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Laparoscopic Colon Laparoscopic Colon Surgery in the Obese Surgery in the Obese Patient Patient Alessio Pigazzi Alessio Pigazzi City of Hope City of Hope Duarte, CA Duarte, CA

Laparoscopic Colon Surgery in the Obese Patient Alessio Pigazzi City of Hope Duarte, CA

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Page 1: Laparoscopic Colon Surgery in the Obese Patient Alessio Pigazzi City of Hope Duarte, CA

Laparoscopic Colon Laparoscopic Colon Surgery in the Obese Surgery in the Obese

PatientPatient

Alessio PigazziAlessio PigazziCity of HopeCity of HopeDuarte, CADuarte, CA

Page 2: Laparoscopic Colon Surgery in the Obese Patient Alessio Pigazzi City of Hope Duarte, CA

Obesity epidemic 2005-Obesity epidemic 2005-20062006

Percent of adults age 20 years and over Percent of adults age 20 years and over who are overweight or obese: who are overweight or obese: 67%67%

Percent of adults age 20 years and over Percent of adults age 20 years and over who are obese: who are obese: 34%34%

Percent of adolescents age 12-19 years Percent of adolescents age 12-19 years who are overweight: who are overweight: 18%18%

Percent of children age 6-11 years who are Percent of children age 6-11 years who are overweight: overweight: 15%15%

Percent of children age 2-5 years who are Percent of children age 2-5 years who are overweight: overweight: 11%11%

Source: CDC

Page 3: Laparoscopic Colon Surgery in the Obese Patient Alessio Pigazzi City of Hope Duarte, CA

Lap Colon in Obese patientLap Colon in Obese patient

Harder?Harder? Easier?Easier? Contraindicated?Contraindicated? Beneficial?Beneficial? Every obese patient the same?Every obese patient the same?

Page 4: Laparoscopic Colon Surgery in the Obese Patient Alessio Pigazzi City of Hope Duarte, CA

CaseCase

36 year old woman admitted to the 36 year old woman admitted to the hospital with two week history of hospital with two week history of increasing abdominal distension and increasing abdominal distension and constipation. Last BM/flatus three constipation. Last BM/flatus three days agodays ago

PMHx: Severe obesity BMI 36 PMHx: Severe obesity BMI 36 PE: Obese woman in moderate pain; PE: Obese woman in moderate pain;

no peritoneal signsno peritoneal signs

Page 5: Laparoscopic Colon Surgery in the Obese Patient Alessio Pigazzi City of Hope Duarte, CA

CaseCase

Ct scan shows obstructing lesion at Ct scan shows obstructing lesion at splenic flexuresplenic flexure

Page 6: Laparoscopic Colon Surgery in the Obese Patient Alessio Pigazzi City of Hope Duarte, CA

CaseCase

What next? What next? • LaxativesLaxatives• OR open surgeryOR open surgery• OR lap SurgeryOR lap Surgery• Attempt colonoscopic stentingAttempt colonoscopic stenting

Page 7: Laparoscopic Colon Surgery in the Obese Patient Alessio Pigazzi City of Hope Duarte, CA

Cleveland Case-matched Study Cleveland Case-matched Study Obese vs NonobeseObese vs Nonobese

Dis Colon Rectum 2005; 48: 975–981

Page 8: Laparoscopic Colon Surgery in the Obese Patient Alessio Pigazzi City of Hope Duarte, CA

ConversionsConversions

Dis Colon Rectum 2005; 48: 975–981

Conversion rate: 30 %

Page 9: Laparoscopic Colon Surgery in the Obese Patient Alessio Pigazzi City of Hope Duarte, CA

German Laparoscopic German Laparoscopic Colorectal Surgery Study groupColorectal Surgery Study group

BMI 30-35 BMI>35

Conversion rate and length of operation correlate with degree of obesitySame outcomes

OBES SURG (2008) 18:66–70

Page 10: Laparoscopic Colon Surgery in the Obese Patient Alessio Pigazzi City of Hope Duarte, CA

Is every obese patient the Is every obese patient the same?same?

On whom would you prefer to operate ?

Page 11: Laparoscopic Colon Surgery in the Obese Patient Alessio Pigazzi City of Hope Duarte, CA

Japanese studyJapanese study

Visceral Obesity vs BMIVisceral Obesity vs BMI BMI readily available anthropometric BMI readily available anthropometric

indexindex BMI does not tell you anything about BMI does not tell you anything about

body fat depositsbody fat deposits Visceral obesity predictor of metabolic Visceral obesity predictor of metabolic

syndromesyndrome Half of nonobese pts by BMI have Half of nonobese pts by BMI have

visceral obesityvisceral obesityDCR 51: 1757–1767 (2008)

Page 12: Laparoscopic Colon Surgery in the Obese Patient Alessio Pigazzi City of Hope Duarte, CA

Determination of Visceral Fat Area (VFA)Visceral obesity > 130 CM2

Page 13: Laparoscopic Colon Surgery in the Obese Patient Alessio Pigazzi City of Hope Duarte, CA

Japanese studyJapanese study

VFA VFA NonobesNonobes

ee

(n=65)(n=65)

VFA VFA

obeseobese

(n=68)(n=68)

PP BMI BMI NonobesNonobes

ee

(n=106)(n=106)

BMI BMI

ObeseObese

(n=27)(n=27)

PP

Or TimeOr Time

(min)(min)190190 220220 0.0060.006 207207 235235 0.010.01

Hospital Hospital staystay

(days)(days)

99 10.510.5 0.0070.007 9.59.5 99 NSNS

ComplicatiComplicationon

(%)(%)

1212 3232 .006.006 2020 3030 nsns

DCR 51: 1757–1767 (2008)

Page 14: Laparoscopic Colon Surgery in the Obese Patient Alessio Pigazzi City of Hope Duarte, CA

ConclusionsConclusions

LAP colectomy in obese patients safe LAP colectomy in obese patients safe and feasibleand feasible

Superior postoperative outcomes Superior postoperative outcomes compared with open surgerycompared with open surgery

Maybe Higher conversion rateMaybe Higher conversion rate In experienced hands conversion does In experienced hands conversion does

not result in higher complicationsnot result in higher complications Type of obesity appears to determine Type of obesity appears to determine

ouctome more than BMIouctome more than BMI