disorders


Disorders in the cardiovascular Disorders in the cardiovascular systemsystem


CT scanCT 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


BMI effect on abdominal P/V BMI effect on abdominal P/V relationrelation

Effect of BMI on PV0

-4

-2

0

2

4

6

8

10

0 10 20 30 40 50 60

BMI

PV

0 in

mm

Hg

Effect of BMI on E

0

0,002

0,004

0,006

0,008

0,01

0,012

0 20 40 60

BMI

E in

mm

Hg

/l

J Mulier ISPUB 2009J Mulier ISPUB 2009 Pressure volume relation is linearPressure volume relation is linear PV0 and E define each patientPV0 and E define each patient

J Mulier IFSO 2007J Mulier IFSO 2007


Android versus Gynoid fat Android versus Gynoid fat distribution has a different distribution has a different

ElastanceElastance

Abdominal pressure volume relation: Android vs Gynoid

0

5

10

15

20

25

0 1 2 3 4

IAV Liter

IAP

mm

Hg

android

gynoid


Two types of android Two types of android obesityobesity

Intra visceral adiposity Intra visceral adiposity Extra visceral adiposity Extra visceral adiposity Subcutaneus fat is scant and Subcutaneus fat is thick and Subcutaneus fat is scant and Subcutaneus fat is thick and

intra abdominal fat is thick and intra abdominal fat is scant.intra abdominal fat is thick and intra abdominal fat is scant.

Subcutaneus FatSubcutaneus Fat Visceral fatVisceral fat


Large intra visceral fat volume, or Large intra visceral fat volume, or liver steatosis makes the relation non liver steatosis makes the relation non

linear !linear !

-50

0

50

0 0,5 1 1,5 2 2,5 3 3,5 4

vol lit er

meting 2

meting 3

meting 4

meting 5

meting 6

0

0,5

1

1,5

0 0,2 0,4 0,6 0,8 1 1,2

meting 1

meting 2

meting 3

meting 4

meting 5

abdominal pressure in android shape with intra visceral fat

0

5

10

15

20

25

0 1 2 3 4

IAV in liter

IAP

in m

mH

g

If the abdomIf the abdominal fasciainal fascia is a is already circular lready circular instead of ellipticinstead of elliptic No deformation possibleNo deformation possible No radius decrease with increasing volumeNo radius decrease with increasing volume


What can we do to improve What can we do to improve the abdominal physiology?the abdominal physiology?

Improve surgical workspaceImprove surgical workspace Facilitate ventilationFacilitate ventilation Reduce mortalityReduce mortality

Methods available ? Methods available ?


Muscle relaxation effect on Muscle relaxation effect on PV0PV0

E or Compliance no changeE or Compliance no change E is by fascia, size en shape E is by fascia, size en shape

determineddetermined PV0 lowerPV0 lower

Relaxants identical to 2 MAC Sevo or Relaxants identical to 2 MAC Sevo or DesfluDesflu

J Mulier B dillemans EJA 2006, IFSO 2008J Mulier B dillemans EJA 2006, IFSO 2008


Table inclination changes Table inclination changes PVOPVO

J Mulier, B Dillemans Ifso 2009J Mulier, B Dillemans Ifso 2009


Leg flexion lowers ELeg flexion lowers E

J Mulier B Dillemans IFSO 2009J Mulier B Dillemans IFSO 2009


Lapararoscopy lowers ELapararoscopy lowers E

Effect of 1 hour laparoscopy

0

5

10

15

20

25

0 0,5 1 1,5 2 2,5 3 3,5

IAV: liter

IAP

: m

mH

gBegin laparoscopy

End laparoscopy

Begin Begin laplap

End lapEnd lap

IAV at 15IAV at 15 2.85 +/- 2.85 +/- 0.460.46

4.83 +/- 4.83 +/- 0.78 *0.78 *

ElastanceElastance 3.32 +/- 3.32 +/- 0.480.48

2.17 +/- 2.17 +/- 0.5 *0.5 *

PV0PV0 5.7 +/- 5.7 +/- 0.880.88

4.89 +/- 4.89 +/- 1.01.0

Mean IAP: 15,4 +/- 1,5 mmHg Mean IAP: 15,4 +/- 1,5 mmHg Mean pneumoperitoneum time: 59 +/- 19 Mean pneumoperitoneum time: 59 +/- 19

minutes minutes J Mulier PGA 2009J Mulier PGA 2009


What can we do to improve What can we do to improve the abdominal physiology?the abdominal physiology?

Improve surgical workspaceImprove surgical workspace Facilitate ventilationFacilitate ventilation Reduce mortalityReduce mortality

Weigth reduction pre op lowers the PV0Weigth reduction pre op lowers the PV0 Muscle relaxation lowers the PV0Muscle relaxation lowers the PV0 Trendelenburg lowers the PV0Trendelenburg lowers the PV0 Beach chair position lowers the E Beach chair position lowers the E Prolonged pneumoperitoneum lowers Prolonged pneumoperitoneum lowers

the Ethe E Gravidity lowers EGravidity lowers E


ConclusionConclusion

Android vs gyneoid fat distributionAndroid vs gyneoid fat distribution Intra visceral vs extra visceral fat accumulationIntra visceral vs extra visceral fat accumulation

Metabolic syndrome with cardiovascular risk and Metabolic syndrome with cardiovascular risk and diabetesdiabetes

Higher intra abdominal pressures PV0Higher intra abdominal pressures PV0 Lower Elastance ELower Elastance E Higher mortalityHigher mortality

Respiratory function is decreasedRespiratory function is decreased Higher cardiac output with possible obesity Higher cardiac output with possible obesity

cardiomyopathy and pulmonary hypertensioncardiomyopathy and pulmonary hypertension Muscle relaxation, beach chair, weight reductionMuscle relaxation, beach chair, weight reduction


The obese patient is a challenge The obese patient is a challenge for anaesthesia for anaesthesia

if android shape with intra visceral if android shape with intra visceral fat.fat.


Become member of ESPCOP today Become member of ESPCOP today everyone has obese patients in the futureeveryone has obese patients in the future

Documents

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