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Chapter 41 - Perioperative medical management of obese patients

from Section 13 - Obesity

Published online by Cambridge University Press:  05 September 2013

By
Madhuri Rao  and
John G. Kral
Edited by
Michael F. Lubin ,
Thomas F. Dodson  and
Neil H. Winawer
Michael F. Lubin
Affiliation:
Emory University, Atlanta
Thomas F. Dodson
Affiliation:
Emory University, Atlanta
Neil H. Winawer
Affiliation:
Emory University, Atlanta
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Summary

Introduction

The high prevalence of obesity and its comorbidities requires physicians to recognize obesity as a serious condition affecting all specialties. This is especially true for patients needing operations. New developments in the practice of surgery and new insights into the pathogenesis and pathophysiology of obesity have profound impacts on the perioperative management of these patients.

This chapter incorporates recent advances affecting the medical management of obese patients having surgery.

Prevalence

In 2007–2008, the age-adjusted prevalence of obesity in the USA was 33.8% overall, 32.2% among adult men, and 35.5% among adult women. The corresponding prevalence estimates for overweight and obesity combined (BMI > 25) were 68.0%, 72.3%, and 64.1% [1].

Although the increases in the prevalence of obesity previously observed did not appear to be continuing at the same rate over the past 10 years, the high prevalence is still worrisome because of the unrelenting increases in children and also the dramatic rise in severe obesity, a devastating rapidly increasing form of the disorder (see Figure 41.1). An estimated 17% of children and adolescents aged 2–19 years are obese and Fontaine et al. showed that younger adults lose more years of life than older adults [2].

Type
Chapter
Information
Medical Management of the Surgical Patient
A Textbook of Perioperative Medicine
 , pp. 441 - 450
Publisher: Cambridge University Press
Print publication year: 2013

