Sleep Apnea and Bariatric
Surgery
Richard P. Millman, MD
Medical Director
Sleep Disorders Center of Lifespan Hospitals
Vice Chairman and Professor of Medicine
Alpert Medical School of Brown University
Disclosures
• Consultant Johnson and Johnson
Development Corporation
LapBand
• Most widely used bariatric surgery
world wide
• Received FDA approval in 2002 for
US
• Expected weight loss 30 – 40 % of
excess body weight in the first year
and 50 – 55 % in 5 – 10 years
LapBand
• May be longer term issues with
durability
• 15 year data shows some weight
regain with 35% excess body weight
loss maintained
• Band tightness needs constant
monitoring and may need
readjustment
Roux en Y gastric bypass
• Designed after observed weight loss in
total gastrectomy patients
• Small proximal pouch
• Duodenum excluded
• 90 to150 cm Roux limb
• Can be done open or laparoscopically
• Excess body weight loss 60% at one year
Selection Criteria
• BMI > 35 with significant
comorbidities
• BMI > 40
• Failed conventional weight loss
attempts
Selection Criteria
• Psychiatrically stable
• Women should not plan to be
pregnant for 2 years
• Able to tolerate anesthesia
Comparative Risk to Medical
Management
• Long term studies – patients eligible for
surgery who don’t versus those who have
surgery
232 Morbidly Obese Diabetics
154
78
Operation refused
for personal or
insurance reasons
Gastric Bypass
Mortality
14/154 (9%)/ 9 yrs
1%/yr
22/78 (28%)/6.2 yrs
P<0.0003
4.5%/yr
Nicolas V. Christou MD PhD
Mc Gill University 2004
n
Mortality
Controls
1,035
6.17%
Bariatric
Surgery
5,746
0.68%
Reduction of relative risk of death by 89%
Longitudinal Assessment of
Bariatric Surgery (LABS)
•
•
•
•
NIH/NIDDK Consortium
Six sites / 5 years
Short term –operative risk, selection
Long term – comorbidity control,
behavioral issues, economics
• $15,000,000 direct
Comorbidities Raise Operative Risk
•
•
•
•
Obstructive sleep apnea
Diabetic vascular disease
Reflux with reactive airway disease
NASH with hepatomegaly
Why is Sleep Apnea an Issue?
Anesthetic agents and narcotics can
• Increase pharyngeal muscle
relaxation leading to airway collapse
• Depress respiratory drive
Mary and Bariatric Surgery
• 50 year old woman with known sleep
apnea on PAP
• Underwent a Roux en Y procedure
• After leaving the PACU was sent to a
regular surgery floor
• CPAP was not given since the
surgeon felt that the pressure could
blow out the sutures
• The surgeon saw her a couple of hours
later and increased the basal rate on her
PCA morphine pump because she had
7/10 pain
• Later on she demonstrated increasing
confusion but a blood gas was not
checked
• She had an arrest and eventually died
• The family marched outside the hospital
carrying signs stating “They Killed My
Mother”
How could have this been
prevented?
• Sending the patient to a stepdown unit
with continuous monitoring of heart rate,
respiratory rate and pulse oximetry
• Putting the patient on her PAP post
operatively
• Avoidance of a continuous infusion of
morphine
What if we do not know if they have
sleep apnea?
• Sleep apnea is common in obese
individuals
• What should we do about patients who
haven’t been diagnosed with sleep apnea?
• Sleep studies are expensive and
inconvenient. We certainly do not want to
perform sleep studies in every patient
going for weight loss surgery; do we?
Does this woman have sleep
apnea?
Does this one?
Predicting Obstructive Sleep Apnea
Among Women Candidates for Bariatric
Surgery
• 296 consecutive women being
evaluated for bariatric surgery who
had undergone polysomnography
• Mean age 42 years (age 19-61)
• 86% had OSA (AHI = 5 or higher)
• 53 % had moderate to severe disease
(AHI > 15)
•
Sharkey et al JOURNAL OF WOMEN’S HEALTH 2010; 19: 1-9
Results
• Age, BMI, neck circumference, the
presence of hypertension, observed
apneas during sleep, and snoring all
predicted to some degree AHI
• The presence or absence of
symptoms of snoring, observed
apneas or daytime sleepiness did
not correlate with:
1. the absence of OSA
2. the presence of any sleep apnea
3. the presence of moderate to severe
OSA
Conclusions
• In other words we could not predict
who had moderate to severe sleep
apnea
• Everybody needed polysomnography
Is there anything special about
sleep studies prior to bariatric
surgery?
Yes
• You should make sure you study
them on their back!
What about CPAP?
Who needs CPAP and how much?
• You have to decide ahead of time
who needs a CPAP titration?
• Should it be an AHI of 5, 15, 30?
• When you do a titration in the sleep
center study them on their back to
mimic a post-op condition.
Possible Protocol
• Set the patient up on appropriate PAP
settings for a month
• See them in followup and assess
objectively and subjectively whether
they are using PAP
• Make appropriate adjustments in
therapy
The Day of Surgery
• Patient should bring PAP device to
the hospital (or should bring in
settings for a Respiratory Therapy
unit)
• After leaving the PACU the patient
should go to a stepdown unit with
monitoring capabilities
• The patient should be put on PAP
• Continuous basal rates of narcotics
should be avoided if possible
Should the patient continue to use
PAP at home?
• They definitely should if they had
symptoms of OSA prior to the surgery or
had severe OSA on polysomnography
• A repeat sleep study should be performed
off PAP once stable weight loss has been
obtained
• Pressures may need to be decreased as
the patient is losing weight