1. Saad Al-Shamma
MBChB DA CABA & IC
Department of anesthesia/Al-yarmook Teaching
Hospital
Baghdad-Iraq

2. Overweight and obesity are
defined as abnormal or
excessive fat accumulation
that presents a risk to
health.

3. A-Body mass index
BMI=WT(kg)/HT(cm)^2
18.5-24.9 NR
25-29.9 Overweight
30-34.9 class 1 obesity
35-39.9 class2 obesity
40-49.9 class 3 obesity
>50 superobese
B-Brocas index
Wt=ht-100(in males)
or ht(cm)-105 (infemales)

4. Multifactorial
1-E intake>E expenditure
(if 2% increase then body wtincrease by2.3 kg in
1 yr
2-genetic
>41 obesity related gene are discovered
-high caloric diet + sedentary life style.
To maintain body wt after a period of wt loss we
need to decrease E intake by 15%.

6. -At 2008 the WHO estimates that at least 500 million
adults (greater than 10%) are obese, with higher rates
among women than men.
-In basrah a study of 29,107 adult found 55.1% (overall
obese &overweight)
23.8% obese
Women>men

9.  Any 3 of the following:

10.  -Complete cessation (or>50% decrease in hypopnea)of
airflow lasting=>10sec despite maintainance of nr N-M
ventilatory effort occuring >=5/hr associated with >=4%
decrease in SaO2.
 -Dx:polysomnograghy
 (EEG,ECG,EOG,EMG,oral or naso-pharyngeal
airflow,SaO2,BP,esophageal tonometry,room noise)
 -Apnea/hypopnea index(AHI)=No. of episode/sleep time
 OSAHS severity depend on AHI
 5-15/hour mild
 15-30/hour moderate
 >30/hour severe


13. One study of 170 obese pt where 15%
are previosly Dx as OSAHS,preoperative
testing showed 76% to be OSAHS

14. Non-surgical manegement
-therapeutic life style change
(diet,exercise(>30 min/d),quit smoking)
-behavioral modification
-pharmacotherapy:
Indicated to help wt lossif BMI>30 or >27 with comorbidity hpt
,dm, hyperlipidemia)
FDA liecenced:
Phenteramine(Adipex-P):adrenergic reuptake inhibitor ,appetite
suppressantand increse BMR,S,E,increase HR,HPT(max.12 weeks therapy)
,sibutramine(MEREDIA):inhibit reuptake of dopamine serotonine & NA
,decrease appetite &is thermogenic ,orlistat(xenical):lipase
inhibitor(decrease fat absorption,SE steatorhea,flatulence)
Herbs(chitosan,ephedra ma huang,…etc)
_

15.  Requirement
 1. AGE: 18 years of age or older.
2. BMI: Body Mass Index (BMI) between 40 and 60;
or Body Mass Index (BMI) of 35 or greater
with significant co-morbid coinditions such as
diabetes mellitus, sleep apnea, high cholesterol, the
metabolic syndrome or infertility.
3. PHYSICIAN or PROFESSIONALLY SUPERVISED
WEIGHT LOSS PROGRAMS: The patient must have
made a significant effort at weight loss by
participating in Physician or Professionally supervised
weight loss programs over a prolonged period of time
and failed to have achieved sustained weight loss.

16.  1-unstable angina
 2-ca with life expectancy<5 years
 3- psychiatric disorder,mental
retardation(IQ<50).
 4-Patient not able to cooperate or
understand the complication of surgery

17.  A-restrictive
1-vertical band gastroplasty
2- laproscopic adjustable gastric band
B-malabsorptive
1-Roux-en-y gastric bypass
2-billio-pancreatic diversion

18.  Early:bleeding ,leak,bowel
obstruction, ,perforation,infection,peritoniti
s,DVT &PE
& death(mortality 0.5-1.5%)higher in bypass
&BPD
Late: cholecystitis,cholelithiasis,pouch
dilatation, aspiration pneumonia , marginal
ulceration ,malnutrition especially fat
soluble vitamin (vit B12),

20. 1-difficult intubation&/or
ventilation
Difficult intubation neck
circumference>40 cm or mallampati
3or 4
Patient with home cpap>10 usually
have difficult mask ventiation
2-associated comorbidities
Hpt, DM ,OSAHS,heart problems

21. CBC,FBS,LFT,renal function,TFT,lipid
profile,vitamin B12,D
s.Ferritin
Cxr , echo, ECG, pulmonary Function
Test,sleep study

22. Metoclopromide,proton pump
inhibitor , sodiom bicitrate
Thromboprophylaxis (LMWH,graded
elastic stockings)
Avoid sedative and opiods especially
in patient with evidence of sleep
apnea

23.  Monitoring
 NIBP:large cuff is needed (should cover75%
or entire arm)or use forearm cuff ,
 IBP required in morbid oesity with severe
cardiopulmonary diseasea as well as
CVP,PCWP,and intraop. ECHo may also be
required
 N-m monitoring(adequate relaxation is
needed in bariatric procedure &
 Special operating table capable of holding
up to 455 kg instead of 205kg for regular
table

24. Intubation with fiberoptic bronchoscope in selected
patients.
Ramped position: to keep ears level with sternum
If needed 25-30% head up
Pre-oxygenation+cpap(10-12 cm H2O or a value equal to
the level used by the patient)
10-12 cm peep,
recruitment method is required.
Extubation is done head up & fully reversed from
muscle relaxant,& can sustain head lift for 5 sec.
Cpap is continued in the early postop period

25. The ideal intraoperative ventilation
strategy in obese patients remains
obscure. There is some evidence
that RM added to PEEP compared
with PEEP alone improves
intraoperative oxygenation and
compliance without adverse effects.
There is no evidence of any
difference between PCV and VCV.

26. Recruitment method
40cm of water for 40 second
Or
40 cm of water for 10 sec repeated
4 times

27.  Pain control
 Nsaid
 Iv patient controlled analgesia( PCA) : using ideal
body wieght for opiod dosing,
thoracic epidural PCA can also be used(using
minimum concentration of local anasthetic to allow
early mobilization .
-Local infiltration of the wound with long acting
la+nsaid(eg.paracetamol vial)+opiod pca is
reasonable approach for most patients
Or dexmedetomedine infusion +opiod pca(this method
limit the total opiod dose to less than1/3)