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References

Flegal, KM, Carroll, MD, Ogden, CL, Curtin, LR.Prevalence and trends in obesity among US adults, 1999–2008. J Am Med Assoc 2010; 303: 235–41.CrossRefGoogle ScholarPubMed
Fontaine, KR, Redden, DT, Wang, C, Westfall, AO, Allison, DB.Years of life lost due to obesity. J Am Med Assoc 2003; 289: 187–93.CrossRefGoogle ScholarPubMed
Isono, S.Obstructive sleep apnea of obese adults: pathophysiology and perioperative airway management. Anesthesiology 2009; 110: 908–21.CrossRefGoogle ScholarPubMed
Vassallo, J.Pathogenesis of obesity. J Malta Coll Pharm Pract 2007; 12: 19–22.Google Scholar
Decoda Study Group, Nyamdori, R, Qiao, Q et al. BMI compared with central obesity indicators in relation to diabetes and hypertension in Asians. Obesity (Silver Spring) 2008; 16: 1622–35.Google Scholar
Bray, GA, Clearfield, MB, Fintel, DJ.Nelinson, DS.Overweight and obesity: the pathogenesis of cardiometabolic risk. Clin Cornerstone 2009; 9: 30–40.CrossRefGoogle ScholarPubMed
Wang, SZ, Chen, Y, Lin, HY, Chen, LW.Comparison of surgical stress response to laparoscopic and open radical cystectomy. World J Urol 2010; 28: 451–5.CrossRefGoogle ScholarPubMed
Miyake, H, Kawabagta, G, Gotoh, A et al. Comparison of surgical stress between laparoscopy and open surgery in the field or urology by measurement of humoral mediators. Int J Urol 2002; 9: 329–33.CrossRefGoogle ScholarPubMed
Bokey, EL, Moore, JW, Chapuis, PH, Newland, RC.Morbidity and mortality following laparoscopic-assisted right hemicolectomy for cancer. Dis Colon Rectum 1996; 39(10 Suppl): S24–8.CrossRefGoogle ScholarPubMed
Ho, YH, Tan, M, Eu, KW, Leong, A, Choen, FS.Laparoscopic-assisted compared with open total colectomy in treating slow transit constipation. Aust N Z J Surg 1997; 67: 562–65.CrossRefGoogle ScholarPubMed
Young-Fadok, TM, HallLong, K, McConnell, EJ, Gomez, RG, Cabanela, RL.Advantages of laparoscopic resection for ileocolic Crohn's disease. Improved outcomes and reduced costs. Surg Endosc 2001; 15: 450–4.CrossRefGoogle ScholarPubMed
Young-Fadok, TM, Radice, E, Nelson, H, Harmsen, WS.Benefits of laparoscopic-assisted colectomy for colon polyps: a case-matches series. Mayo Clin Proc 2000; 75: 344–8.CrossRefGoogle ScholarPubMed
Muckleroy, SK, Ratzer, ER, Fenoglio, ME.Laparoscopic colon surgery for benign disease: a comparison to open surgery. J Surg Laparosc Surg 1999; 3: 33–7.Google ScholarPubMed
Kakisako, K, Sato, K, Adachi, Y et al. Laparoscopic colectomy for Dukes A colon cancer. Surg Laparosc Endosc Percutan Tech 2000; 10: 66–70.CrossRefGoogle ScholarPubMed
Marubashi, S, Yano, H, Monden, T et al. The usefulness, indications, and complications of laparoscopy-assisted colectomy in comparison with those of open colectomy for colorectal carcinoma. Surg Today 2000; 30: 491–6.CrossRefGoogle ScholarPubMed
Marcello, PW, Milsom, JW, Wong, SK et al. Laparoscopic restorative proctocolectomy: case-matched comparative study with open restorative proctocolectomy. Dis Colon Rectum 2000; 43: 604–8.CrossRefGoogle ScholarPubMed
Varela, JE, Hinojosa, MW, Nguyen, NT.Laparoscopy should be the approach of choice for acute appendicitis in the morbidly obese. Am J Surg 2008; 196: 218–22.CrossRefGoogle ScholarPubMed
Corneille, MG, Steigelman, MB, Myers, JG et al. Laparoscopic appendectomy is superior to open appendectomy in obese patients. Am J Surg 2007; 194: 877–81.CrossRefGoogle ScholarPubMed
Kamoun, S, Alves, A, Bretagnol, F et al. Outcomes of laparoscopic colorectal surgery in obese and nonobese patients: a case-matched study of 18 patients. Am J Surg 2009; 198: 450–5.CrossRefGoogle Scholar
Fugita, OEH, Chan, DY, Roberts, WW, Kavoussi, LR, Jarrett, TW.Laparoscopic radical nephrectomy in obese patients: outcomes and technical considerations. Urology 2004; 63: 247–52.CrossRefGoogle ScholarPubMed
Kapoor, A, Nassir, A, Chew, B et al. Comparison of laparoscopic radical renal surgery in morbidly obese and non-obese patients. J Endourol 2004; 18: 657–60.CrossRefGoogle ScholarPubMed
