Metabolic Surgery 15 min V Congreso Internacional de Cirugia Bariatrica y Metabolica Mendoza Argentina May 19 & 20, 2011
Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Sur...
Cummings DE, Weigle DS, Frayo RS et al. Plasma ghrelin levels after diet-induced weight loss or gastric bypass surgery. N ...
Decreased  Basal Ghrelin after Surgery Advanced Laparoscopic Surgery Associates Medical Group Leonetti F, Silecchia G, Iac...
Unchanged  Basal Ghrelin after Surgery Advanced Laparoscopic Surgery Associates Medical Group Schindler K, Prager G, Balla...
Increased  Basal Ghrelin after Surgery Advanced Laparoscopic Surgery Associates Medical Group Schindler K, Prager G, Balla...
Is ghrelin the culprit for weight loss after gastric bypass surgery? Probably not.  But this started us thinking... Advanc...
 
BMI Fasting insulin Fasting leptin PYY Enteroglucagon GLP-1 Hunger Satiety
Metabolic Surgery? <ul><li>Bariatric surgery - weight loss - weight dependent benefits </li></ul><ul><li>Metabolic surgery...
Central Signals Brain NPY AGRP galanin Orexin-A dynorphin Stimulate α-MSH CRH/UCN GLP-I CART NE 5-HT Inibit Peripheral sig...
Molecular basis <ul><li>adipokines: regulating energy balance </li></ul><ul><ul><li>leptin, adiponectin, resistin </li></u...
Impact on treatment algorithms <ul><li>Changing perspective on surgical recommendations - not based on BMI - based on meta...
 
 
evolution <ul><li>Procedure that were purely mechanical, VBG - short-term benefits, but disappointing long-term effects </...
Insulin secretion and resistance <ul><li>Early, weight independent improvement in insulin resistance with VSG, BPD, GBP </...
Leptin <ul><li>1994 Friedman: obesity (ob) gene - Leptin deficiency - child with congenital leptin deficiency reversed obe...
CCK: Cholecystokinin Advanced Laparoscopic Surgery Associates Medical Group Kellum JM, Kuemmerle JF, O'Dorisio TM et al. G...
GIP: Gastric Inhibitory Polypeptide Advanced Laparoscopic Surgery Associates Medical Group Rubino F, Gagner M, Gentileschi...
Enteroglucagon Advanced Laparoscopic Surgery Associates Medical Group Kellum JM, Kuemmerle JF, O'Dorisio TM et al. Gastroi...
GLP-1: Glucagon-like Peptide 1 Advanced Laparoscopic Surgery Associates Medical Group Naslund E, Gryback P, Hellstrom PM e...
PYY: Peptide YY Advanced Laparoscopic Surgery Associates Medical Group Naslund E, Gryback P, Hellstrom PM et al. Gastroint...
PYY GLP-1 GIP <ul><li>Hind-gut  </li></ul><ul><li>PYY -> PYY 3-36  -> NPY neurons  </li></ul><ul><li>GLP-1 release 40-60 m...
PP: Pancreatic Polypeptide Advanced Laparoscopic Surgery Associates Medical Group Sorensen TI, Lauritsen KB, Holst JJ et a...
Metabolic Surgery <ul><li>Reduced ingestive motivation </li></ul><ul><li>Rebound weight gain after dieting not seen after ...
Results of Metabolic Surgery <ul><li>Increased results with greater degree of intestinal bypass - foregut - hindgut </li><...
