Efectos metabólicos del by pass gástrico

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Efectos metabólicos del by pass gástrico

  1. 1. Efectos Metabolicos del Bypass Gastrico <ul><li>Ricardo Cohen MD </li></ul><ul><ul><li>The Center for the Surgical Treatment of Morbid Obesity and Metabolic Disorders, Hospital Oswaldo Cruz , Sao Paulo, Brazil </li></ul></ul><ul><ul><li>President, Brazilian Society for BAriatric and Metabolic Surgery </li></ul></ul>
  2. 2. Restriction- transient and initial decreased food intake Ghrelin- Anorexigenic effect Duoenal Exclusion Inctetin effect + PROXIMAL Mechanism Faster food delivery DISTAL Mechanism Mild Malabsorption Why RYGB works?
  3. 3. <ul><li>RYGB </li></ul><ul><li>Energy restriction- IMPORTANT!! </li></ul><ul><li>Plays a role in decreasing hepatic glucose output and increased hepatic insulin sensitivity </li></ul><ul><li>HOWEVER,studies have shown that it happens way before weight loss, so it seems that they are independent factors. </li></ul>Mechanisms of action and procedures
  4. 4. <ul><li>Increasing insulin secretion mechanisms </li></ul><ul><li>RYGB stimulates GIP, GLP-1 secretion ( incretin effect) and some satiety peptides, as PYY and PP. It seems to be weight loss independent. (Le Roux,2006;Laferrere, 2008;Salinari,2009;Ferranini,2009;Andrelli, 2009) </li></ul><ul><li>The report of postoperative hypoglycemia(Nesidioblastosis) (Kaiser,2005;Service,2005) </li></ul>
  5. 5. Fed at the 5th week postop X Mechanistic aspects of RYGB x
  6. 6. <ul><li>Peroral feeding reduced 2 h post prandial glucose compared with gastroduodenal route </li></ul>Marked increased secretion of GLP1 and C peptide in the operated group “ “
  7. 7. Incretins: Early & Late postop Increased GLP1 secretion and insulin sensitivity
  8. 8. RYGB Mechanisms of action Mechanisms of action <ul><li>Increased insulin sensitivity mechanisms </li></ul><ul><li>Collapse of Ghrelin secretion and enhanced antidiabetic effect (??) </li></ul><ul><li>Decreased lipotoxicity , decreasing TG and FFA, without direct relation to weight loss </li></ul>
  9. 9. RYGB Mechanisms of action Mechanisms of action <ul><li>Changes in vagal tone of the excluded intestine. Interruption of afferent vagal stimulation may increase insulin sensitivity and hepatic glucose production </li></ul><ul><li>Intestinal gluconeogenesis after food transit rearrangement, not incretin mediated </li></ul>
  10. 10. <ul><li>Change of adipocytokine secretion, decreasing inflammatory response, thus leading to increased insulin sensitivity </li></ul>
  11. 11. DECREASED GLUCOSE TRANSPORT FUNCTION & REDUCTION OF GLUCOSE ABSORPTIVE CAPACITY
  12. 12. Metabolomics <ul><li>Decreased BCAA and its metabolites leads to increased insulin sensitivity in a RYGB x Diet induced WL </li></ul>
  13. 13. RNY Gold Standard? <ul><li>History </li></ul><ul><li>Efficacy </li></ul><ul><li>Durability </li></ul><ul><li>Safety </li></ul><ul><li>Reproducibility </li></ul><ul><li>Physiology </li></ul>
  14. 14. RNY Gold Standard? <ul><li>History </li></ul><ul><li>Efficacy </li></ul><ul><li>Durability </li></ul><ul><li>Safety </li></ul><ul><li>Reproducibility </li></ul><ul><li>Physiology </li></ul>
  15. 15. RNY <ul><li>History </li></ul><ul><li>Procedure used for GI tract reconstruction </li></ul><ul><li>Excessive weight loss not seen with the operation </li></ul><ul><li>Patients remain at 77% preoperative BMI Surgery(1991) </li></ul>
  16. 16. RNY Gold Standard? <ul><li>History </li></ul><ul><li>Efficacy </li></ul><ul><li>Durability </li></ul><ul><li>Safety </li></ul><ul><li>Reproducibility </li></ul><ul><li>Physiology </li></ul>
  17. 17. Efficacy Buchwald H. JAMA, 2004 Buchwald,2004 Procedure % EWL T2DM (Controled) Gastric Banding 47% (n=1848) 48% Gastroplasty 68% (n=506) 68% Gastric Bypass 62% (n=4204) 84% BPD 70% (n=2480) 98%
  18. 18. Effect on Long-term Mortality Compared to Non-Operated Controls Study Procedure F/U Mortality Reduction MacDonald,1997 RYGB 9 yrs 88% Flum, 2004 RYGB 4.4yrs 33% Christou, 2004 RYGB 5 yrs 89% Sowemimo, 2007 RYGB 4.4 yrs 50% Adams, 2007 RYGB 8.4 yrs 40% Sjostrom, 2007 VBG/RYGB 14 yrs 31% Perry, 2008 (Medicare) RYGB, VBG, LAGB 2 yrs 48 % age < 65 34% age > 65
