Disclosure. Objectives 10/2/2015. Surgical Techniques for Morbid Obesity Gynecology. Speaker for Astra Zeneca

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1 Surgical Techniques for Morbid Obesity Gynecology Eva Chalas, MD, FACOG, FACS Professor and Vice Chair Department of Obstetrics and Gynecology Winthrop University Hospital Mineola, New York Disclosure Speaker for Astra Zeneca Objectives Detail special considerations in preoperative assessment and preparation Discuss intraoperative management approaches for the morbidly obese patients Demonstrate optimization of post surgical recovery 1

2 Health Hazards of Obesity Overweight BMI 25 to 29.9 kg/m² Obese BMI > 30kg/m² Severely obese >40 kg/m² Trends in Overweight* Prevalence (%) Adults 18 and Older, US, Less than 50% 50 to 55% More than 55% State did not participate in survey *Body mass index of 25.0 kg/m 2 or greater. Source: Behavioral Risk Factor Surveillance System, CD ROM ( , 1998) and Public Use Data Tape (2004, 2005), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 2000, 2005, Incidence of Obesity Obesity and Severe Obesity Forecasts Through 2030 Eric A. Finkelstein, PhD, MHA, Olga A. Khavjou, MA, Hope Thompson, BA,Justin G. Trogdon, PhD, Liping Pan, MD, MPH, Bettylou Sherry, PhD, RD, William Dietz, MD, PhD Background: Previous efforts to forecast future trends in obesity applied linear forecasts assuming that the rise in obesity would continue unabated. However, evidence suggests that obesity prevalence may be leveling off. Purpose: This study presents estimates of adult obesity and severe obesity prevalence through 2030 based on nonlinear regression models. The forecasted results are then used to simulate the savings that could be achieved through modestly successful obesity prevention efforts. Methods: The study was conducted in and used data from the 1990 through 2008 Behavioral Risk Factor Surveillance System (BRFSS). The analysis sample included nonpregnant adults aged 18 years. The individual level BRFSS variables were supplemented with state level variables from the U.S. Bureau of Labor Statistics, the American Chamber of Commerce Research Association, and the Census of Retail Trade. Future obesity and severe obesity prevalence were estimated through regression modeling by projecting trends in explanatory variables expected to influence obesity prevalence. Results: Linear time trend forecasts suggest that by 2030, 51% of the population will be obese. The model estimates a much lower obesity prevalence of 42% and severe obesity prevalence of 11%. If obesity were to remain at 2010 levels, the combined savings in medical expenditures over the next 2 decades would be $549.5 billion. Conclusions: The study estimates a 33% increase in obesity prevalence and a 130% increase in severe obesity prevalence over the next 2 decades. If these forecasts prove accurate, this will further hinder efforts for healthcare cost containment. Finkelstein EA et al, Am J Prev Med

3 Health Hazards of Obesity Compared to normal weight Higher all cause mortality HR 1.18 (95% CI ) 111, ,000 excess deaths attributable to obesity in the US Factors affecting mortality Demographics, smoking and associated health conditions Metabolically healthy v. adiposity related cardiometabolic abnormalities Flegal KM et al, JAMA 2013 Mokdad AH et al, JAMA 2005 Flegal KM et al, JAMA 2005 Health Hazards of Obesity Cause specific mortality increase for every 5 kg/m² increase over 25 in BMI Ischemic heart disease HR 1.39 Stroke HR 1.39 Malignancies HR 1.10 Respiratory diseases HR 1.20 Whitlock G et al, Lancet 2009 Health Hazards of Obesity Years of Life Lost compared to normal BMI at age 40 BMI > 30 lived 6 7 years less BMI 25 to 29.9 lived 3 years less Smokers years less Peeters A et al, Ann Intern Med

4 Audience Response Question 1 Which of these conditions is not related to obesity? A. Nephrolithiasis B. Cataracts C. Dementia D. Cancer Health Hazards of Obesity Morbidity Cardiovascular Hypertension Dyslipidemia Heart disease Stroke VTE Endocrine Diabetes Mellitus Gastrointestinal GERD Hepatobiliary Genitourinary Incontinence Nephrolithiasis Musculoskeletal Gout Osteoarthritis Neurologic Dementia Respiratory diseases Other Cancer Infection Depression NASH 4

5 Health Hazards of Obesity Annual health care costs relative to BMI 20 to 24.9 kg/m² 25% higher for BMI kg/m² 44% higher for BMI 35 kg/m² and more Quesenbery CP Jr et al, Arch Intern Med 1998 Preoperative Evaluation Obese Patient Obesity leads to work of breathing O₂ consump on Disordered V/Q matching Anesthesia me to desatura on Hypoventilation with supine spontaneous ventilation with obstruc on sleep apnea (OSA) CV changes with blood volume, SVR, CO, LV hypertrophy, L or R heart failure Littleton SW, Respirology 2012 Audience Response Question 2 Which patient should receive VTE prophylaxis prior to a dilation and curettage? A. 45 year old healthy nonsmoker on oral contraceptives B. 59 year old obese woman with history of breast cancer on Tamoxifen C. 35 year old with varicose veins D. 39 year old with abnormal bleeding hospitalized for a stroke 5

6 Caprini Risk Assessment Model Scoring system 0 5 for each of 4 categories Total score linked to risk of VTE without prophylaxis Very low (0) <0.5% Low (1 2) 1.5% Moderate(3 4) 3.0% High (> 5) 6.0 Gould MK et al, Chest 2012 Intraoperative Management Concerns Dosing of lipophilic drugs Higher drug clearance Sensitivity to sedatives (OSA) Need for supine or lithotomy position Antibiotic dosing Dose increased for weight > 120 kg VTE prophylaxis Surgical Approaches to Hysterectomy Minimally invasive (MIS) Laparoscopy LSCH +/ BSO TLH, LAVH +/ BSO Vaginal approach TVH +/ BSO Laparotomy SCH +/ BSO TAH +/ BSO 6

