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• W2060691561 abstract "The most recent government figures show that 26% of the UK's adult population are obese (BMI >30 kg m−2) with over 3% designated as morbidly obese (BMI >40 kg m−2). To put this into perspective, the average UK district general hospital serving an adult population of 200 000 will have 52 000 obese and more than 6000 morbidly obese patients in their catchment area. As the obese are more prone to concomitant disease, the proportion of obese patients presenting to hospital is even higher. The demand this places on the National Health Service (NHS) is inexorably increasing, reflected in a 10-fold increase in the number of patients admitted to NHS hospitals with a primary diagnosis of obesity in the decade between 2000 and 2010 (1054 vs 11 574).1Statistics on obesity, physical activity and diet: England, 2012 www.ic.nhs.uk/pubs/opad12.Google Scholar Medical researchers initially documented this adipose explosion in a leisurely fashion. Entering the single search term ‘Obesity' into Medline returns 894 hits for the year 1971 and 1324 for 1991, representing a <50% increase in two decades. In contrast, the subsequent 20 yr have witnessed a 700% increase in medical papers on the subject, a 2001 search returning 3300 hits, increasing to over 9000 in 2011. Anaesthesia, however, has come late to the table. Looking back at the history of articles on obesity in the BJA reveals only 10 during the whole of the 1990s and only 47 during the decade up to 2010. The October 2012 edition of the BJA, therefore, is possibly a landmark in the documentation of the role of obesity in anaesthesia with no less than four articles2Hennis PJ Meale PM Hurst RA et al.Cardioplumonary exercise testing predicts postoperative outcome in patients undergoing gastric bypass surgery.Br J Anaesth. 2012; 109: 566-571Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar, 3Aldenkortt M Lysakowski C Elia N Brochard L Tramèr MR Ventilation strategies in obese patients undergoing surgery: a quantitative systematic review and meta-analysis.Br J Anaesth. 2012; 109: 493-502Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar, 4Campos JH Hallam EA Ueda K Lung isolation in the morbidly obese patient: a comparison of a left-sided double-lumen tracheal tube with the Arndt® wire-guided blocker.Br J Anaesth. 2012; 109: 620-635Abstract Full Text Full Text PDF Scopus (32) Google Scholar, 5Pérus O Marsot A Ramain E et al.Performance of alfentanil target-controlled infusion in normal and morbidly obese female patients.Br J Anaesth. 2012; 109: 551-560Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar in this single edition examining the topic. To kick off this new age of obesity enlightenment, Hennis and colleagues2Hennis PJ Meale PM Hurst RA et al.Cardioplumonary exercise testing predicts postoperative outcome in patients undergoing gastric bypass surgery.Br J Anaesth. 2012; 109: 566-571Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar looked at the usefulness of cardiopulmonary exercise testing (CPET) to predict outcome after bariatric surgery. Most anaesthetists inherently feel that the obese patient is at higher risk of postoperative complications than their non-obese counterpart. However, the evidence to support this assertion is patchy. One can find as many papers citing an increase in surgical complications in the obese as those showing no difference between obese and lean patients, indeed some workers have shown a protective effect of obesity.6Mullen JT Moorman DW Davenport DL The obesity paradox: body mass index and outcomes in patients undergoing non-bariatric general surgery.Ann Surg. 2009; 250: 166-172Crossref PubMed Scopus (380) Google Scholar Why is this? The problem lies in how we measure obesity. The calculation of BMI has become the accepted standard by which we judge the presence of obesity and nearly all clinical studies use BMI as the sole determinant for identifying the obese subject. Those of a certain age might remember one Jonah Lomu, the New Zealand rugby union wing who terrorized England in the 1995 Rugby World Cup. At his peak, Lomu had a BMI of over 34. Muscle is more dense than fat and as England fullback Mike Catt will testify, Lomu was pure muscle not fat, yet would have qualified for most obesity-related studies! It is clear that BMI alone is a poor determinant of what constitutes obesity and its concomitant complications. What is becoming clear is that the important issue is not the actual BMI of the patient, but where this excess weight is carried, the concept termed visceral adiposity. Put in simplistic terms, we look at whether a person has an ‘apple' or ‘pear'-shaped body morphology. ‘Apple'-shaped individuals have proportionately more abdominal fat and are said to exhibit central obesity. They are more likely to exhibit the metabolic syndrome (dyslipidaemia, hypertension, and diabetes) and tend to have higher resting C-reactive protein (CRP) levels, an indication that the body treats obesity as a chronic inflammatory state.7Faber DR van der Graaf Y Westerlink J Visseren FL Increased visceral adipose mass is associated with increased C-reactive protein in patients with manifest vascular disease.Atherosclerosis. 