Sleeve gastrectomy in bahawalpur

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This talk was given to General Practioners about Bariatric Surgery

This talk was given to General Practioners about Bariatric Surgery

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  • 1. Javed Iqbal, FCPS, FRCS Professor of SurgeryQuaid-e-Azam Medical College, Bahawalpur, Pakistan
  • 2. Whats new in surgery for the Diabetics
  • 3.  “240 million people worldwide are living with diabetes; 380 million by 2025” “It kills one person every 10 seconds”
  • 4. The usual domain of the surgeons in Diabetes  Diabetic foot  Infections.  Neuropathies.  Vascular narrowing
  • 5. The Surgical Cure of Diabetes
  • 6. The Key Questions. Is there a surgical cure? Can we cut out Diabetes?
  • 7. Background. The Historical Perspectives of gastrointestinal anastomosis. The Rebirth of Bariatric surgery
  • 8. Metabolic SurgeryTreatment of metabolic derangements withalterations of the gut anatomy remission of diabetes
  • 9. The Evidence There is overwhelming evidence indicating that several types of bariatric operations promote profound weight loss and cause complete remission of type 2 diabetes. Pories and Swanson, Ann surg 222:339-350 Sjostrom and Larsonet al NEJM 357: 741-752
  • 10. Association of Diabetes and ObesityDIABETES + OBESITY = DIABESITY DIABETES OBESITY 90% WEIGHT LOSS T2D WEIGHT GAIN T2D
  • 11. How can we correct it ?  Dietary control  Lifestyle changes.  Medical management
  • 12. Why Surgery ? Non Surgical methods of weight loss are associated with higher failure rates. NIH consensus Panel 1991 recommendation:“Surgery is the only long term sustainable weight loss method” *American Diabetic association has also recommended weight loss surgery in Diabetics with BMI 35 or above. *ADA clinical practice recommendations 2008
  • 13. Benefits of surgical weight loss (morbidity and mortality improvement) Weight loss is associated with resolution of co morbidities. ◦ DM=>80% ◦ Hypertension=>60% ◦ Hyperlipidemia=>60-95% ◦ Obstructive Sleep Apnoea => 80-80% ◦ Pories and Swanson, Ann surg 222:339-350 Swedish obese subjects study shows clear benefit of survival for surgery patients from cardiovascular events.(24%) Sjostrom and Larsonet al NEJM 357: 741-752
  • 14. BARIATRIC SURGERY AND DIABETES Bariatric patients would have a sustained weight loss and thus would have a complete resolution of diabetes T2D even if are not obese still would achieve resolution after SG or GBP Schauer&Burguera AnnalsSurgery 2003;238:467-84 Gann ss& Horgensen ANZ J Surgery 2007;77:958-62
  • 15. BARIATRIC SURGERY Gastric Banding Sleeve Gastrectomy Gastro-Biliary Bypass
  • 16. Bariatric Surgeries
  • 17. Mechanisms of Diabetes Resolution after Gastrointestinal Bypass Surgery Enhanced secretion of something good for glucose homeostasis ?Reduced production of something bad for glucose homeostasis ?
  • 18. What is The Mechanism?  Sudden reduction in caloric intake  Reduced Ghrelin Levels  Increased production of bile acidsBA + TGR 5 c AMP dependant THAE Increased Energy Expenditure
  • 19. The QueryWeight loss surgery patients experience areduction in or resolution of diabeticsymptoms immediately following surgery,before weight loss has had a chance to takeplace.
  • 20. THE ANSWER The Immediate control The Entero insular Axis The Francesco Rubino Experiment. The Foregut Hypothesis The Hindgut Hypothesis The role of GLP-I& GIP
  • 21. The exclusion of theduodenal nutrientpassage may offset anabnormality ofgastrointestinalphysiology responsiblefor insulin resistanceand type 2 diabetes
  • 22. Nutrients reach the distalileum within 5 min of theingestion of food and thisstimulates the secretion ofGLP1 by L cellslocated in this area
  • 23. The Entero Insular Axis Anti-Incretins DPP-4 INCREASED INSULIN AVAILABILTY GLP-1 Insulin Production Incretins GIP b-cell Neogenesis PYY Statiety.
  • 24. THE ANSWER Long Term Resolution Decreased adipose tissue leads to modulation of the Adipo Insular Axis Adipocytokines. Leptin.Adiponectin. Decreased Insulin Resistance Resistin.
  • 25. The Net Effect Decreased insulin destruction  Increased Insulin Production Decreased Insulin Resistance
  • 26. WHO WOULD HAVE THOUGHT IT? An Operation Can be The mosteffective Therapy For Adult Onset Diabetes Mellitus
  • 27. Where do we stand?
  • 28.  Workshop in Rome Workshop with Mufazzal Lakhdawala Spent some time with Prof. Mumtaz Maher Extensive hands of course with Prof Karl Miller Acquired all necessary equipments Extensive training hand-swen gut surgery Developed a team Regularly performing sleeve gastrectomy
  • 29. How much it costs?Nothing is more costly than a healthy life