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Opciones quirúrgicas válidas r cohen
 

Opciones quirúrgicas válidas r cohen

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    Opciones quirúrgicas válidas r cohen Opciones quirúrgicas válidas r cohen Presentation Transcript

      • Ricardo Cohen MD
      Novel GI procedures for low BMI T2DM
      • The Center for the Surgical Treatment of Morbid Obesity and Metabolic Disorders. Hospital Oswaldo Cruz , Sao Paulo, Brazil
      • President, Brazilian Society for Bariatric and Metabolic Surgery
      • Research Grant, Covidien
      • Research Grant, GI Dynamics
      • SAB, GI Dynamics
      • Disclosures
      • Why address low BMI patients?
      • What’s the background for novel procedures?
      • Critical analysis of DJB and I T
      • Do we need novel procedures?
    • Need to address the “real world” in investigational protocols 50 % of Diabetics in the world have BMI<35 Int J Clin Practice, 2007(NHANES and SHIELD) Dtsch Int Arztebl. 2010, 107 SOARD, 2010
      • RYGB tested in BMIs 30-35 with sustained ( 6 years) DM remission and weight loss.
      Why novel procedures? Cohen,2006; Cohen and Cummings, 2010
      • Do lower BMIs need massive weight loss? Do low BMI pts, with mild insulin resistance need the pylorus to conquer better glycemic/metabolic control?
      • BPD Scopinaro may achieve good long term glycemic/metabolic control in lower BMIs. But are the nutritional risks worth the operation?
      Scopinaro, 2011
    • Is there any phisiological importance for preserving the pylorus?
      • Delaying gastric emptying proved to be an efficient mean of reducing postprandial glucose excursions in diabetics and healthy subjects secondary to incretin effect
      • The higher the glucose loads pronounced decrease in gastric emptying
      • Glucose excursions are dampened and prolonged, serving to avoid proximal bowel glucose overload
      Nauck, 1986; Pilichiewicz, 2007; Bagger, JCEM, March 2011 SO, PRESERVING THE PYLORUS MAY BE IMPORTANT TO DM CONTROL AFTER GI SURGERY
    • Ileal Transposition with sleeve gastrectomy and with or without duodenal exclusion without duodenal exclusion
    • What are the proposed novel procedures? Duodenal jejunal bypass
    • Text Not at new concept at all !! Studied back on early 80’s by Koopmans and Scalfani in animals. Very high mortality rates reported in animals
    • IT + SG +- Duodenal Exclusion IT + SG IT+ SG + Duodenal Exclusion 1) Surg Endosc, March 2008 2) Surg Endosc, Jun 2008 3)Surg Endosc, 2009 4)J Gastro Intest Surg, 2010 5) World J Surg, 2011 Almost Exclusively Championed by De Paula
    • Outcomes * A1c < 7 % #PTS Preop BMI(mean) TBWL % DM remission * FU (mean) Study 1,March2008 Both SGIT+DSGIT 39 30,1 22 86,9 7 mo Study 2,June 2008 Both SGIT+DSGIT 60 30,1 23 86,7 7,4 mo Study 3,2009 DSGIT ONLY 69 25,7 17,7 95,7 21,7mo Study 4,2010 Both SGIT+DSGIT 72 27 22 86,5 90% Lipid profile improvement 24,5 mo Study 5,2011 DSGIT ONLY 454 29,7 BMI to 25,9 @ 1 mo 1 mo study 1 mo study
    • DSGIT/SGIT Other outcomes Other outcomes
      • Expressive lipid control
      • Significant blood pressure control
      • Reported improvement of macro and microalbumunuria
    • And Complications and Mortality? Major Complications(%) Intraop complications(%) Mortality(%) Study 1,March2008 Both SGIT+DSGIT 10,5 7,7 -30% related to ischemia of the transposed ileum 2,6 Study 2,June 2008 Both SGIT+DSGIT 11,7 5 0 Study 3,2009 DSGIT ONLY 7,7 5 0 Study 4,2010 Both SGIT+DSGIT 13,9 8,3 0 Study 5,2011 DSGIT ONLY 6,4 4 -50% related to ischemia of the transposed ileum 0,4
      • 10 pts, mean BMI 33.8 kg/m2
      • 9 mo follow up
      • 70% remission(A1c<7)
      • WL between 15 and 30% (TBWL)
      • Mortality and complications not reported
      • Seems effective, but very complex :
      • Expressive and rapid WL, that can be credited for short/mid term improvement
      • Too many surgical variables: What works?( SG; IT or DE?)
      • Peculiar intraoperative complications(ischemia of the transposed segment) happen in a relatively high number
      • Difficult operation, difficult pts, ~ 10,1 % major complications
