So why is it important to us??? Take a look at the prevalence of metabolic syndrome in the United States population; great market for surgeons for treatment of metabolic syndrome with bypass procedures
Reported as high as 67% in the 60-69 year old population
The pathophysiology of metabolic syndrome is very complex and not fully elucidated; however, you can easily see that there is significant interplay between hormonal signals and metabolic mediators resulting in the classic constellation of symptoms
Increased fatty acids also mediate vasoconstricton independently
Dr.Ferzli, please add a few words about your expereince in the Dominican Rebuplic and early results!
Resolution of Metabolic Syndrome & Morbid Obesity Surgery George S.Ferzli, M.D., Benjamin Chandler, Giancarlo Cires, M.D. , Rosemarie E.Hardin, M.D Metabolic Surgery Symposium New Mexico, 2007
History 1947: Dr.Jean Vague; made observation that upper body obesity predisposed to diabetes, Atherosclerosis, gout and calculi 1967: Avogaro & Crepaldi; described 6 moderately obese patients with diabetes hypercholesterolemia and marked triglyceridemia, all of which improved with a Hypocaloric, low carbohydrate diet In 1977: Haller used the term “ metabolic syndrome ”: obesity, diabetes mellitus, hyperlipoproteinemia, hyperuricemia and steatosis hepatitis when describing the additive effects of risk factors on atherosclerosis In 1977: Gerald B. Phillips; developed the concept that Risk factors for myocardial infarction concur to form a “constellation of abnormalities” : glucose intolerance, hyperinsulinemia, hyperlipidemia and hypertension is associated with heart disease and obesity MUST BE LINKING FACTOR 1988: Gerald M. Reaven proposed insulin resistance as the linking factor and named the constellation of abnormalities Syndrome X X
Resolution of diabetes mellitus and metabolic syndrome following Roux-en-Y gastric bypass and a variant of biliopancreatic diversion in patients with morbid obesity. Alexandrides TK , Skroubis G , Kalfarentzos F . Endocrine Division, Department of Internal Medicine, School of Medicine, University of Patras, Greece
The objective of this study was to investigate the effects of RYGBP and BPD-RYGBP, a variant of BPD with a lower rate of metabolic deficiencies than BPD, on DM2 and the major components of metabolic syndrome in patients with morbid obesity and DM2.
METHODS : The prospective database of our unit, from June 1994 until May 2006, was analyzed and 137 patients with DM2 were found. 26 underwent RYGBP (BMI 46.1 +/- 2.9 kg/m2) and 111 BPD-RYGBP (BMI 59.7 +/- 10.6 kg/m2). 7 of the patients were on insulin (4.90%) and 37 on oral hypoglycemic agents (25.87%). Pre- and postoperative medications, and clinical and biochemical parameters were considered in the analysis. The mean
follow-up was 26.39 +/- 21.17 months.
RESULTS : Excess weight loss was approximately 70% after either procedure. DM2 resolved in 89% and 99% of the cases following RYGBP and BPD-RYGBP, respectively. 2 years after BPD-RYGBP all the patients had blood glucose < 110 mg/dl, 95% had normal cholesterol, 92% normal triglycerides and 82% normal blood pressure. The respective values following RYGBP were 66%, 33%, 78% and 44%. Uric acid decreased significantly only after BPD-RYGBP. Liver enzymes improved in both groups.
CONCLUSIONS: RYGBP and BPD-RYGBP are safe and lead to normalization of blood glucose, lipids, uric acid, liver enzymes and arterial pressure in the majority of patients, although this variant of BPD was more effective than RYGBP. We suggest that further studies should also investigate its usefulness in patients with milder degrees of obesity, DM2 and metabolic syndrome.
Changes in GI hormones have been proposed to contribute to the restoration of euglycemia after RYGB
Bypass of the duodenum and proximal jejunum and rapid passage of food from stomach to distal ileum augment the secretion of GLP-1
GLP-1 potently increases insulin secretion and possibly insulin sensitivity.
Roux-en-Y Gastric Bypass Prospective Study : enrolled 36 obese patients prior to undergoing Roux-en-Y gastric bypass compared to age and sex matched controls Fasting glucose, HDL cholesterol, triglyceride level, BP, waist circumference & inflammatory markers were measured pre-op, 6wks post op & 52 weeks post op
312 BPD, obese patients with type 2 DM were followed for pre and postoperative serum glucose, triglycerides, cholesterol & arterial pressure measurements
After BPD, fasting serum glucose fell within normal values in 310 patients; remained normal up to 10 years in all but 6 patients
Evidence of hypertension disappeared in majority of patients
Glycemic control translates into a reduced mortality for these patients as well as a low frequency of death from cardiovascular events
TRUE CLINICAL RECOVERY
Scopinaro N, Marinari GM, Camerini GB et al. Specific Effects of Biliopancreatic Diversion on the Major Components of Metabolic Syndrome. Diabetes Care . 2005. 28:2406-2411
Biliopancreatic Diversion (BPD) Scopinaro N, Marinari GM, Camerini GB et al. Specific Effects of Biliopancreatic Diversion on the Major Components of Metabolic Syndrome. Diabetes Care . 2005. 28:2406-2411
Madan AK, Orth W, Ternovits CA et al. Metabolic Syndrome: yet another co-morbidity gastric bypass helps cure. Surgery for Obesity&Related Diseases. Jan 2006; 2 (1):48-51
Retrospective Study ( n=53 )
Chart review of all patients undergoing laparoscopic gastric bypass surgery during a 6 month period performed to identify patients with
pre-op diagnosis of metabolic syndrome (using NCEP guidelines)
32/53 (60%) pts had metabolic syndrome
No difference in pre-op body mass index between patients who had metabolic syndrome (47.4 kg/m 2 )and those who did not (49.8 kg/m 2 )
The percentage of excess body weight lost after one year was 78% in patients with metabolic syndrome
Post-operatively, 1/53 (2%) patients had metabolic syndrome (P<.0001)