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Metabolic Sequlae of Obesity Surgery

Metabolic Sequlae of Obesity Surgery

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Bariatric Surgery Bariatric Surgery Presentation Transcript

  • Metabolic Sequelae of Bariatric Surgery Dr Sumeet Shah Laparoscopic & Bariatric Surgeon Sir Ganga Ram Hospital
  • WEIGHT LOSS SURGERY Gastric Bypass
  • Potential Consequences of Obesity
    • Obesity is associated with a rise in many comorbid conditions, including:
      • Type 2 Diabetes
      • Hyperlipidemia
      • Hypertension
      • Obstructive Sleep Apnea
      • Heart Disease
      • Stroke
      • Asthma
      • Back and lower extremity weight-
      • bearing degenerative problems
      • Cancer
      • Depression
      • AND MORE!
  • 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
  • Types of Bariatric Surgery
    • Purely Restrictive
      • Gastric Balloons
      • Sleeve Gastrectomy
      • Gastric adjustable banding
    • Restrictive > Malabsorptive
      • Short-limb/Roux-en-Y gastric bypass
    • Malabsorptive > Restrictive
      • Biliopancreatic diversion (BPD)
      • BPD with duodenal switch
      • Long limb Roux-en-Y gastric bypass
  • Weight Loss Benefits vs . Nutritional Risk
  • N Engl J Med. May 24 2007;356(21):2176-2183.
  • Long Term Complications: Nutritional Deficiencies
    • Nutritional deficiencies are uncommon with purely restrictive procedures unless
      • Eating habits are excessively restricted or complications occur (emesis)
      • Folate is the most common deficiency after restrictive procedures
  •  
    • Hormonal Sequelae - Human body regulates nutrient intake over time by secreting hormones. Over 40 hormones play a role in regulation of feeding.
    • Nutritional Sequelae
    Metabolic Sequelae
  • Metabolic Sequelae
    • Two types :
      • Satiety hormones
        • Short-term
        • Help regulate meal size; daily intake
        • Secretion decreases meal size; reduces time to stop
        • Includes (among others) cholecystokinin, amylin, glucagon-like-peptide 1 (GLP-1), enterostatin, and bombesin
      • Adiposity hormones
        • Long-term
        • Related to energy stores
        • Secretion delays onset of beginning of meal
        • Includes insulin, leptin
  • PROTEINS: GHRELIN
    • A peptide secreted by Gastric mucosa on an empty stomach (Fasting   Ghrelin Levels)
    • Also releases growth hormone
    • Ghrelin  during fasting
      •   Appetite   Food intake
      •   Fat utilization
      • In Obesity, GHRELIN LEVELS ARE 
  • GHRELIN..
    • Activates appetite stimulating neurons in Hypothalamus
    • Short term appetite control
    • Overproduction  OBESITY
      • PRADER-WILLI SYNDROME
        • Highest level of ghrelin ever measured in humans
  • GHRELIN
    • Ghrelin levels  when weight is lost while dieting
      • Opposes the effect of dieting
    • In Gastric Bypass and Sleeve Gastrectomy, GHRELIN LEVEL  at least in the short term due to exclusion/ removal of the fundus
  • Metabolic Sequelae
    • 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).
  • Role of Incretins
    • GIP
    • Released from K cells in duodenum
    • Modest effect on gastric emptying
    • No significant inhibition of glucagon secretion
    • No significant effects on satiety or body weight
    • GLP-1
    • Released from L cells in ileum
    • Potent inhibition of gastric emptying
    • Potent inhibition of glucagon secretion
    • Reduction of food intake and body weight
  • Role of Incretins
    • GIP
    • Potential effects on beta cell growth & survival
    • Stimulate insulin secretion via beta cell
    • Inactivation by DPP-4
    • GLP-1
    • Significant effects on beta cell growth and survival
  • 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
  • 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
  • Effect on Comorbid Conditions
    • Diabetes
      • 76.8% - Completely resolved
      • 86.0% - Resolved or improved
    • Hyperlipidemia
      • 70% - Improved
    • HTN
      • 61.7% - Resolved
      • 85.7% - Resolved or improved
    • Obstructive Sleep Apnea
      • 83.6% - Resolved
      • 85.7% - Resolved or improved
    Buchwald H, et al. Bariatric Surgery: A Systematic Review and Meta-analysis. JAMA, 14:1724-37, 2004
  • Metabolic Changes and Diabetes
    • Many metabolic changes contribute to improvement and/or resolution of DM
      • Recovery of acute insulin response
      • Decreases of inflammatory indicators (C-reactive protein and interleukin 6)
      • Improvement in insulin sensitivity correlated w/increases in plasma adiponectin
      • Changes in the enteroglucagon response to glucose
      • Reduction in ghrelin levels
      • Improvement in beta cell function
  • Risk of Vitamin and Mineral Deficiencies Post-op
    • Calcium and Vitamin D
      • Reduced absorption d/t bypassed duodenum, proximal jejunum (R-en-Y)
      • Life-long supplements mandatory
    • Iron
      • Absorption decreased d/t decreased contact of food with gastric acid; reduced conversion of iron from ferrous to ferric form (MVI)
    • Vitamin B12
      • Absorption decreased d/t decreased contact with intrinsic factor
      • 60% of patients require long term supplementation of B12
    • Thiamine
      • Connection to Wernicke’s syndrome
      • Cases not well documented
  • Review: what gets absorbed where?
  • Recommended management
    • Dietary modification
    • Reduce food volume consumed, chew food very well, slow pace of eating
    • Do not consume fluids with food
      • 30 minutes before or after meal
    • Protein rich-food should be major component of each meal
      • Cheese, fish, poultry, eggs & meat
      • 40-60g/day after RYGB
      • 60-90g/day after BPD-DS
    • Avoid empty calories
  • Recommended management
    • Dietary supplements
    • All patients should receive
      • Multivitamin with iron
      • Vitamin B12, B complex with thiamine
      • Vitamin C
      • Calcium
    • Additional supplements may be needed for menstruating or pregnant women
    • Depending on procedure, patient may need fat soluble vitamin supplements (BPD)
  • Recommended management Am J Med Sci. Apr 2006;331(4):219-225 .
  • In Summary……
    • Role of Gut and G I hormones
    • Fat as Endocrine organ
    • Nutritional Sequlae
    • Resolution of diabetes mellitus and improvement in lipid profile central in providing metabolic role to bariatric surgery