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  • 1. Efecto metabólico de la manga gástrica Camilo Boza MD FACS Assitant Professor of Surgery Pontificia Universidad Católica de Chile
  • 2. Background
    • Obesity ↔ Diabetes
    OBESIDAD: Ono T, Guthold R, Strong K, WHO Global Comparable Estimates, 2005 DIABETES: IDF Diabetes Atlas, 4th ed.International Diabetes Federation, 2009
  • 3. clinicaltrials.gov Bariatric surgery for the treatment of Diabetes
  • 4. Diabetes Resolution
  • 5. Co-morbid conditions after Gastric Bypass BMI >35 n:1500 Preoperative (%) 1 year (Res/Imp) 5 year (Res/Imp) Hypertension 35.8 60/32 60/30 T2 Diabetes 11.5 76/20 80/20 Insulin resistance 60.4 88/11 100/0 Dyslipidemia 55 87/12 93/7
  • 6. Restrictives techniques Weight loss Weight loss Hormonal effect AGB Sleeve
  • 7. Wilcoxon Sign-Rank Test—Geometric mean (interquartile range). Dixon et al. Diabetes Care . 2002;25:358-363 .
  • 8. Resolution of Diabetes Metanalysis n: 22.400 Total LAGB GBP BPD/DS % Resolved 82.1 55.3 80.5 99.4 % Resolved or Improved 100.0 – 100.0 – % Improved 20.4 – 20.4 – % Unchanged 0.3 – 0.0 0.7 Insulin (pml/L) -98.0 -99.6 -40.2 -125.0 HbA1c (%) -2.1 -1.4 -2.2 – Glucose (mmol/L) -4.4 -2.5 -3.9 -5.4
  • 9. Boza et al, Surgical endoscopy 2009
  • 10. Boza et al, Surgical endoscopy 2009
  • 11. Sleeve gastrectomy Restriction Fast gastric emptying Rise in gut hormones Role of Ghrelin
  • 12. % Diabetes Resolution Vidal, Lacy , Obesity Surgery 2007 BMI:49
  • 13. % Diabetes Resolution Sleeve gastrectomy versus Bypass Boza et al, ASMBS 2010
  • 14. Sleeve gastrectomy versus Bypass Boza et al, ASMBS 2010 Bypass Sleeve Pre Res Imp Pre Res Imp Chol ≥ 200 mg/dL 44,2 71,2 0,0 41,9 47,1 0,0 Trygl ≥ 150 mg/dL 40,7 71,4 0,0 42,0 65,7 0,0 IR 47,3 93,5 5,5 33,6 81,0 16,2 Arterial Hyp 26,8 58,2 22,3 23,5 57,5 34,8 T2DM 5,5 86,6 6,6 3,9 90,9 9,1
  • 15. Diabetes Resolution Basso, Surg Endosc 2009
  • 16. % Diabetes Resolution Basso, Surgical endoscopy 2009
  • 17. % Diabetes Resolution Shaa, SOARD 2009 36 months after surgery
  • 18. % Sleeve Gastrectomy and Diabetes Shaa, SOARD 2009 36 months after surgery
  • 19. % Sleeve Gastrectomy and Diabetes Shaa, SOARD 2009 36 months after surgery
  • 20. Why ?
  • 21. % Melissas Vaciamiento Melissas, Obesity Surgery 2007 T1/2 Gastric Emptying
  • 22. PYY after Sleeve and Bypass Valderas, 2009 SOARD 2009 Bypass Sleeve Med Treat
  • 23. Glp1 Melissas Vaciamiento Peterli, Annals of Surgery 2007 Bypass Sleeve
  • 24. GLP1 after Sleeve and Bypass Valderas, Boza 2010 Bypass Sleeve Med Treat
  • 25. AUC for GLP1 after Sleeve and Bypass Valderas, Boza 2010
  • 26. Sleeve gastrectomy as a Metabolic Surgery Camilo Boza MD FACS Assitant Professor of Surgery Pontificia Universidad Católica de Chile
  • 27. Guess the BMI BMI 42. No metabolic Syndrome
  • 28. Guess the BMI BMI 30. Metabolic Syndrome and Diabetes
  • 29. Sleeve gastrectomy for the treatment of T2DM in patients with BMI 30-35 n:12 Age (years) 47,4 (21-59) Male Gender (%) 9 (75%) BMI (kg/m2) 33,7 (32,1-34,6) Glucosa (mg/dl) 137 (83-187) Years of Diabetes 2,5 (1-7) HA1C (%) 7,3 (6,3-8,9)
  • 30. Sleeve gastrectomy for Diabetes in BMI 30-35 n:12 Preop 1 año Postop ∆ p BMI (kg/m 2 ) 33,7 (32,1-34,6) 27,5 (21,8-30) - 6,2 0,01 Medication % 75 17 - 58 --- Glucosa (mg/dl) 137 (83-187) 93,5 (80-172) - 43,5 0,01 Hb A1c (%) 7,3 (6,3-8,9) 5,8 (4,9-6,9) - 2,4 0,06 Homa - IR 6,46 (1,6-14,2) 1,8 (1,7-6,5) - 4,7 0,06 Insulin 25,4 (9,3-45) 9,9(6,7-16,9) -15,5 0,04
  • 31. 12 Month Diabetes resolution Resolution (HbA1c normal sin medicación) 70% Better control 13,3 % No change 16,7%
  • 32. BMI evolution for Sleeve 30-35
  • 33. Bypass versus Sleeve for Diabetes BMI 25-35 BMI 25-35 Lee, 2012
  • 34. Conclusion
    • Restrictive procedures help to control Diabetes
    • LAGB achieves a 40-50% resolution of diabetes based on weight loss.....
    • Sleeve gastrectomy appears to be an attractive option offering restriction with a hormonal effect.
    • Sleeve gastrectomy could be offered as a treatment for patients BMI below 35.
    • ARE THESE EFFECTS LONG LASTING FOR A CHRONIC DISEASE ???
    • Prospective randomized trials are necessary.
  • 35.