      • Reported mortality of 2.6% ( 0.28% RYGB)
      • Better designed studies needed
    • And Duodenal jejunal bypass?
    • Time Post Surgery (month) Time Post Surgery (month) R Cohen et.al SOARD, 2007 4 9 8 7 6 5 0 1 2 3 4 5 6 7 8 9 HbA 1c (%) 26 30 29 28 27 0 1 2 3 4 5 6 7 8 9 BMI (kg/m2)
    • Classic DJB
      • We tested the hypothesis that bypassing the UGI tract with a DJB, without marked weight loss or restriction, may have a role on glucose homeostasis and beta cell function compared to a matched NGT group.
      Cohen R & Klein S ,2011
    • Results - 20% of all med free with A1c<6.5% @ 12 mo. - Significant decrease in med score @ 6 and 12 mo Cohen R & Klein S ,2011 Mean preop BMI 27.8 WL 6.9+- 4.9% @ 3mo Most returned to baseline @12mo. 5 gained weight x baseline
    • Delta BMI x A1c Delta BMI HAS NO IMPACT in the negative variation of A1c from preop to 12 months
    • Beta cell function T2DM x NGT T2DM x NGT Cohen R & Klein S ,2011
    • Conclusions
      • Glycemic control not related to WL
      • Improvement of beta cell function- all indices of responsiveness to glucose ingestion increased 2-3 fold after DJB
      • It does not normalize beta cell function, but it has significant effects over it
      Klein S&Cohen R
    • Sleeve Gastrectomy + Duodenal Jejunal Bypass Non restrictive SG Pylorus preserving duodenal exclusion ( 100 cm biliary and 150 cm alimentary limbs
    • What’s behind those changes?
      • The role of Ghrelin- direct and counter regulatory diabetogenic effects
      • The role of the biliary limb lenght - bile acids induced incretin secretion (?)
    • Sleeved DJB or Short DS
      • First 50 pts @ 18 mo Follow up
      • Mean preop BMI = 28.9
      • TBWL 6.8% +- 3.7%
      • 27 insulin users
      * 8 ( 16 %) pts with A1c less than 6 100 % between Control &Resolution Follow-up Mean A1c Insulin Unchanged Control, A1c<7 Less meds Resolution No meds,A1c<7 18 mo 6.2+-0.5* NONE 0 - NO 32% (16 pts) 68% (34 pts)
    • NO malabsortive component?
      • 100% of non significant fecal fat detection
      • Hb A1c preop to 18 months - * p<0,05
      8..9+-0.9 7.3+-0.4 6.8+-0.6 6.4+-0.5*
      • FPG preop to 18 months - * p<0,05
      8..9+-0.9 7.3+-0.4 6.8+-0.6 6.4+-0.5*
      • Post prandial preop to 18 months - *p<0,05
      8..9+-0.9 7.3+-0.4 6.8+-0.6 6.4+-0.5*
    • Other Metabolic Outcomes
      • Significant decrease in CIT (0,71±0,16 preop to 0,61±0,13* 12 mo)
      • Significant decrease in SBP and DBP
      • Significant decrease in LDL and TG
    • Duodenal Jejunal Bypass
      • Seems to be effective
      • Diabetes resolution/improvement without direct relation to weight loss
      • Low major complication’s rate (1.5%)
      • Known and simpler operation - Duodenal switch with shorter limbs, minimized nutritional risks
    • We are not alone Biliopancreatic Diversion Preserving the Stomach and Pylorus in the Treatment of Hypercholesterolemia and Diabetes Type II: Results in the First 10 cases Giuseppe Noya , 1999, Obesity Surgery Excellent reported results, 7 “controlled”pts
    • We are not alone 1.9% major complication rate
    • DJB-literature 1.3% major complication rate Remission Improvement Remission and Improvement LSG+DJB 93% 7% 100%
    • DJB-literature Modest decrease in BMI, with decrease in A1c @ 6 mo
    • What is the role of Duodenal Exclusion Per se on diabetes?
      • Is Duodenal Exclusion per se Antidiabetic?
    • De Paula’s CT COMPARED IT + SG x IT+SG+ Duod Exclusion( only variable)
    • Adding a duodenal exclusion improves results
    • • GI Bypass Surgery (Duodenal Exclusion) Repair of underlying pathophysiologic mechanisms of diabetes?
    • Why Sleeved DJB? X No gastric remnant No dumping Pylorus-preserving Well known Easier ? BETTER THAN RNYGB?
    • T2DM surgery in lower BMIs
      • Although we believe that we have several SILENT EVIDENCES , that point us that surgery may benefit T2DM in lower BMIs, we need to start speaking NATIVE CONTEMPORARY DIABETOLESE!
      RANDOMIZED CONTROLLED TRIALS!!! RYGB x Sleeved DJBxBest Med treatment in BMIs 26-35 Work in Progress !! RYGBxSGX Best Med Treatment im=n BMIs 26-35
    • Released Sept 2010
    •