HEGAZY SURGERY

1. Mohey Elbanna, MD FACS
Prof. of Surgery
Ain Shams University

2. What is Metabolic Surgery ?
 It is Surgery that aims to cure or improve Metabolic
Sydrome

3. Metabolic Syndrome
 Metabolic syndrome is defined by the presence of any three
of the following conditions:
1- Elevated Fasting Blood Glucose > 126 mg/dL
2- Elevated BP > 130/85 mm Hg
3- Elevated Triglycerides > 150 mg/dL
4- Reduced HDL Cholesterol <40 mg/dL (M) – 50 mg/dL (F)
Higher Risk of Cardiovascular Disease

4. What are the surgical operations ?
 1- Duodenal Switch
 2- Gastric Bypass
 3- Sleeve Gastrectomy

5. Can this redefine Metabolic
Surgery ?
 Metabolic Surgery is Surgery that Cures or improves
Metabolic Syndrome
 It is GIT Surgery
 And It is Bariatric Surgery

6. What is Bariatric Surgery ?
 Bariatric ?
 Baros in Greek = Weight
 Weight Loss Surgery

7. Bariatric Surgery
 1- Restrictive Procedures:
 Sleeve Gastrectomy
 Adjustable Gastric Band
 Vertical Banded Gastroplasty
 Greater Curve Plication
 2- Malabsorptive Procedures:
 Biliopancreatic Diversion
 Duodenal Switch
 3- Combined Procedures:
 Gastric Bypasses

8. Are All Bariatric Procedures
Metabolic?
 No
 Metabolic Surgeries are those that alter the GIT
function to improve or cure Diabetes and Metabolic
Syndrome

9. The Best Metabolic Procedure

10. Duodenal Switch

11. Gastric Bypass

12. Mini Gastric Bypass

13. Sleeve Gastrectomy

14. What are the results ?
Mean ratios of patients with resolution of
T2DM after 2 years:
 Gastric Banding 48 %
 Vertical Banded Gastroplasty 68 %
 Sleeve Gastrectomy 80 %
 RYGB 84 %
 BPD or Duodenal Switch 98%

15. Efficacy
 A prospective study by Lee et al. (2008) evaluated the
effects of gastric bypass surgery in 44 patients with
T2DM and BMI <35 kg/m2 as compared with 157
patients with BMI >35 kg/m2.3
 After 4 years of postoperative follow-up, 90% of
patients with BMI <35 kg/m2 and 98% of patients with
BMI >35 kg/m2 experienced normalization of glycemia
 The investigators concluded that 77% of those with a
BMI <35 kg/m2 achieved the targets determined by
the American Diabetes Association

16. What is the Goal Of Surgery?
American Diabetes Association sets the targets:
 HbA1C level <7.0%
 LDL-cholesterol level <2.59 mmol/l
 Serum triglyceride level <1.695 mmol/l

17. What is the SAFETY Profile ?
 In this study including 201 patients
 2.2% of patients experienced major complications (one
fatality)
 6.2% minor complications

18. Meta-analysis
 A meta-analysis of 361 studies that included a total of
85,048 patients showed an overall mortality of 0.28%
within 30 days after surgery, and a mortality of 0.35%
between 30 days and 2 years after surgery.31 Several
other studies reported surgical mortality of 0.25%–
0.50%.

19. Non-glycemic Effects
 70% of patients esperienced improvement in
hyperlipidemia
 79% of patients experienced improvement or
resolution of hypertension

20. Is the Effect of Bariatric/Metabolic
Surgery related to Weight Loss
 Several studies proved that the improvement in the
Metabolic Profile of the patient is independent of the
weight loss effect of surgery

21. Adipocytokines (Adipokines)
1. Leptin
2. Tumor Necrosis Factor-alpha
3. Interleukin-6 (IL-6)
4. Angiotensinogen / PAI-1
5. Adiponectin
6. Adipsin
7. Resistin
8. Visfatin
9. Omentin

22. The Incretins
 Two:
 1- Glucagon-Like Peptide 1 (GLP 1)
 2- Gastric Inhibitory Peptide (Glucose-dependent
insulinotropic polypeptide - GIP)
 Both are rapidly inactivated by the enzyme dipeptidyl
peptidase-4 (DPP-4)

23. Anti-incretin Hypothesis
 Incretins include gut hormones, such as GLP-1 and
GIP, whose secretion is triggered by the passage of
nutrients through the small bowel
 These hormones increase glucose-stimulated insulin
secretion by pancreatic β cells and also affect gastric
emptying, nitrite influx and β-cell prolifereation (via
anti-apoptotic effects)

24. Alterations of GIT hormones
 A number of gastrointestinal hormonal changes have
been reported to occur following gastric surgery,
consistent with the hypotheses that alterations in GIT
anatomy affect endocrine functioning of the gut
 For example, RYGB induces substantial hormonal
changes, even before weight loss takes places
 Increased levels of peptide YY and GLP have been
consistently reported in several animal and human
studies
 RYGB seems to alter secretion of ghrelin and GIP

25. GIT and Hormones
 These hormones are all involved in the regulation of
energy homeostasis via their effects on peripheral
organs, as well as the brain
 Although the exact molecular mechanisms that
underlie the improvements in metabolism following
gastric bypass surgery are not known, these findings
establish that changes in GIT anatomy have profound
effects on metabolism

26. Conclusions
Take Home Messages
 When behavioral and pharmacological interventions
fail to manage T2DM, metabolic surgery offers an
effective alternative, with the potential of complete
remission of the disease
 Traditional bariatric or metabolic surgeries are highly
safe and effective in patients with obesity and T2DM
 Gastrointestinal bypass techniques improve glucose
homeostasis through mechanisms beyond reduced
caloric intake and weight loss

27. Thank You
 Thank You