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

2. Obesity epidemic 2005-2006 Percent of adults age 20 years and over who are overweight or obese: 67% Percent of adults age 20 years and over who are overweight or obese: 67% Percent of adults age 20 years and over who are obese: 34% Percent of adults age 20 years and over who are obese: 34% Percent of adolescents age 12-19 years who are overweight: 18% Percent of adolescents age 12-19 years who are overweight: 18% Percent of children age 6-11 years who are overweight: 15% Percent of children age 6-11 years who are overweight: 15% Percent of children age 2-5 years who are overweight: 11% Percent of children age 2-5 years who are overweight: 11% Source: CDC

3. Lap Colon in Obese patient Harder? Harder? Easier? Easier? Contraindicated? Contraindicated? Beneficial? Beneficial? Every obese patient the same? Every obese patient the same?

4. Case 36 year old woman admitted to the hospital with two week history of increasing abdominal distension and constipation. Last BM/flatus three days ago 36 year old woman admitted to the hospital with two week history of increasing abdominal distension and constipation. Last BM/flatus three days ago PMHx: Severe obesity BMI 36 PMHx: Severe obesity BMI 36 PE: Obese woman in moderate pain; no peritoneal signs PE: Obese woman in moderate pain; no peritoneal signs

5. Case Ct scan shows obstructing lesion at splenic flexure Ct scan shows obstructing lesion at splenic flexure

6. Case What next? What next? LaxativesLaxatives OR open surgeryOR open surgery OR lap SurgeryOR lap Surgery Attempt colonoscopic stentingAttempt colonoscopic stenting

7. Cleveland Case-matched Study Obese vs Nonobese Dis Colon Rectum 2005; 48: 975–981

8. Conversions Conversion rate: 30 %

9. German Laparoscopic Colorectal Surgery Study group BMI 30-35BMI>35 Conversion rate and length of operation correlate with degree of obesity Same outcomes OBES SURG (2008) 18:66–70

10. Is every obese patient the same? On whom would you prefer to operate ?

11. Japanese study Visceral Obesity vs BMI Visceral Obesity vs BMI BMI readily available anthropometric index BMI readily available anthropometric index BMI does not tell you anything about body fat deposits BMI does not tell you anything about body fat deposits Visceral obesity predictor of metabolic syndrome Visceral obesity predictor of metabolic syndrome Half of nonobese pts by BMI have visceral obesity Half of nonobese pts by BMI have visceral obesity DCR 51: 1757–1767 (2008)

12. Determination of Visceral Fat Area (VFA) Visceral obesity > 130 CM 2

13. Japanese study VFA Nonobese (n=65) (n=65)VFAobese(n=68)P BMI Nonobese (n=106)BMIObese(n=27)P Or Time (min)1902200.0062072350.01 Hospital stay (days)910.50.0079.59NS Complication(%)1232.0062030ns DCR 51: 1757–1767 (2008)

14. Conclusions LAP colectomy in obese patients safe and feasible LAP colectomy in obese patients safe and feasible Superior postoperative outcomes compared with open surgery Superior postoperative outcomes compared with open surgery Maybe Higher conversion rate Maybe Higher conversion rate In experienced hands conversion does not result in higher complications In experienced hands conversion does not result in higher complications Type of obesity appears to determine ouctome more than BMI Type of obesity appears to determine ouctome more than BMI