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Successful weaning from mechanical ventilation after abdominal lipectomy and omentectomy in an obese patient with multiple rib fractures
* E-mail: kyyoo{at}jnu.ac.krEditor—Obesity1 and old age2 3 are major risk factors for pulmonary complications following trauma or general anaesthesia. We report our experience with a morbidly obese, elderly patient with multiple rib fractures, who was successfully weaned off the mechanical ventilation after abdominal lipectomy and omentectomy.
A 69-yr-old, morbidly obese female was admitted with severe shortness of breath following traumatic injury to her chest in a motor vehicle accident. She was 155 cm and 95 kg, with body mass index 39.5 kg m–2. Computed tomography scans taken a few hours after the injury showed multiple right rib fracture (3rd to 11th), pulmonary contusion with small amount of haemopneumothorax in the right chest, and significant fatty tissue in the thoracic and peritoneal cavities. The arterial blood pressure was 160/90 mm Hg and the heart rate (HR) 68 beats min–1. Her respiratory status deteriorated progressively over 12 h, the respiratory rate being increased up to 30 bpm. She was transferred to the intensive care unit and was given supplemental oxygen via facemask. She received i.v. patient-controlled analgesia, and diuretics to improve pulmonary compliance in a sitting position. A tube thoracostomy was placed in the right chest for drainage of associated haemopneumothorax. She was encouraged to cough vigorously and breathe deeply. Chest physiotherapy was carried out frequently to prevent retention of secretions and development of atelectasis. Her 
increased progressively, although arterial oxygenation was maintained with supplemental oxygen. On day 8, she was intubated and lungs were mechanically ventilated, when her increased to 13.2 kPa and 
decreased to 6.2 kPa. Chest symptoms subsided within 2 weeks after the injury. However, after 8 days of mechanical ventilation, attempts at weaning on three occasions over the following 2 weeks were unsuccessful. A surgical removal of abdominal fat was considered to reduce the intra-abdominal pressure and to improve respiratory mechanics. On day 21 of mechanical ventilation, she underwent abdominal lipectomy (2940 g) and omentectomy (1650 g) under general anesthesia. The surgery lasted 5.7 h and was uneventful. The tidal volume increased from preoperative value of 350–400 ml to 450–550 ml, and static compliance from 0.033 to 0.05 litre cm H2O–1 on the 1st postoperative day. From the 5th postoperative day, weaning trials were continuously made during the day time with progressive decreases of pressure support. On the 14th postoperative day, the patient was successfully weaned off the ventilator.
Abdominal lipectomy is a safe and reliable measure for the removal of excess abdominal fat in obese subjects.4 In addition, weight reduction itself is among the most effective measures to treat pulmonary complications in the obese.1 The removal of excessive abdominal and omental fat may have reduced intra-abdominal pressure against the diaphragm, resulting in an enhanced respiratory mechanics and successful weaning away from mechanical ventilation.
The surgery involving the thorax and upper abdomen, however, is associated with an increased risk of pulmonary complications.5 Moreover, obese patients have a higher incidence of postoperative pulmonary complications.6 The lung function can also be influenced by the type of body fat distribution (central or peripheral),7 and the fat removal may be more useful in the central type of obesity as in our case. Clinicians should be aware of the risks and benefits of abdominal lipectomy in different clinical settings.
References
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3 Holcomb JB, McMullin NR, Kozar RA, et al. Morbidity from rib fractures increases after age 45. J Am Coll Surg 2003; 196: 549–55[Medline]
4 Masson JK. Lipectomy: the surgical removal of excess fat. Postgrad Med 1962; 32: 481–8[Medline]
5 von Ungern-Sternberg BS, Regli A, Schneider MC, et al. Effect of obesity and site of surgery on perioperative lung volumes. Br J Anaesth 2004; 92: 202–7
6 Waltemath CL, Bergman NA. Respiratory compliance in obese patients. Anesthesiology 1974; 41: 84–5[CrossRef][Web of Science][Medline]
7 Collins LC, Hoberty PD, Walker JF, et al. The effect of body fat distribution on pulmonary function tests. Chest 1995; 107: 1298–302
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