  19. 19. RNY Gold Standard? <ul><li>History </li></ul><ul><li>Efficacy </li></ul><ul><li>Durability </li></ul><ul><li>Safety </li></ul><ul><li>Reproducibility </li></ul><ul><li>Physiology </li></ul>
  20. 20. RYGB & T2DM Long lasting effect <ul><li>Authors Pories WJ, Swanson MS, MacDonald KG, et al 1995;222:339-350 </li></ul><ul><li>Key point : Surgery is more efficient than medical treatment. A good number of patients leave the hospital with their T2DM controlled </li></ul>83% euglicemic in up to 14 years of follow-up
  21. 21. Weight and Type 2 Diabetes after Bariatric Surgery: Systematic Review and Meta-analysis 1990-2006; 19 studies, 4, 070 diabetic patients The American Journal of Medicine (2009) 122, 248-256
  22. 22. RNY Gold Standard? <ul><li>History </li></ul><ul><li>Durability </li></ul><ul><li>Safety </li></ul><ul><li>Reproducibility </li></ul><ul><li>Efficacy </li></ul><ul><li>Physiology </li></ul>
  23. 23. Mortality Rates Following Common Operations in U.S. Hospitals ] Dimick JB, Welch HG, Birkmeyer JD. Surgical mortality as an indicator of hospital quality. JAMA 2004,292, 847-851 SRC: Bariatric Surgery Mortality 0.28% (55,567 patients) Aortic Aneur CABG Craniot Esophag Resect Hip Replac Panc Ped. Heart Surgery Number of Hospitals performing operation 2485 1036 1600 1717 3445 1302 458 National Average Mortality rate( %) 3.9 3.5 10.7 9.1 0.3 8.3 5.4 Average Hospital caseloads Median 30 491 12 5 24 8 4
  24. 24. Lap Chole: 0.35-0.60
  25. 25. RNY Gold Standard? <ul><li>History </li></ul><ul><li>Efficacy </li></ul><ul><li>Durability </li></ul><ul><li>Safety </li></ul><ul><li>Reproducibility </li></ul><ul><li>Physiology </li></ul>
  26. 26. Reproducibility RYGB & EWL &T2DM Control Author Procedure EWL T2DM Control Pories,1995 RYGB 77% 89% Schauer,2003 RYGB 73.7% 82% Sugerman,2003 RYGB 79% 86% Torquati,2005 RYGB 74% 81% Cohen,2006 RYGB 77% 97%
  27. 27. RNY Gold Standard? <ul><li>History </li></ul><ul><li>Efficacy </li></ul><ul><li>Durability </li></ul><ul><li>Safety </li></ul><ul><li>Reproducibility </li></ul><ul><li>Physiology </li></ul>
  28. 28. RNY Gold Standard? <ul><li>Less nutritional problems long term when compared to malabsortive procedures </li></ul>
  29. 29. RNY Gold Standard? <ul><li>Reversible, when compared to sleeve gastrectomy </li></ul>
  30. 30. Diabetes & BMI at least 50 % of DM in the world have BMI<35 Int J Clin Practice, 2007(NHANEMCS and SHIELD) Dtsch Int Arztebl. 2010 SOARD, 2010
  31. 31. That’s where we started <ul><li>RYGB in BMI < 35 </li></ul>Cohen, 2010
  32. 32. Prospective Study of RYGB for Type 2 DM in Caucasians With BMI 30–35 kg/m 2 <ul><li>66 Caucasian patients </li></ul><ul><ul><li>100% F/U to 6 years </li></ul></ul><ul><li>BMI 30–35 kg/m 2 </li></ul><ul><ul><li>Mild obesity for this population </li></ul></ul><ul><li>Type 2 DM </li></ul><ul><ul><li>Confirmed with Abs, C-peptide, FHx </li></ul></ul><ul><li>Severe diabetes </li></ul><ul><ul><li>Mean duration: 13 years </li></ul></ul><ul><ul><li>40% on insulin (the rest on oral DM meds) </li></ul></ul><ul><ul><li>HbA1c: 9.7% at start </li></ul></ul>Cohen RV….. Cummings DE
  33. 33. 70 60 50 40 30 20 10 0 Number Of Patients Cohen RV….. Cummings DE 6-Year Study of RYGB for Type 2 DM in Patients With BMI 30–35 kg/m 2 1% No Change 11% T2DM Improvement 88% T2DM Remission
  34. 34. A 5 6 7 8 9 10 11 0 6 12 24 48 60 72 Months After Surgery Hemoglobin A1c (%) Rapid & Durable Improvement in HbA1c Cohen RV….. Cummings DE
  35. 35. LRYGB, BMI 30-35 Cohen at al. Cohen at al. Significant decrease-p<0.05
  36. 36. UKPDS Risk Engine 10-Year Cardiovascular Risk Predictions (%) COHEN&CUMMINGS Pre-Op Post-Op Coronary Heart Disease * Fatal Coronary Heart Disease * Stroke * Fatal Stroke *
  37. 37. LRYGB, BMI 30-35 Cohen at al. Cohen at al. <ul><li>No mortality </li></ul><ul><li>No leaks </li></ul><ul><li>No reoperations </li></ul><ul><li>4.5% minor complications( port site hematomas, vomiting) </li></ul>VERY EFFECTIVE
  38. 38. Laferrere,2008 RYGB Mechanisms of action

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