7 Procedure Results Hysterectomy by Type and Diagnosis Benign Malignant Total TAH* (24.8) 5480 (53.6) (29.8) SCH* 2332 (4.7) 112 (1.1) 2444 (4.1) TVH* (22.0) 185 (1.8) (18.6) LAVH/TLH* (36.1) 4346 (42.5) (37.2) LSCH* 6085 (12.3) 99 (0.97) 6184 (10.4) Total Laparotomy* (29.5) 5592 (54.7) (33.9) Total MIS* (70.5) 4630 (45.3) (66.1) Total Hysterectomies *All of the differences are statistically significant (p<0.001) Results Complications Rates by Type of Hysterectomy Benign Diagnosis TAH SCH TVH TLH/LAVH LSCH WC* 503 (4.1) 76 (3.3) 185 (1.7) 376 (2.1) 115 (1.9) VTE* 69 (0.56) 17 (0.73) 21 (0.19) 43 (0.24) 14 (0.23) UTI* 294 (2.4) 59 (2.5) 405 (3.7) 480 (2.7) 103 (1.7) S* 95 (0.77) 12 (0.5) 62 (0.57) 79 (0.44) 13 (0.21) BT* 698 (5.7) 122 (5.2) 188 (1.7) 231 (1.3) 69 (1.1) Other* 1 41 (0.33) 5 (0.21) 8 (0.07) 27 (0.2) 4 (0.07) Any* (12.1) 259 (11.1) 758 (7.0) 1101 (6.2) 293 (4.8) URR* (2.2) 37 (1.6) 147 (1.4) 361 (2.0) 69 (1.1) ROR* (1.0) 19 (0.81) 94 (0.86) 184 (1.0) 28 (0.46) *All of the differences are statistically significant (p<0.001) 1 Include unplanned intubations within 30 days, ventilator > 48 hours, renal insufficiency or acute renal failure, coma > 24 hours, graft/flap failure 2 Includes wound complications, sepsis, UTI, VTE, transfusions, other complications, but excludes ROR and unplanned readmissions 3 Data available for years only Results Complications Rates by Type of Hysterectomy Malignant Diagnosis TAH SCH TVH TLH/LAVH LSCH WC* 447 (8.2) 9 (8.0) 6 (3.2) 94 (2.2) 2 (2.0) VTE* 135 (2.5) 3 (2.7) 2 (1.1) 31 (0.71) 2 (2.0) UTI 206 (3.8) 4 (3.6) 5 (2.7) 107 (2.5) 3 (3.0) S* 153 (2.8) 2 (1.8) 1 (0.54) 36 (0.83) 0 (0.0) BT* 1038 (18.9) 31 (27.7) 6 (3.2) 88 (2.0) 7 (7.1) Other* (2.2) 5 (4.5) 0 (0.0) 23 (0.53) 2 (2.0) Any* (29.2) 39 (34.8) 17 (9.2) 310 (7.1) 12 (12.1) URR* (5.5) 10 (8.9) 7 (3.8) 137 (3.2) 3 (3.0) ROR 3 94 (1.7) 3 (2.7) 2 (1.1) 39 (0.90) 0 (0.0) *All of the differences are statistically significant (p<0.001) p=0.01, p= Include unplanned intubations within 30 days, ventilator > 48 hours, renal insufficiency or acute renal failure, coma > 24 hours, graft/flap failure 2 Includes wound complications, sepsis, UTI, VTE, transfusions, other complications, but excludes ROR and URR 3 Data available for years only 7

8 Audience Response Question 3 Which of the following statements is true regarding risk of Any Complications by type of hysterectomy? A. Total vaginal = total laparoscopic in benign disease B. Laparoscopic supracervical = Total vaginal hysterectomy in benign disease C. Total abdominal hysterectomy risk is same for benign and malignant disease D. The risk for 4.8% for laparoscopic supracervical hysterectomy Surgical Approaches Minimally invasive approach preferred Longer trochars and/or Veress needle may be necessary Location of port sites by bony landmarks Lower pressures possible with robot assisted approach Visceral adiposity limits exposure, increases risk of injury and blood loss 8

9 Patient Position and Docking Robot Docked Picture from Patient s Right Sentinel Node Endometrial Cancer 9

10 Surgical Approaches Total vaginal hysterectomy Relatively low rate of complications BSO can be facilitated by use of energy devices Should be considered in patients with medical comorbidities Endometrial cancer 5 10 year survival > 80% Susini T et al, Gynecol Oncol 2005 Chan JK et al, Obtet Gynecol

11 Incision Types Transverse Pfannenstiel Cherney Maylard Vertical Midline Paramedian Alternative Panniculectomy Choice of Incision Adequacy of exposure Need for rapid entry, nature of disease Patient and physician preference Wound healing characteristics Body habitus, prior scars Post operative pain Physiologic effect Cosmetic appearance Surgical Approaches Obese Patients Principles Avoid pannus Hemostasis Appropriate dosing/re dosing of antibiotics Scalpel v. diathermy without different infection rates Use of drains/minimizing the depth of subcutaneous layer to be considered Longitudinal incisions Greater risk of adhesion formation analgesia use, pulmonary compromise, wound dehiscence 11

12 Post surgical Management Risks Atelectasis Aggressive use of incentive spirometry Early ambulation Sleep apnea O₂ saturation > 90% CPAP as indicated Fluid management VTE prophylaxis Anticoagulant use Mechanical prophylaxis Pain control with early ambulation Infection risk of dehiscence Thank you 12