Metabolic surgery
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1. Bariatric surgery, such as gastric bypass and sleeve gastrectomy, can lead to high rates of remission or improvement of type 2 diabetes by altering gut hormone levels and increasing insulin sensitivity. 2. Clinical guidelines recommend bariatric surgery for adults with a BMI over 40, or between 35-40 with other obesity-related health conditions, when non-surgical weight loss efforts have failed. 3. Pre-operative risk stratification is important to reduce risks, and bariatric surgery may be a first-line treatment option for diabetes instead of lifestyle/drug interventions.
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Metabolic surgery
- 1. Bariatric Surgery Metabolic Aspects, Indications & Pre-Operative Preparation Abeezar I. Sarela St James’s University Hospital &The Nuffield Hospital Leeds, UK
- 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. How does surgical treatment affect Type 2 Diabetes Mellitus?
- 7. Components of Intestinal Bypass Procedures Goldfine et al Nature Med 2009;15:616
- 8. Murphy & Bloom Nature 2006;444:854 Gut Hormones
- 13. Cummings DE et al. - N Engl J Med 2002 Ghrelin After Gastric Bypass
- 16. Anti-Incretins Rubino & Gagner Ann Surg 2002
- 17. Anti-Incretins: The Effect of Duodenal Exclusion Rubino & Gagner Ann Surg 2002
- 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
- 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
- 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
- 30. Kahn et al Nature 2006;444:840 Link between Obesity & Type 2 Diabetes
Editor's Notes
- 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!