Eltabbakh, GH, Shamonki, MI, Moody, JM, Garafano, LL.Hysterectomy for obese women with endometrial cancer: laparoscopy or laparotomy: Gynecol Oncol 2000; 78: 329–35.CrossRefGoogle ScholarPubMed
Nguyen, NT, Lee, SL, Goldman, C et al. Comparison of pulmonary function and postoperative pain after laparoscopic versus open gastric bypass: a randomized trial. J Am Coll Surg 2001; 192: 469–76.CrossRefGoogle ScholarPubMed
Baumgartner, RN, Stauber, PM, McHugh, D, Koehler, KM, Garry, PJ.Cross-sectional age differences in persons 60+ years of age. J Gerontol A Biol Sci Med Sci 1995; 50: M307–16.CrossRefGoogle ScholarPubMed
Carter, A, Côté, M, Lemieux, I et al. Age-related differences in inflammatory markers in men: contribution of visceral adiposity. Metabolism 2009; 58: 1452–8.CrossRefGoogle Scholar
Ross, R, Pedwell, H, Rissanen, J.Response of total and regional lean tissue and skeletal muscle to a program of energy restriction and resistance exercise. Int J Obes Relat Metab Disord 1995; 19: 781–7.Google ScholarPubMed
Choban, PS, Weireter, LJ, Maynes, C.Obesity and increased mortality in blunt trauma. J Trauma 1991; 31: 1253–7.CrossRefGoogle ScholarPubMed
Neville, A, Brown, CV, Weng, J, Demetriades, D, Velmahos, G.Obesity is an independent risk factor for mortality in severely injured blunt trauma patients. Arch Surg 2004; 139: 983–7.CrossRefGoogle ScholarPubMed
Brown, CV, Neville, AL, Rhee, P et al. The impact of obesity on the outcomes of 1,153 critically injured blunt trauma patients. J Trauma 2005; 59: 1048–51.CrossRefGoogle ScholarPubMed
Byrnes, MC, McDaniel, MD, Moore, MB, Helmer, SD, Smith, RS.The effect of obesity on outcomes among injured patients. J Trauma 2005; 58: 232–7.CrossRefGoogle ScholarPubMed
Xanthakos, SA.Nutritional deficiencies in obesity and after bariatric surgery. Pediatr Clin North Am 2009; 56: 1105–21.CrossRefGoogle ScholarPubMed
Kaidar-Person, O, Person, B, Szomstein, S, Rosenthal, RJ.Nutritional deficiencies in morbidly obese patients: a new form of malnutrition? Part A: Vitamins. Obes Surg 2008; 18: 870–6.CrossRefGoogle Scholar
DeMaria, EJ, Murr, M, Byrne, K et al. Validation of the obesity surgery mortality risk score in a multicenter study proves it stratifies mortality risk in patients undergoing gastric bypass for morbid obesity. Ann Surg 2007; 246: 578–84.CrossRefGoogle Scholar
Greenway, F.Clinical evaluation of the obese patient. Prim Care 2003; 30: 341–56.CrossRefGoogle ScholarPubMed
Flegal, KM, Shepherd, JA, Looker, AC et al. Comparisons of percentage body fat, body mass index, waist circumference, and waist-stature ratio in adults. Am J Clin Nutr 2009; 89: 500–5.CrossRefGoogle ScholarPubMed
Qiao, Q, Nyamdorj, R.Is the association of type II diabetes with waist circumference or waist-to-hip ratio stronger than that with body mass index?Eur J Clin Nutr 2010; 64: 30–4.CrossRefGoogle ScholarPubMed
Kahn, HS, Valdez, R.Metabolic risks identified by the combination of enlarged waist and elevated triacylglycerol concentration. Am J Clin Nutr 2003; 78: 928–34.CrossRefGoogle ScholarPubMed
Sjöström, CD, Häkangärd, AC, Lissner, L, Sjöström, L.Body compartment and subcutaneous adipose tissue distribution – risk factor patterns in obese subjects. Obes Res 1995; 3: 9–22.CrossRefGoogle ScholarPubMed
Yang, L.Visceral adiposity is closely correlated with neck circumference and represents a significant indicator of insulin resistance in WHO grade III obesity. Clin Endocrinol 2010; 73: 197–200.Google ScholarPubMed
Preis, SR.Neck circumference as a novel measure of cardiometabolic risk: the Framingham Heart study. J Clin Endocrinol Metab 2010; 95: 3701–10.CrossRefGoogle ScholarPubMed
Varela, JE, Hinojosa, M, Nguyen, N.Correlations between intra-abdominal pressure and obesity-related co-morbidities. Surg Obes Relat Dis 2009; 5: 524–8.CrossRefGoogle ScholarPubMed
Nguyen, NT, Lee, SL, Anderson, JT et al. Evaluation of intra-abdominal pressure after laparoscopic and open gastric bypass. Obes Surg 2001; 11: 40–5.CrossRefGoogle ScholarPubMed
