Bariatric Surgery


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Metabolic Sequlae of Obesity Surgery

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Bariatric Surgery

  1. 1. Metabolic Sequelae of Bariatric Surgery Dr Sumeet Shah Laparoscopic & Bariatric Surgeon Sir Ganga Ram Hospital
  2. 2. WEIGHT LOSS SURGERY Gastric Bypass
  3. 3. Potential Consequences of Obesity <ul><li>Obesity is associated with a rise in many comorbid conditions, including: </li></ul><ul><ul><li>Type 2 Diabetes </li></ul></ul><ul><ul><li>Hyperlipidemia </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Obstructive Sleep Apnea </li></ul></ul><ul><ul><li>Heart Disease </li></ul></ul><ul><ul><li>Stroke </li></ul></ul><ul><ul><li>Asthma </li></ul></ul><ul><ul><li>Back and lower extremity weight- </li></ul></ul><ul><ul><li>bearing degenerative problems </li></ul></ul><ul><ul><li>Cancer </li></ul></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>AND MORE! </li></ul></ul>
  4. 4. Visceral Obesity Heart Disease, Stroke Risk Insulin Resistance & Hyperinsulinemia Dense LDL HDL Cholesterol Triglycerides Source: NAASO, 2005 The emergence of metabolic disease: a direct clinical pathway from obesity
  5. 5. Types of Bariatric Surgery <ul><li>Purely Restrictive </li></ul><ul><ul><li>Gastric Balloons </li></ul></ul><ul><ul><li>Sleeve Gastrectomy </li></ul></ul><ul><ul><li>Gastric adjustable banding </li></ul></ul><ul><li>Restrictive > Malabsorptive </li></ul><ul><ul><li>Short-limb/Roux-en-Y gastric bypass </li></ul></ul><ul><li>Malabsorptive > Restrictive </li></ul><ul><ul><li>Biliopancreatic diversion (BPD) </li></ul></ul><ul><ul><li>BPD with duodenal switch </li></ul></ul><ul><ul><li>Long limb Roux-en-Y gastric bypass </li></ul></ul>
  6. 6. Weight Loss Benefits vs . Nutritional Risk
  7. 7. N Engl J Med. May 24 2007;356(21):2176-2183.
  8. 8. Long Term Complications: Nutritional Deficiencies <ul><li>Nutritional deficiencies are uncommon with purely restrictive procedures unless </li></ul><ul><ul><li>Eating habits are excessively restricted or complications occur (emesis) </li></ul></ul><ul><ul><li>Folate is the most common deficiency after restrictive procedures </li></ul></ul>
  9. 10. <ul><li>Hormonal Sequelae - Human body regulates nutrient intake over time by secreting hormones. Over 40 hormones play a role in regulation of feeding. </li></ul><ul><li>Nutritional Sequelae </li></ul>Metabolic Sequelae
  10. 11. Metabolic Sequelae <ul><li>Two types : </li></ul><ul><ul><li>Satiety hormones </li></ul></ul><ul><ul><ul><li>Short-term </li></ul></ul></ul><ul><ul><ul><li>Help regulate meal size; daily intake </li></ul></ul></ul><ul><ul><ul><li>Secretion decreases meal size; reduces time to stop </li></ul></ul></ul><ul><ul><ul><li>Includes (among others) cholecystokinin, amylin, glucagon-like-peptide 1 (GLP-1), enterostatin, and bombesin </li></ul></ul></ul><ul><ul><li>Adiposity hormones </li></ul></ul><ul><ul><ul><li>Long-term </li></ul></ul></ul><ul><ul><ul><li>Related to energy stores </li></ul></ul></ul><ul><ul><ul><li>Secretion delays onset of beginning of meal </li></ul></ul></ul><ul><ul><ul><li>Includes insulin, leptin </li></ul></ul></ul>
  11. 12. PROTEINS: GHRELIN <ul><li>A peptide secreted by Gastric mucosa on an empty stomach (Fasting   Ghrelin Levels) </li></ul><ul><li>Also releases growth hormone </li></ul><ul><li>Ghrelin  during fasting </li></ul><ul><ul><li>  Appetite   Food intake </li></ul></ul><ul><ul><li>  Fat utilization </li></ul></ul><ul><ul><li>In Obesity, GHRELIN LEVELS ARE  </li></ul></ul>
  12. 13. GHRELIN.. <ul><li>Activates appetite stimulating neurons in Hypothalamus </li></ul><ul><li>Short term appetite control </li></ul><ul><li>Overproduction  OBESITY </li></ul><ul><ul><li>PRADER-WILLI SYNDROME </li></ul></ul><ul><ul><ul><li>Highest level of ghrelin ever measured in humans </li></ul></ul></ul>
  13. 14. GHRELIN <ul><li>Ghrelin levels  when weight is lost while dieting </li></ul><ul><ul><li>Opposes the effect of dieting </li></ul></ul><ul><li>In Gastric Bypass and Sleeve Gastrectomy, GHRELIN LEVEL  at least in the short term due to exclusion/ removal of the fundus </li></ul>
  14. 15. Metabolic Sequelae <ul><li>Further investigation is needed, but the reason why certain types (i.e., RYGB/ Sleeve) of bariatric surgery are successful at reducing food intake and causing weight loss may be related to enhanced secretion of satiety signals (ghrelin or others). </li></ul>