Upcoming SlideShare
Loading in...5
×

Resultados de la cirugía metabólica

991

Published on

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
991
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
0
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • Regulation of food intake The regulation of food intake involves a complex interaction of systems that determine the size, content, and frequency of feedings. Presumably, the brain is the final processing center that translates central and peripheral signals to initiate or stop feeding. Neuronal circuits have been identified in the hypothalamus that affect satiation (level of fullness during a meal which regulates the amount of food consumed) and satiety (level of hunger after a meal is consumed which regulates the frequency of eating). Regulatory mechanisms also must be present that integrate determinants of short-term energy intake with long-term energy requirements. The discovery of leptin, the protein product of the ob/ob gene, in 1995 [1] led to a marked increase in our understanding of the regulation of food intake. Leptin is produced by fat cells, released into the circulation, and it crosses the blood-brain barrier to bind to its receptor in the hypothalamus, which stimulates the expression of neuropeptides and neurotransmitters that inhibit food intake. Therefore, leptin provides a unique feedback signaling system that transmits information regarding adipose tissue energy stores to the central nervous system. Other peripheral organs also communicate with the brain about energy intake through neural signaling and endocrine pathways. The gastrointestinal system, which is responsible for digesting and absorbing ingested nutrients, is particularly involved. The gastrointestinal tract produces cholecystokinin (CCK), glucagon-like peptide-1 (GLP-1), apolipoprotein A-IV (apo A-IV), ghrelin, insulin, and glucose, which are likely involved in short-term, and possibly long-term, regulation of food intake. Central neuropeptides and neurotransmitter signals produced in hypothalamic nuclei stimulate 1) neuropeptide Y (NPY), 2) agouti-related protein (AGRP), 3) galanin, 4) orexin-A, and 5) dynorphin, or inhibit 1) a-melanocyte-stimulating hormone (a-MSH), a peptide derived from proopiomelanocortin (POMC), 2) corticotropin-releasing hormone/urocortin (CRH/UCN), 3) glucagon-like peptide-1 (GLP-1), 4) cocaine- and amphetamine-regulated transcript (CART), 5) norepinephrine (NE), and 5) serotonin (5-HT) [2]. There is a hierarchy in the relative importance, magnitude, and duration of each afferent input, and certain signals can override the effect of others. The redundancy of these complex signaling pathways tend to defend food intake and provides a formidable barrier to treating obesity. Therefore, a clear understanding of the factors involved in regulating food intake has important implications in designing therapeutic agents for obesity management. Zhang Y, Proenca R, Maffei M, et al. Positional cloning of the mouse obese gene and its human homologue. Nature 1994;372:425-432. Schwartz MW, Woods SC, Porte D Jr, et al. Central nervous system control of food intake. Nature 2000;404:661-671.
  • Transcript of "Resultados de la cirugía metabólica"

    1. 1. Metabolic Surgery 15 min V Congreso Internacional de Cirugia Bariatrica y Metabolica Mendoza Argentina May 19 & 20, 2011
    2. 2. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995 Metabolic Surgery 1978
    3. 3. Cummings DE, Weigle DS, Frayo RS et al. Plasma ghrelin levels after diet-induced weight loss or gastric bypass surgery. N Eng J Med 2002; 346: 1623-30. GHRELIN Insight into metabolic mechanisms Advanced Laparoscopic Surgery Associates Medical Group
    4. 4. Decreased Basal Ghrelin after Surgery Advanced Laparoscopic Surgery Associates Medical Group Leonetti F, Silecchia G, Iacobellis G et al. Different plasma ghrelin levels after laparoscopic gastric bypass and adjustable gastric banding in morbid obese subjects. J Clin Endocrinol Metab 2003; 88: 4227-31. Cummings DE, Weigle DS, Frayo RS et al. Plasma ghrelin levels after diet-induced weight loss or gastric bypass surgery. N Eng J Med 2002; 346: 1623-30. Tritos NA, Mun E, Bertkau A et al. Serum ghrelin levels in response to glucose load in obese subjects post-gastric bypass surgery. Obes Res 2003; 11: 919-24. Fruhbeck G, Diez-Caballero A, Gil MJ et al. The decrease in plasma ghrelin concentrations following bariatric surgery depends on the functional integrity of the fundus. Obes Surg 2004; 14: 606-12. Geloneze B, Tambascia MA, Pilla VF et al. Ghrelin: a gut-brain hormone: effect of gastric bypass surgery. Obes Surg 2003; 13: 17-22. Morinigo R, Casamitjana R, Moize V et al. Short-term effects of gastric bypass surgery on circulating ghrelin levels. Obes Res 2004; 12: 1108-16.
    5. 5. Unchanged Basal Ghrelin after Surgery Advanced Laparoscopic Surgery Associates Medical Group Schindler K, Prager G, Ballaban T et al. Impact of laparoscopic adjustable gastric banding on plasma ghrelin, eating behaviour and body weight. Eur J Clin Invest 2004; 34: 549-54. Faraj M, Havel PJ, Phelis S et al. Plasma acylation-stimulating protein, adiponectin, leptin, and ghrelin before and after weight loss induced by gastric bypass surgery in morbidly obese subjects. J Clin Endocrinol Metab 2003; 88: 1594-602. @ 18 months Stoeckli R, Chanda R, Langer I et al. Changes of body weight and plasma ghrelin levels after gastric banding and gastric bypass. Obes Res 2004; 12: 346-50. Adami GF, Cordera R, Marinari G et al. Plasma ghrelin concentratin in the short-term following biliopancreatic diversion. Obes Surg 2003; 13: 889-92.