Ayazi, S, Hagen, JA, Chan, LS et al. Obesity and gastroesophageal reflux: quantifying the association between body mass index, esophageal acid exposure, and lower esophageal sphincter status in a large series of patients with reflux symptoms. J Gastrointest Surg 2009; 13: 1440–7.CrossRefGoogle Scholar
Schneider, JH, Küper, M, Königsrainer, A, Brücher, B.Transient lower esophageal sphincter relatation in morbid obesity. Obes Surg 2009; 19: 595–600.CrossRefGoogle ScholarPubMed
Davis, G, Patel, JA, Gagne, DJ.Pulmonary considerations in obesity and the bariatric surgical patient. Med Clin North Am 2007; 91: 433–42.CrossRefGoogle ScholarPubMed
Naimark, A, Cherniack, RM.Compliance of the respiratory system and its components in health and obesity. J Appl Physiol 1960; 15: 377–82.CrossRefGoogle ScholarPubMed
Phillips, BG, Hisel, TM, Kato, M et al. Recent weight gain in patients with newly diagnosed obstructive sleep apnea. J Hypertens 1999; 17: 1297–300.CrossRefGoogle ScholarPubMed
Phillips, BG, Kato, M, Narkiewicz, K, Choe, I, Somers, VK.Increases in leptin levels, sympathetic drive, and weight gain in obstructive sleep apenea. Am J Physiol Heart Circ Physiol 2000; 279: H234–7.CrossRefGoogle Scholar
Kim, TH, Chun, BS, Lee, HW, Kim, JS.Differences of upper airway morphology according to obesity: study with cephalometry and dynamic MD-CT. Clin Exp Otorhinolaryngol 2010; 3: 147–52.CrossRefGoogle ScholarPubMed
Kuruba, R, Koche, LS, Murr, MM.Preoperative assessment and perioperative care of patients undergoing bariatric surgery. Med Clin North Am 2007; 91: 339–51.CrossRefGoogle ScholarPubMed
Association of Anaesthetists of Great Britain and Ireland. Peri-operative Management of the Morbidly Obese Patient. June 2007.
Schwartz, AR.Obesity and obstructive sleep apnea: pathogenic mechanisms and therapeutic approaches. Proc Am Thorac Soc 2008; 5: 185–92.CrossRefGoogle ScholarPubMed
Ip, MS, Lam, B, Ng, MM et al. Obstructive sleep apnea is independently associated with insulin resistance. Am J Respir Crit Care Med 2002; 165: 670–6.CrossRefGoogle ScholarPubMed
Punjabi, NM, Shahar, E, Redline, S et al. Sleep-disordered breathing, glucose intolerance, and insulin resistance: the Sleep Heart Health Study. Am J Epidemiol 2004; 160: 521–30.CrossRefGoogle ScholarPubMed
Gross, JB, Bachenberg, KL, Benumof, JL et al. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on perioperative management of patients with obstructive sleep apnea. Anesthesia 2006; 104: 1081–93.Google ScholarPubMed
Peppard, PE, Young, T, Palta, M, Dempsey, J, Skatrud, J.Longitudinal study of moderate weight change and sleep-disordered breathing. J Am Med Assoc 2000; 284: 3015–21.CrossRefGoogle ScholarPubMed
Fleetham, JA.Upper airway imaging in relation to obstructive sleep apnea. Clin Chest Med 1992; 13: 399–416.Google ScholarPubMed
Agarwal, N, Shibutani, K, San Filippo, JA, Del Guercio, LR.Hemodynamic and respiratory changes in surgery in the morbidly obese. Surgery 1982; 92: 226–34.Google Scholar
Alpert, MA, Terry, BE, Cohen, MV et al. The electrocardiogram in morbid obesity. Am J Cardiol 2000; 85: 908–10.CrossRefGoogle ScholarPubMed
Alpert, MA, Terry, BE, Hamm, CR et al. Effect of weight loss on the ECG of normotensive morbidly obese patients. Chest 2001; 119: 507–10.CrossRefGoogle ScholarPubMed
Lastra, G, Manrique, C, Sowers, JR.Obesity, cardiometabolic syndrome, and chronic kidney disease: the weight of the evidence. Adv Chronic Kidney Dis 2006; 13: 365–73.CrossRefGoogle ScholarPubMed
Serra, A, Romero, R, Lopez, D, Navarro, M et al. Renal injury in the extremely obese patients with normal renal function. Kidney Int 2008; 73: 947–55.CrossRefGoogle ScholarPubMed
Diercks, GF, van Boven, AJ, Hillege, HL et al. Microalbuminuria is independently associated with ischaemic electrocardiographic abnormalities in a large non-diabetic population. Eur Heart J 2000; 21: 1922–7.CrossRefGoogle Scholar
Elsayed, EF, Sarnak, MJ, Tighiouart, H et al. Waist-to-hip ratio, body mass index, and subsequent kidney disease and death. Am J Kidney Dis 2008; 52: 29–38.CrossRefGoogle ScholarPubMed
