Metabolic surgery

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  • Precise BMI cut-off at 35 is not an accurate parameter to predict the potential of surgery to induce glycaemic and metabolic control. No existing studies have shown evidence of excessive weight loss following conventional bariatric operations in patients with BMI 30-35.
  • Weight loss alone explains diabetes control after LAGB (A) Intestinal bypass procedures (RYGB, BPD, D-J bypass) appear to engage additional anti-diabetic mechanisms beyond those restricted to food intake and weight.(A)
  • Why has gastric bypass not become the accepted treatment for diabetes for obese patients? The concept of GI surgery as an endocrine modifier has been fully embraced by the clinical community. Perception that bariatric surgery offers nothing more than the motivation to change unhealthy lifestyle habits - precept that surgery treats diseases through mechanical changes rather than changes in the underlying pathophysiological mechanisms. Willingness to wait and hope for a new drug!
  • Metabolic surgery

    1. 1. Bariatric Surgery Metabolic Aspects, Indications & Pre-Operative Preparation Abeezar I. Sarela St James’s University Hospital &The Nuffield Hospital Leeds, UK
    2. 2. Agenda <ul><li>Metabolic basis of bariatric operations </li></ul><ul><li>Conventional indications </li></ul><ul><li>Emerging indications </li></ul><ul><li>Risk stratification </li></ul>
    3. 3. Effects of Bariatric Surgery on Type 2 DM A Systematic Review and Meta-analysis <ul><li>621 studies: 1990-2006 </li></ul><ul><li>135, 246 patients </li></ul><ul><li>Women: 80% </li></ul><ul><li>Mean BMI 48 kg/m 2 </li></ul><ul><li>Resolution of T2DM : 78% </li></ul><ul><li>Resolution or improvement: 84% </li></ul>Buchwald et al. Am J Med 2009;122:248-256
    4. 4. Resolution of T2DM is “Dose-Related” Buchwald et al. JAMA 2004;292:1724-1737 98% 84% 48% Resolution of T2DM 1.1% 0.5% 0.1% Operative mortality 70% 62% 47% Excess weight loss Duodenal Switch Bypass Band
    5. 5. How does surgical treatment affect Type 2 Diabetes Mellitus?
    6. 6. <ul><li>increase insulin sensitivity </li></ul><ul><li>decrease insulin resistance </li></ul><ul><li>protect pancreatic beta-cell function </li></ul>Impact of Weight Loss Kahn et al. Nature.2006;444:840
    7. 7. Components of Intestinal Bypass Procedures Goldfine et al Nature Med 2009;15:616
    8. 8. Murphy & Bloom Nature 2006;444:854 Gut Hormones
    9. 9. Incretins <ul><li>Glucagon-Like Peptide 1 (GLP-1) </li></ul><ul><li>Released by intestinal L cells (ileum>jejunum) </li></ul><ul><li>Stimulate release of insulin </li></ul><ul><li>Anorectic </li></ul>
    10. 10. Gut Hormone Profiles Following Bariatric Surgery <ul><li>Compared with lean and obese controls, gastric bypass patients had increased postprandial plasma PYY and GLP-1 </li></ul><ul><li>Gastric bypass patients had early and exaggerated insulin responses </li></ul><ul><li>Neither effect observed in patients losing equivalent weight through gastric banding </li></ul>le Roux et al. Ann Surg 2006;243:108-114
    11. 11. Hindgut or Distal Small Intestinal Hypothesis <ul><li>Expedited delivery of nutrients to </li></ul><ul><li>distal small bowel results in: </li></ul><ul><li>Increased release of GLP-1 and PYY </li></ul><ul><ul><li>Anorectic </li></ul></ul><ul><ul><li>Incretin effect </li></ul></ul><ul><li>Triggers the ileal brake mechanism </li></ul>
    12. 12. Ghrelin <ul><li>Only known hormone that increases appetite – “Hunger Hormone” </li></ul><ul><li>Diabetogenic </li></ul><ul><ul><li>increases growth hormone, cortisol, and adrenaline levels </li></ul></ul><ul><ul><li>suppresses insulin </li></ul></ul>
    13. 13. Cummings DE et al. - N Engl J Med 2002 Ghrelin After Gastric Bypass
    14. 16. Anti-Incretins Rubino & Gagner Ann Surg 2002
    15. 17. Anti-Incretins: The Effect of Duodenal Exclusion Rubino & Gagner Ann Surg 2002
    16. 18. Foregut or Proximal Small Intestinal Hypothesis <ul><li>Exclusion of stomach, duodenum and proximal jejunum from the alimentary circuit </li></ul><ul><ul><li>Decreased release of “anti-incretin” from duodenum/proximal jejunum </li></ul></ul><ul><ul><li>Suppression of Ghrelin (?) </li></ul></ul>
    17. 19. Sleeve Gastrectomy vs. Roux-en-Y Gastric Bypass <ul><li>Randomized clinical trial </li></ul><ul><li>Mainly non-diabetic patients </li></ul><ul><ul><li>Bypass: 13 patients </li></ul></ul><ul><ul><li>Sleeve: 14 patients </li></ul></ul><ul><li>Similar excess weight loss at 3 months </li></ul><ul><li>Increased insulin & GLP-1 after both procedures </li></ul><ul><li>Early response with bypass but no difference at 3 months </li></ul><ul><li>Does not support foregut hypothesis </li></ul>Peterli et al. Ann Surg 2009;250:234-241