    6. 6. Increased Basal Ghrelin after Surgery Advanced Laparoscopic Surgery Associates Medical Group Schindler K, Prager G, Ballaban T et al. Impact of laparoscopic adjustable gastric banding on plasma ghrelin, eating behaviour and body weight. Eur J Clin Invest 2004; 34: 549-54. Nijhuis J, van Dielen FM, Buurman WA et al. Ghrelin, leptin and insulin levels after restrictive surgery: a 2-year follow-up study. Obes Surg 2004; 14: 783-7. Stoeckli R, Chanda R, Langer I et al. Changes of body weight and plasma ghrelin levels after gastric banding and gastric bypass. Obes Res 2004; 12: 346-50. Faraj M, Havel PJ, Phelis S et al. Plasma acylation-stimulating protein, adiponectin, leptin, and ghrelin before and after weight loss induced by gastric bypass surgery in morbidly obese subjects. J Clin Endocrinol Metab 2003; 88: 1594-602. @ 12 months Vendrell J, Broch M, Vilarrasa N et al. Resistin, adiponectin, ghrelin, leptin, and proinflammatory cytokines: relationships in obesity. Obes Res 2004; 12: 962-71. Holdstock C, Engstrom BE, Ohrvall M et al. Ghrelin and adipose tissue regulatory peptides: effect of gastric bypass surgery in obese humans. J Clin Endocrinol Metab 2003; 88: 3177-83 Adami GF, Cordera R, Andraghetti G et al. Changes in serum ghrelin concentration following biliopancreatic diversion for obesity. Obes Res 2004; 12: 684-7.
    7. 7. Is ghrelin the culprit for weight loss after gastric bypass surgery? Probably not. But this started us thinking... Advanced Laparoscopic Surgery Associates Medical Group
    8. 9. BMI Fasting insulin Fasting leptin PYY Enteroglucagon GLP-1 Hunger Satiety
    9. 10. Metabolic Surgery? <ul><li>Bariatric surgery - weight loss - weight dependent benefits </li></ul><ul><li>Metabolic surgery - weight independent benefits - T2DM </li></ul><ul><li>CNS integration of molecular manipulation of surgical procedures </li></ul>
    10. 11. Central Signals Brain NPY AGRP galanin Orexin-A dynorphin Stimulate α-MSH CRH/UCN GLP-I CART NE 5-HT Inibit Peripheral signals Peripheral organs + − − + Gastrointestinal tract Adipose tissue Food Intake Adrenal glands External factors Emotions Food characteristics Lifestyle behaviors Environmental cues Glucose CCK, GLP-1, Apo-A-IV vagal afferents Insulin Ghrelin Leptin Cortisol Advanced Laparoscopic Surgery Associates Medical Group
    11. 12. Molecular basis <ul><li>adipokines: regulating energy balance </li></ul><ul><ul><li>leptin, adiponectin, resistin </li></ul></ul><ul><li>satiety </li></ul><ul><ul><li>GLP-1, PYY, ghrelin, FGF 19/21 </li></ul></ul><ul><li>hepatic signals: lipid absorption </li></ul><ul><ul><li>bile acids, farnesoid X </li></ul></ul><ul><li>pancreatic signals </li></ul><ul><li>CNS </li></ul>Kohli R, Stefater A, Inge T: Molecular insights from bariatric surgery. Rev Endocr Metab Disord 2011
    12. 13. Impact on treatment algorithms <ul><li>Changing perspective on surgical recommendations - not based on BMI - based on metabolic syndrome </li></ul><ul><li>Impact on revision procedure - “Do the same thing over and over again and expect different results.” </li></ul>
    13. 16. evolution <ul><li>Procedure that were purely mechanical, VBG - short-term benefits, but disappointing long-term effects </li></ul><ul><li>“Restrictive” “malabsorptive” did not characterize observed effects of procedures </li></ul><ul><li>Reduced ingestive motivation is the common underlying theme </li></ul>
    14. 17. Insulin secretion and resistance <ul><li>Early, weight independent improvement in insulin resistance with VSG, BPD, GBP </li></ul><ul><li>Late, weight dependent improvement </li></ul>
    15. 18. Leptin <ul><li>1994 Friedman: obesity (ob) gene - Leptin deficiency - child with congenital leptin deficiency reversed obesity with leptin </li></ul><ul><li>Obese: leptin resistance - excessive leptin does not suppress appetite </li></ul><ul><li>Changes in levels of leptin are secondary to fat loss and does not drive changes in body fat after surgery </li></ul>