Virani, SS, Nambi, V, Lee, W et al. Obesity: an independent predictor of in-hospital postoperative renal insufficiency among patients undergoing cardiac surgery?Tex Heart Inst J 2009; 36: 540–5.Google ScholarPubMed
Glance, LG, Wissler, R, Mukamel, DB et al. Perioperative outcomes among patients with the modified metabolic syndrome who are undergoing noncardiac surgery. Anesthesiology 2010; 113: 859–72.CrossRefGoogle ScholarPubMed
Machado, M, Marques-Vidal, P, Cortez-Pinto, H.Hepatic histology in obese patients undergoing bariatric surgery. J Hepatol 2006; 45: 600–6.CrossRefGoogle ScholarPubMed
Dindo, D, Muller, MK, Weber, M, Clavien, PA.Obesity in general elective surgery. Lancet 2003; 361: 2032–5.CrossRefGoogle ScholarPubMed
Prandoni, P, Bilora, F, Marchiori, A et al. An association between atherosclerosis and venous thrombosis. N Engl J Med 2003; 348: 1435–41.CrossRefGoogle ScholarPubMed
Colles, SL, Dixon, JB, Marks, P, Strauss, BJ, O'Brien, PE.Preoperative weight loss with a very-low-energy diet: quantitation of changes in liver and abdominal fat by serial imaging. Am J Clin Nutr 2006; 84: 304–11.Google ScholarPubMed
Bern, MM, Bothe, A, Bistrian, B et al. Effects of low-dose warfarin on antithrombin III levels in morbidly obese patients. Surgery 1983; 94: 78–83.Google ScholarPubMed
Simone, EP, Madan, AK, Tichansky, DS, Kuhl, DA, Lee, MD.Comparison of two low-molecular-weight heparin dosing regimens for patients undergoing laparoscopic bariatric surgery. Surg Endosc 2008; 22: 2392–5.CrossRefGoogle ScholarPubMed
Waki, M, Kral, JG, Mazariegos, M et al. Relative expansion of extracellular fluid in obese vs. non-obese women. Am J Physiol 1991; 26: E199–203.Google Scholar
Colt, EWD, Wang, J, Stallone, F et al. A possible low intra-cellular potassium in obesity. Am J Clin Nutr 1981; 34: 367–72.CrossRefGoogle Scholar
Kral, JG, Lundholm, K, Sjöström, L et al. Hepatic lipid metabolism in severe human obesity. Metabolism 1977; 26: 1025–31.CrossRefGoogle ScholarPubMed
Mechanick, JI, Kushner, RF, Sugerman, HJ et al. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic and Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Endocr Pract 2008; 14 (Suppl 1): 1–83.CrossRefGoogle Scholar
Fris, RJ.Preoperative low energy diet diminishes liver size. Obes Surg 2004; 14: 1165–70.CrossRefGoogle ScholarPubMed
Benotti, PN, Still, CD, Wood, GC et al. Preoperative weight loss before bariatric surgery. Arch Surg 2009; 144: 1150–5.CrossRefGoogle ScholarPubMed
Sugerman, HJ, Kral, JG.Evidence-based medicine reports on obesity surgery: a critique. Int J Obes 2005; 29: 735–45.CrossRefGoogle ScholarPubMed
Karlsson, J, Taft, C, Sjöström, L, Sullivan, M.Ten-year trends in health-related quality of life after surgical and conventional treatment for severe obesity: the SOS intervention study. Int J Obes 2007; 31: 1248–61.CrossRefGoogle ScholarPubMed
Kral, JG, Otterbeck, P, Touza, MG.Preventing and treating the accelerated ageing of obesity. Maturitas 2010; 66: 223–30.CrossRefGoogle ScholarPubMed
Kral, JG.Obesity. In Lubin, MF, Walker, HK, Smith III, RB, eds. Medical Management of the Surgical Patient. Fourth Edition. Philadelphia, PA: Lippincott; 2006, pp. 467–78.Google Scholar
Smith, Al, Funder, JW.Proopiomelanocortin processing in the pituitary, central nervous system, and peripheral tissues. Endocr Rev 1988; 9: 159–79.CrossRefGoogle ScholarPubMed
Hotamisligil, GS, Arner, P, Caro, JF, Atkinson, RL, Spiegelman, BM.Increased adipose tissue expression of tumor necrosis factor-a in human obesity and insulin resistance. J Clin Invest 1995; 95: 2409–15.CrossRefGoogle Scholar
Koltermann, OG, Olefsky, JM, Kurakara, C, Taylor, K.A defect in cell-mediated immune function in insulin-resistant diabetic and obese subjects. J Lab Clin Med 1980; 96: 535–43.Google Scholar
Poirier, P, Alpert, MA, Fleisher, LA et al. Cardiovascular evaluation and management of severely obese patients undergoing surgery. Circulation 2009; 120: 86–95.CrossRefGoogle ScholarPubMed

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