2010; 212: 274-280Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar 8Mathieu P Poirier P Pibarot P Lemieux I Despres JP Visceral obesity: the link among inflammation, hypertension, and cardiovascular disease.Hypertension. 2009; 53: 577-584Crossref PubMed Scopus (350) Google Scholar A simple determinant of central obesity is a waist circumference of >88 cm in women and >102 cm in men.9National Cholesterol Education ProgramThird Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III Final Report). National Institutes of Health, 2002Google Scholar If this is used as the measure of obesity rather than BMI, then differences in postoperative outcome begin to emerge. Balentine and colleagues10Balentine CJ Robinson CN Marshall CR et al.Waist circumference predicts increased complications in rectal cancer surgery.J Gast Surg. 2010; 14: 1669-1679Crossref PubMed Scopus (26) Google Scholar showed that in patients undergoing rectal surgery, complication rates were unrelated to BMI but that waist circumference was an independent predictor of both infection rates and having one or more postoperative complication. Girerd and colleagues11Girerd N Pibarot P Fournier D et al.Middle-aged men with increased waist circumference and elevated C-reactive protein level are at higher risk for postoperative atrial fibrillation following coronary artery bypass grafting surgery.Eur Heart J. 2009; 30: 1270-1278Crossref PubMed Scopus (74) Google Scholar found that in male patients undergoing coronary artery bypass grafting, the only predictors for the onset of new postoperative arrhythmias were a waist circumference of >102 cm or a raised preoperative CRP, both indicators of apple rather than pear habitus. Currently, the most widely accepted method for risk prediction in the obese is a scoring system called the Obesity Surgery Mortality Risk Score (OSMRS). This was developed in 2007 by DeMaria and colleagues,12DeMaria EJ Murr M Byrne K et al.Validation of the obesity surgery mortality risk score in a multicentre study proves it stratifies mortality risk in patients undergoing gastric bypass for morbid obesity.Ann Surg. 2007; 246: 578-582Crossref PubMed Scopus (4) Google Scholar and uses a simple five-point scale to determine the likelihood of mortality after elective bariatric surgery (Table 1). Patients scoring 0–1 points had a predicted 90 day postoperative mortality of 0.2%, while those who scored 4–5 had a 12-fold increase in mortality at 2.4%. While this score is only validated for those patients undergoing bariatric surgery, it is the authors' belief that the trend of a higher score equating to a higher predicted mortality would be equally applicable to the obese patient undergoing non-bariatric operations, as the score is essentially identifying those patients who are more likely to be apples: male gender, high BMI, hypertension, sleep apnoea.Table 1One point is attributed to the presence of each of the following risk factors. The DeMaria Obesity Surgery Mortality Risk Score (OSMRS)12DeMaria EJ Murr M Byrne K et al.Validation of the obesity surgery mortality risk score in a multicentre study proves it stratifies mortality risk in patients undergoing gastric bypass for morbid obesity.Ann Surg. 2007; 246: 578-582Crossref PubMed Scopus (4) Google Scholar •BMI >50 kg m−2•Male gender•Presence of arterial hypertension•Age >45 yr•Presence of risk factors for pulmonary emboli: •○ Previous DVT or PE•○ Pulmonary hypertension•○ Hypoventilation (sleep apnoea or obesity hypoventilation syndrome)•○ ImmobilityOSMR scorePredicted 90 day mortality 0–10.2% 2–31.1% 4–52.4% Open table in a new tab When looking for specific tests for outcome prediction, to date CPET has proved to be one of the most promising in the general surgical population. However, in most CPET studies, obese patients are intentionally excluded due to concerns about the applicability of the derived CPET values in patients outside of the ‘normal' body habitus or the ability of the test equipment to safely accommodate the patient (normally an upper limit of around 200 kg). Hennis and colleagues bucked this trend by looking specifically at the usefulness of CPET in the prediction of outcome in a purely obese patient population: those undergoing bariatric surgery. This is only the second published study examining CPET in the obese.13McCullough PA Gallagher MJ de Jong AT et al.Cardiorespiratory fitness and short term complications after bariatric surgery.Chest. 