    18. 20. Clinical Implications
    19. 21. NIH (USA)/NICE (UK) Clinical Guideline Indications for Bariatric Surgery <ul><li>BMI of 40 kg/m 2 or more, or between 35 kg/m 2 and 40 kg/m 2 and other significant disease that could be improved by weight loss </li></ul><ul><li>all appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months </li></ul><ul><li>the person has been receiving or will receive intensive management in a specialist obesity service </li></ul><ul><li>the person is generally fit for anaesthesia and surgery </li></ul><ul><li>the person commits to the need for long-term follow </li></ul>
    20. 22. Appropriate BMI for Asian populations and its implications for policy and intervention strategies. WHO expert consultation. Lancet 2004;363:157-163. Indian Population Overweight: BMI>23 kg/m 2 Obese: BMI>25 kg/m 2 Morbid obesity (+co-morbidity): BMI>32.5 kg/m 2 Abnormal Waist Circumference Men >90 cm Women >80 cm
    21. 23. Unified Criteria for Clinical Diagnosis of the Metabolic Syndrome Lancet 2010;375:181-183 > 100 mg/dl Increased fasting blood glucose (or medication) Systolic ≥130 or Diastolic ≥ 85 mmHg Increased blood pressure (or medication) <40 mg/dl in men <50 mg/dl in women Reduced HDL cholesterol (or medication) ≥ 150 mg/dl Increased triglycerides (or medication) Population-specific definition Increased waist circumference
    22. 24. Diabetes Surgery Summit Consensus Conference Rubino et al. Annals of Surgery, 2009 <ul><li>Consider surgery (Bypass, Band, BPD) for treatment of T2DM inadequately controlled by lifestyle & medical therapy in patients with BMI>35 kg/m 2 </li></ul><ul><li>Gastric Bypass may be a non-primary alternative for inadequately controlled T2DM with BMI 30-35 kg/m 2 </li></ul><ul><li>Novel surgical techniques (sleeve gastrectomy, endoluminal sleeves, D-J bypass, ileal interposition) should currently be used only in registered clinical trials </li></ul>
    23. 25. Preparation for Bariatric Surgery <ul><li>Safety </li></ul><ul><li>One size does not fit all </li></ul>
    24. 26. Obesity Surgery-Mortality Risk Score <ul><li>Risk Factors </li></ul><ul><ul><li>BMI≥50kg/m2 </li></ul></ul><ul><ul><li>Male gender </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Risk of PE </li></ul></ul><ul><ul><li>Age≥45y </li></ul></ul>DeMaria et al. SOARD 2007 DeMaria et al. Ann Surg 2007 2.4-7.6% 4-5 C 3-5% 1.2-1.9% 2-3 B 48% 0.2-0.3% 0-1 A 46-49% Reported Mortality No. of factors Category
    25. 27. Incidence of Adverse Events by OS-MRS Class A: 4% 229 patients Class B: 6% 137 patients Class C: 23% 15 patients One death 7% of OS-MRS C 0.3% of total AI Sarela, SP Dexter, MJ McMahon. 381 operations in 2009. SOARD, 2010
    26. 28. Prospective Risk Stratification <ul><li>Implement risk reduction strategies </li></ul><ul><ul><li>Liver reduction diet </li></ul></ul><ul><ul><li>Smoking cessation </li></ul></ul><ul><ul><li>Intra-gastric balloon </li></ul></ul><ul><ul><li>Staged operations </li></ul></ul><ul><li>Enhance vigilance for high risk patients </li></ul><ul><li>Counsel patients accurately </li></ul>
    27. 29. Conclusion <ul><li>Intestinal re-arrangement promotes powerful hormonal alterations </li></ul><ul><li>Paradigm shift: GI surgery as front-line treatment for type II diabetes mellitus </li></ul><ul><li>Pre-operative risk stratification is critical preparation for metabolic surgery </li></ul>
    28. 30. Kahn et al Nature 2006;444:840 Link between Obesity & Type 2 Diabetes
    29. 31. NIH (USA)/NICE (UK) Clinical Guideline Indications for Bariatric Surgery <ul><li>First-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI ≥ 50 kg/m 2 </li></ul><ul><li>Not generally recommended for children or young people (< 18 years) </li></ul><ul><li>Individuals with BMI of 30-35 kg/m 2 may benefit from bariatric surgery </li></ul>
    30. 32. Diabetes Surgery Summit Consensus Conference Rubino et al. Annals of Surgery, 2009 <ul><li>Rome. Multi-disciplinary Group of 50 voting delegates. 2007. </li></ul><ul><li>New York. World Congress on Interventional Therapies for T2DM. 2008 </li></ul><ul><li>DSS endorsed by 21 scientific organisations </li></ul><ul><ul><li>ADA, ASMBS, ACS, ACN, AGA, ASPEN, SAGES, Diabetes UK, EASD, EASO, IASO, IFSO </li></ul></ul>

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