    16. 19. CCK: Cholecystokinin Advanced Laparoscopic Surgery Associates Medical Group Kellum JM, Kuemmerle JF, O'Dorisio TM et al. Gastrointestinal hormone responses to meals before and after gastric bypass and vertical banded gastroplasty. Annals of Surgery 1990; 211: 763-70; discussion 770-1. Foschi D, Corsi F, Pisoni L et al. Plasma cholecystokinin levels after vertical banded gastroplasty: effects of an acidified meal. Obes Surg 2004; 14: 644-7. Naslund E, Gryback P, Hellstrom PM et al. Gastrointestinal hormones and gastric emptying 20 years after jejunoileal bypass for massive obesity. Int J Obes Relat Metab Disord 1997; 21: 387-92. Rubino F, Gagner M, Gentileschi P et al. The early effect of the Roux-en-Y gastric bypass on hormones involved in body weight regulation and glucose metabolism. Annals of Surgery 2004; 240: 236-42 Sorensen TI, Toftdahl DB, Hojgaard L et al. Plasma cholecystokinin in obese patients before and after jejunoileal bypass with 3:1 or 1:3 jejunoileal ratio--no role in the increased risk of gallstone formation. Danish Medical Bulletin 1994; 41: 469-72.
    17. 20. GIP: Gastric Inhibitory Polypeptide Advanced Laparoscopic Surgery Associates Medical Group Rubino F, Gagner M, Gentileschi P et al. The early effect of the Roux-en-Y gastric bypass on hormones involved in body weight regulation and glucose metabolism. Annals of Surgery 2004; 240: 236-42. Naslund E, Backman L, Holst JJ et al. Importance of small bowel peptides for the improved glucose metabolism 20 years after jejunoileal bypass for obesity. Obes Surg 1998; 8: 253-60. Sorensen TI, Lauritsen KB, Holst JJ et al. Gut and pancreatic hormones after jejunoileal bypass with 3:1 or 1:3 jejunoileal ratio. Digestion 1983; 26: 137-45. Sarson DL, Scopinaro N, Bloom SR. Gut hormone changes after jejunoileal (JIB) or biliopancreatic (BPB) bypass surgery for morbid obesity. Int J Obes 1981; 5: 471-80.
    18. 21. Enteroglucagon Advanced Laparoscopic Surgery Associates Medical Group Kellum JM, Kuemmerle JF, O'Dorisio TM et al. Gastrointestinal hormone responses to meals before and after gastric bypass and vertical banded gastroplasty. Annals of Surgery 1990; 211: 763-70; discussion 770-1. Sorensen TI, Lauritsen KB, Holst JJ et al. Gut and pancreatic hormones after jejunoileal bypass with 3:1 or 1:3 jejunoileal ratio. Digestion 1983; 26: 137-45. Sarson DL, Scopinaro N, Bloom SR. Gut hormone changes after jejunoileal (JIB) or biliopancreatic (BPB) bypass surgery for morbid obesity. Int J Obes 1981; 5: 471-80. Holst JJ, Sorensen TI, Andersen AN et al. Plasma enteroglucagon after jejunoileal bypass with 3:1 or 1:3 jejunoileal ratio. Scandinavian Journal of Gastroenterology 1979; 14: 205-7. Meryn S, Stein D, Straus EW. Pancreatic polypeptide, pancreatic glucagon and enteroglucagon in morbid obesity and following gastric bypass operation. Int J Obes 1986; 10: 37-42.
    19. 22. GLP-1: Glucagon-like Peptide 1 Advanced Laparoscopic Surgery Associates Medical Group Naslund E, Gryback P, Hellstrom PM et al. Gastrointestinal hormones and gastric emptying 20 years after jejunoileal bypass for massive obesity. Int J Obes Relat Metab Disord 1997; 21: 387-92. Rubino F, Gagner M, Gentileschi P et al. The early effect of the Roux-en-Y gastric bypass on hormones involved in body weight regulation and glucose metabolism. Annals of Surgery 2004; 240: 236-42. Naslund E, Backman L, Holst JJ et al. Importance of small bowel peptides for the improved glucose metabolism 20 years after jejunoileal bypass for obesity. Obes Surg 1998; 8: 253-60. le Roux CW, Aylwin SJ, Batterham RL, Borg CM, Coyle F, Prasad V, Shurey S, Ghatei MA, Patel AG, Bloom SR. Gut hormone profiles following bariatric surgery favor an anorectic state, facilitate weight loss, and improve metabolic parameters. Ann Surg. 2006 Jan;243(1):108-14.
