Javed Iqbal,    FCPS, FRCS     Professor of SurgeryQuaid-e-Azam Medical College,     Bahawalpur, Pakistan
Whats new in surgery for the Diabetics
   “240 million people worldwide are living with    diabetes;   380 million by 2025”   “It kills one person every 10 se...
The usual domain of the surgeons in            Diabetes               Diabetic foot                Infections.          ...
The Surgical Cure of     Diabetes
The Key Questions.   Is there a surgical cure?   Can we cut out Diabetes?
Background.   The Historical Perspectives of gastrointestinal                    anastomosis.   The Rebirth of Bariatric...
Metabolic SurgeryTreatment of metabolic derangements withalterations of the gut anatomy    remission of diabetes
The Evidence   There is overwhelming evidence indicating    that several types of bariatric operations    promote profoun...
Association of Diabetes and ObesityDIABETES + OBESITY    =   DIABESITY   DIABETES          OBESITY 90%                 WEI...
How can we correct it ?     Dietary control    Lifestyle changes.  Medical management
Why Surgery ?   Non Surgical methods of weight loss are    associated with higher failure rates. NIH consensus Panel 199...
Benefits of surgical weight loss        (morbidity and mortality improvement)   Weight loss is associated with resolution...
BARIATRIC SURGERY AND             DIABETES   Bariatric patients would have a sustained    weight loss and thus would have...
BARIATRIC SURGERY Gastric Banding Sleeve Gastrectomy Gastro-Biliary Bypass
Bariatric Surgeries
Mechanisms of Diabetes Resolution        after Gastrointestinal Bypass                  Surgery   Enhanced secretion of so...
What is The Mechanism?            Sudden reduction in caloric intake            Reduced Ghrelin Levels            Incre...
The QueryWeight loss surgery patients experience areduction in or resolution of diabeticsymptoms immediately following sur...
THE ANSWER       The Immediate control          The Entero insular Axis   The Francesco Rubino Experiment.              T...
The exclusion of theduodenal nutrientpassage may offset anabnormality ofgastrointestinalphysiology responsiblefor insulin ...
Nutrients reach the distalileum within 5 min of theingestion of food and thisstimulates the secretion ofGLP1 by L cellsloc...
The Entero Insular Axis         Anti-Incretins           DPP-4      INCREASED INSULIN AVAILABILTY                         ...
THE ANSWER               Long Term Resolution      Decreased adipose tissue leads to     modulation of the Adipo Insular A...
The Net Effect  Decreased insulin destruction  Increased Insulin Production Decreased Insulin Resistance
WHO WOULD HAVE THOUGHT IT?  An Operation Can be The mosteffective Therapy For Adult Onset         Diabetes Mellitus
Where do we stand?
   Workshop in Rome   Workshop with Mufazzal Lakhdawala   Spent some time with Prof. Mumtaz Maher   Extensive hands of...
How much it costs?Nothing is more costly than a healthy                life
Sleeve gastrectomy in bahawalpur
Sleeve gastrectomy in bahawalpur
Sleeve gastrectomy in bahawalpur
Sleeve gastrectomy in bahawalpur
Sleeve gastrectomy in bahawalpur
Sleeve gastrectomy in bahawalpur
Sleeve gastrectomy in bahawalpur
Sleeve gastrectomy in bahawalpur
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Sleeve gastrectomy in bahawalpur

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Sleeve gastrectomy in bahawalpur

  1. 1. Javed Iqbal, FCPS, FRCS Professor of SurgeryQuaid-e-Azam Medical College, Bahawalpur, Pakistan
  2. 2. Whats new in surgery for the Diabetics
  3. 3.  “240 million people worldwide are living with diabetes; 380 million by 2025” “It kills one person every 10 seconds”
  4. 4. The usual domain of the surgeons in Diabetes  Diabetic foot  Infections.  Neuropathies.  Vascular narrowing
  5. 5. The Surgical Cure of Diabetes
  6. 6. The Key Questions. Is there a surgical cure? Can we cut out Diabetes?
  7. 7. Background. The Historical Perspectives of gastrointestinal anastomosis. The Rebirth of Bariatric surgery
  8. 8. Metabolic SurgeryTreatment of metabolic derangements withalterations of the gut anatomy remission of diabetes
  9. 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. 10. Association of Diabetes and ObesityDIABETES + OBESITY = DIABESITY DIABETES OBESITY 90% WEIGHT LOSS T2D WEIGHT GAIN T2D
  11. 11. How can we correct it ?  Dietary control  Lifestyle changes.  Medical management
  12. 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. 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. 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. 15. BARIATRIC SURGERY Gastric Banding Sleeve Gastrectomy Gastro-Biliary Bypass
  16. 16. Bariatric Surgeries
  17. 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. 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. 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. 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. 21. The exclusion of theduodenal nutrientpassage may offset anabnormality ofgastrointestinalphysiology responsiblefor insulin resistanceand type 2 diabetes
  22. 22. Nutrients reach the distalileum within 5 min of theingestion of food and thisstimulates the secretion ofGLP1 by L cellslocated in this area
  23. 23. The Entero Insular Axis Anti-Incretins DPP-4 INCREASED INSULIN AVAILABILTY GLP-1 Insulin Production Incretins GIP b-cell Neogenesis PYY Statiety.
  24. 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. 25. The Net Effect Decreased insulin destruction  Increased Insulin Production Decreased Insulin Resistance
  26. 26. WHO WOULD HAVE THOUGHT IT? An Operation Can be The mosteffective Therapy For Adult Onset Diabetes Mellitus
  27. 27. Where do we stand?
  28. 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. 29. How much it costs?Nothing is more costly than a healthy life
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