2006; 130: 517-525Abstract Full Text Full Text PDF PubMed Scopus (179) Google Scholar Both studies found a significant relationship between preoperative CPET values and outcome. It is known that in obese patients, CPET consistently underestimates the derived variables; it is interesting, therefore, that Hennis and colleagues found the same predictive values as previous work in non-obese subjects, namely that an anaerobic threshold (AT) of <11 ml kg−1 min−1 was indicative of increased risk.14Older P Hall A Clinical review: how to identify high risk surgical patients.Crit Care. 2004; 8: 369-372Crossref PubMed Scopus (67) Google Scholar If we accept that apple-shaped patients with central obesity are at an increased risk of postoperative complications, then would preoperative dieting help? The answer depends on our dietary endpoints. Coe and colleagues15Coe AJ Saleh T Samuel T Edwards R The management of patients with morbid obesity in the anaesthetic assessment clinic.Anaesthesia. 2004; 59: 570-573Crossref PubMed Scopus (9) Google Scholar offered 102 obese patients listed for elective surgery the choice of proceeding, or postponing surgery while they attempt to lose ‘a significant amount of weight'. Of the 52 who elected to diet first, after 18 months of intensive weight management, only eight patients managed to reduce their BMI by 3 points or more. Their conclusion was that although a laudable aim, optimization of a patient's weight before operation was impractical. Perhaps the authors were setting their dietary targets too high as there is evidence that lesser degrees of weight loss are achievable and yet can produce significant benefits in terms of outcome. Most bariatric surgical centres put patients on a preoperative ‘liver diet', a low carbohydrate, high protein regime, designed to reduce liver volume. This is usually introduced for just 1–2 weeks before surgery. Collins and colleagues16Collins J McCloskey C Titchner R et al.Preoperative weight loss in high risk superobese bariatric patients; a computer tomography-based analysis.Surg Obes Relat Dis. 2011; 7: 480-485Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar reported the benefits of extending this dietary regime in a small group of high-risk patients undergoing gastric bypass surgery, aiming for a 10% preoperative weight loss as their dietary endpoint. On average, the patients took only 9 weeks of dieting to achieve this target. Their findings were impressive with significant improvement in diabetic and hypertensive control and a 1 yr mortality of 0% in a recognized high-risk group. Similarly, Benotti and colleagues17Benotti PN Still CD Wood GC et al.Preoperative weight loss before bariatric surgery.Arch Surg. 2009; 44: 1150-1155Crossref Scopus (92) Google Scholar found that a 10% preoperative weight loss resulted in a significant reduction in postoperative complications in patients undergoing bariatric surgery. These studies raise the tantalizing prospect that for those deemed at high risk, short duration preoperative dietary modulation aiming at modest levels of weight loss might prove beneficial. Obesity is the disease of the modern age and impacts on all areas on healthcare. Today's anaesthetist must be prepared to deal with a significant number of obese and morbidly obese patients in his or her daily practice. To date, a waist circumference over 88 cm in women or 102 cm in men, an OSMR score of 4–5, or an AT of <11 ml kg−1 min−1 on preoperative CPET testing would all seem to indicate the high-risk obese patient, allowing us to both give patients a more accurate assessment of the potential risk/benefit of surgery but also to focus postoperative critical care facilities to the most needy patients. We should applaud the increasing interest in the effect of this morphological change on our daily anaesthetic practice, but one thing that studies have so far reinforced is something we have known since Adam and Eve's time: apples are just bad news! None declared." @default.
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• W2060691561 title "III. Obesity anaesthesia: the dangers of being an apple" @default.
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