    20. 23. PYY: Peptide YY Advanced Laparoscopic Surgery Associates Medical Group Naslund E, Gryback P, Hellstrom PM et al. Gastrointestinal hormones and gastric emptying 20 years after jejunoileal bypass for massive obesity. Int J Obes Relat Metab Disord 1997; 21: 387-92. Korner J, Bessler M, Cirilo LJ et al. Effects of Roux-en-Y gastric bypass surgery on fasting and postprandial concentrations of plasma ghrelin, PYY and insulin. J Clin Endocrinol Metab 2004; in press Alvarez Bartolome M, Borque M, Martinez-Sarmiento J et al. Peptide YY secretion in morbidly obese patients before and after vertical banded gastroplasty. Obes Surg 2002; 12: 324-7. le Roux CW, Aylwin SJ, Batterham RL, Borg CM, Coyle F, Prasad V, Shurey S, Ghatei MA, Patel AG, Bloom SR. Gut hormone profiles following bariatric surgery favor an anorectic state, facilitate weight loss, and improve metabolic parameters. Ann Surg. 2006 Jan;243(1):108-14. Korner J, Inabnet W, Conwell IM, Taveras C, Daud A, Olivero-Rivera L, Restuccia NL, Bessler M. Differential effects of gastric bypass and banding on circulating gut hormone and leptin levels.Obesity (Silver Spring). 2006 Sep;14(9):1553-61 Borg CM, le Roux CW, Ghatei MA, Bloom SR, Patel AG, Aylwin SJ. Progressive rise in gut hormone levels after Roux-en-Y gastric bypass suggests gut adaptation and explains altered satiety.Br J Surg. 2006 Feb;93(2):210-5. Chan JL, Mun EC, Stoyneva V, Mantzoros CS, Goldfine AB. Peptide YY levels are elevated after gastric bypass surgery.Obesity (Silver Spring). 2006 Feb;14(2):194-8. Morinigo R, Moize V, Musri M, Lacy AM, Navarro S, Marin JL, Delgado S, Casamitjana R, Vidal J. Glucagon-like peptide-1, peptide YY, hunger, and satiety after gastric bypass surgery in morbidly obese subjects. J Clin Endocrinol Metab. 2006 May;91(5):1735-40.
    21. 24. PYY GLP-1 GIP <ul><li>Hind-gut </li></ul><ul><li>PYY -> PYY 3-36 -> NPY neurons </li></ul><ul><li>GLP-1 release 40-60 minutes after meal: rapidly deactivated by DPP4 </li></ul>Januvia: saliva from Gila monster
    22. 25. PP: Pancreatic Polypeptide Advanced Laparoscopic Surgery Associates Medical Group Sorensen TI, Lauritsen KB, Holst JJ et al. Gut and pancreatic hormones after jejunoileal bypass with 3:1 or 1:3 jejunoileal ratio. Digestion 1983; 26: 137-45. Meryn S, Stein D, Straus EW. Pancreatic polypeptide, pancreatic glucagon and enteroglucagon in morbid obesity and following gastric bypass operation. Int J Obes 1986; 10: 37-42. le Roux CW, Aylwin SJ, Batterham RL, Borg CM, Coyle F, Prasad V, Shurey S, Ghatei MA, Patel AG, Bloom SR. Gut hormone profiles following bariatric surgery favor an anorectic state, facilitate weight loss, and improve metabolic parameters. Ann Surg. 2006 Jan;243(1):108-14.
    23. 26. Metabolic Surgery <ul><li>Reduced ingestive motivation </li></ul><ul><li>Rebound weight gain after dieting not seen after bariatric surgery </li></ul><ul><li>Reduced motivation rather than ability to overeat is primary effect of bariatric surgery </li></ul><ul><li>New “set point” </li></ul>
    24. 27. Results of Metabolic Surgery <ul><li>Increased results with greater degree of intestinal bypass - foregut - hindgut </li></ul><ul><li>Some effect from resectional procedures </li></ul><ul><li>As we do not understand the mechanism(s) of action, clinical application should be based on experience rather than hypotheses </li></ul>

    ×