  15. 16. Role of Incretins <ul><li>GIP </li></ul><ul><li>Released from K cells in duodenum </li></ul><ul><li>Modest effect on gastric emptying </li></ul><ul><li>No significant inhibition of glucagon secretion </li></ul><ul><li>No significant effects on satiety or body weight </li></ul><ul><li>GLP-1 </li></ul><ul><li>Released from L cells in ileum </li></ul><ul><li>Potent inhibition of gastric emptying </li></ul><ul><li>Potent inhibition of glucagon secretion </li></ul><ul><li>Reduction of food intake and body weight </li></ul>
  16. 17. Role of Incretins <ul><li>GIP </li></ul><ul><li>Potential effects on beta cell growth & survival </li></ul><ul><li>Stimulate insulin secretion via beta cell </li></ul><ul><li>Inactivation by DPP-4 </li></ul><ul><li>GLP-1 </li></ul><ul><li>Significant effects on beta cell growth and survival </li></ul>
  17. 18. Regulation of Food Intake Brain NPY AGRP galanin Orexin-A Dynorphin ECS/CB1 Stimulate α -MSH CRH/UCN GLP-I CART NE 5-HT Inibit Central Signals Glucose CCK, GLP-1, Apo-A-IV Vagal afferents Insulin Ghrelin Leptin Cortisol Peripheral signals Peripheral organs Gastrointestinal tract Adipose tissue Food Intake Adrenal glands +   + External factors Emotions, Drugs Food characteristics Lifestyle behaviors Environmental cues
  18. 19. Modified from Marx, Science 2003 February 7; 299: 846-849. (in News) Gastrointestinal Peptides Hormones food intake regulation digestion and metabolism Anti-obesity potential Anti-diabetes potential Vagus nerve Ghrelin Insulin Amylin Glucagon Leptin PYY GLP-1 CCK
  19. 20. Effect on Comorbid Conditions <ul><li>Diabetes </li></ul><ul><ul><li>76.8% - Completely resolved </li></ul></ul><ul><ul><li>86.0% - Resolved or improved </li></ul></ul><ul><li>Hyperlipidemia </li></ul><ul><ul><li>70% - Improved </li></ul></ul><ul><li>HTN </li></ul><ul><ul><li>61.7% - Resolved </li></ul></ul><ul><ul><li>85.7% - Resolved or improved </li></ul></ul><ul><li>Obstructive Sleep Apnea </li></ul><ul><ul><li>83.6% - Resolved </li></ul></ul><ul><ul><li>85.7% - Resolved or improved </li></ul></ul>Buchwald H, et al. Bariatric Surgery: A Systematic Review and Meta-analysis. JAMA, 14:1724-37, 2004
  20. 21. Metabolic Changes and Diabetes <ul><li>Many metabolic changes contribute to improvement and/or resolution of DM </li></ul><ul><ul><li>Recovery of acute insulin response </li></ul></ul><ul><ul><li>Decreases of inflammatory indicators (C-reactive protein and interleukin 6) </li></ul></ul><ul><ul><li>Improvement in insulin sensitivity correlated w/increases in plasma adiponectin </li></ul></ul><ul><ul><li>Changes in the enteroglucagon response to glucose </li></ul></ul><ul><ul><li>Reduction in ghrelin levels </li></ul></ul><ul><ul><li>Improvement in beta cell function </li></ul></ul>
  21. 22. Risk of Vitamin and Mineral Deficiencies Post-op <ul><li>Calcium and Vitamin D </li></ul><ul><ul><li>Reduced absorption d/t bypassed duodenum, proximal jejunum (R-en-Y) </li></ul></ul><ul><ul><li>Life-long supplements mandatory </li></ul></ul><ul><li>Iron </li></ul><ul><ul><li>Absorption decreased d/t decreased contact of food with gastric acid; reduced conversion of iron from ferrous to ferric form (MVI) </li></ul></ul><ul><li>Vitamin B12 </li></ul><ul><ul><li>Absorption decreased d/t decreased contact with intrinsic factor </li></ul></ul><ul><ul><li>60% of patients require long term supplementation of B12 </li></ul></ul><ul><li>Thiamine </li></ul><ul><ul><li>Connection to Wernicke’s syndrome </li></ul></ul><ul><ul><li>Cases not well documented </li></ul></ul>
  22. 23. Review: what gets absorbed where?
  23. 24. Recommended management <ul><li>Dietary modification </li></ul><ul><li>Reduce food volume consumed, chew food very well, slow pace of eating </li></ul><ul><li>Do not consume fluids with food </li></ul><ul><ul><li>30 minutes before or after meal </li></ul></ul><ul><li>Protein rich-food should be major component of each meal </li></ul><ul><ul><li>Cheese, fish, poultry, eggs & meat </li></ul></ul><ul><ul><li>40-60g/day after RYGB </li></ul></ul><ul><ul><li>60-90g/day after BPD-DS </li></ul></ul><ul><li>Avoid empty calories </li></ul>
  24. 25. Recommended management <ul><li>Dietary supplements </li></ul><ul><li>All patients should receive </li></ul><ul><ul><li>Multivitamin with iron </li></ul></ul><ul><ul><li>Vitamin B12, B complex with thiamine </li></ul></ul><ul><ul><li>Vitamin C </li></ul></ul><ul><ul><li>Calcium </li></ul></ul><ul><li>Additional supplements may be needed for menstruating or pregnant women </li></ul><ul><li>Depending on procedure, patient may need fat soluble vitamin supplements (BPD) </li></ul>
  25. 26. Recommended management Am J Med Sci. Apr 2006;331(4):219-225 .
  26. 27. In Summary…… <ul><li>Role of Gut and G I hormones </li></ul><ul><li>Fat as Endocrine organ </li></ul><ul><li>Nutritional Sequlae </li></ul><ul><li>Resolution of diabetes mellitus and improvement in lipid profile central in providing metabolic role to bariatric surgery </li></ul>