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Metabolic Surgery

Metabolic Surgery. Abul Fazal Ali Khan Professor of Surgery Allama Iqbal Medical College Lahore. Dr. Abul Fazal Ali Khan Professor of Surgery Allama Iqbal Medical College Lahore. Who would have thought it? An operation proves to be the most effective therapy for T2DM. Background.

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Metabolic Surgery

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  1. Metabolic Surgery Abul Fazal Ali Khan Professor of Surgery Allama Iqbal Medical College Lahore

  2. Dr. Abul Fazal Ali KhanProfessor of Surgery Allama Iqbal Medical CollegeLahore Who would have thought it?An operation proves to be the most effective therapy for T2DM

  3. Background • Obesity and Metabolic Syndrome are serious chronic diseases associated with complex metabolic dysfunctions that increase the risk for morbidity and mortality • The dramatic rise in the prevalence of obesity and diabetes has become a major public health issue • It demands urgent attention from the government, healthcare systems and the medical community

  4. Objectives • What is Metabolic Syndrome? • Current and future clinical applications of metabolic and diabetes surgery • How I do it. • Recommendations for Family Physicians

  5. Metabolic Syndrome • Abdominal obesity  • waist circumference > 41” men,  > 35” women  • Fasting blood glucose > 110 mg/dl  • Hypertriglyceridemia > 150 mg/dl  • Low HDL­cholesterol <40 mg/dl men,  < 50 mg/dl women  • Hypertension (> 130/ >85) 

  6. Metabolic Surgery Treatment of metabolic derangements  with alterations of the gut anatomy. 

  7. Questions & Skepticism Re: MS • Is there a good medical therapy which can prevent medical complications • How does MS work. • Is it effective? Is it durable ? • Is MS useful even if DM Relapses • In which subset of patients MS is most effective • Does it work in non obese patients • Does MS prevent T2DM

  8. Is There A Good Medical Therapy Which Can Prevent Medical Complications There is now good evidence that while good Med Treatment does benefit : There are associated problems like: • Compliance • Not effective in preventing certain complications • Cost of TM & unmitigated complications • Complications of MT

  9. Is MS Really effective • Improves insulin sensitivity and reduces insulin secretion. • Blood glucose levels in diabetic patients improve within a week of MS, in advance of any weight loss. • Caloric restriction, independent of adipose tissue mass, is one mechanism. • A high proportion of obese patients with diabetes derive substantial metabolic benefit from bariatric surgery.

  10. What is the Evidence to Support the Concept of Diabetes Surgery?What is the Evidence to Support the Concept of Diabetes Surgery?

  11. Who would have thought it?An operation proves to be the most effective therapy for T2DM Surgery is more effective than MT in treating T2DM 83% of type 2 diabetic subjects euglycaemic Pories WJ, Swanson MS, MacDonald KG, et al Annals of Surgery

  12. Adams et al.  • 40% reduction in all­cause mortality  • 56% reduction in cardiovascular mortality  • 56% reduction in cancer mortality  • 90% reduction in diabetes­related mortality

  13. MS: Effects on CVS Risk Factors • Gleysteen and colleagues first reported the beneficial effects of GBP on diabetes, hypertension and lipid profiles, • SOS study confirmed these findings with both GBP and LGB • Regression of LVhypertrophy & reduction of carotid artery intima-media thickness.

  14. Many -although not all - patients with type 2 diabetes are able to reduce or stop their diabetes medication after surgery

  15. Subset of patients MS is most effective • Subjects with shortest duration diabetes • diet-controlled • with greatest weight loss achieved Schaueret al.

  16. Effects of Bariatric Surgery on Type 2 DMAre These Durable? • Greenville series : 82.9% of 165 patients with T2DM remained in remission after an average of 14 years following RYGB • Schaueret al : 83% of subjects undergoing LGBP achieved normal fasting plasma glucose. • Even if DM eventually relapses benefits of MS persist

  17. Does it work in non obese patients Consider surgery (RYGBS, LAGB, BPD) as a non-primary alternative for inadequately controlled T2DM with BMI 30-35 kg/m2Rubino et al. Annals of Surgery, 2009

  18. Lap RYGBS for BMI 35:A tailored approach Ricardo Cohen, M.D.*, Jose S. Pinheiro, M.D., Jose L. Correa, M.D.,Carlos A. Schiavon, M.D. Surgery for Obesity and Related Diseases 2 (2006) 401–404 • 37  Diabetic patients on two oral meds  • 81% EWL at two years  • All patients had normalization of FBG off meds

  19. Does MS Prevent T2DM MS can effectively prevent progression from impaired glucose tolerance to diabetes in severely obese individuals Sjostrom L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. NEnglJMed. 2004;351:2683-93.

  20. 851 bariatric surgery patients  • 852 matched controls  • 10 year follow­up  • Significant reduction in incidence of diabetes in  • surgery group   (7% v. 24%, p< 0.001) at 10 years

  21. Some More Questions • Which procedure is more effective? • Is RYGBS safe?

  22. Which procedure is more effective?Rates of Remission of Diabetes 

  23. ASMBS Bariatric Surgery Center of Excellence Program A total of 235 patients met inclusion criteriaOutcomes of MS to Treat Diabetes • Gastric bypass provided superior weight loss and diabetes. More effective for than adjustable gastric banding within 6 to 12 months • 90-day complications: 18% vs. 3%, P < 0.05.Most complications were minor: No mortalities • Early effectiveness of MS even in patients who did not have morbid obesity. • A prolonged period of normalisation of glycaemic control has benefit for diabetes even if there is eventual relapse

  24. Risk Factors BMI≥50kg/m2 Male gender Hypertension Risk of PE Age≥45y Obesity Surgery-Mortality Risk Score DeMaria et al. SOARD 2007 DeMaria et al. Ann Surg 2007

  25. Recommendations • Bariatric surgery in obese patients with T2D has a range of health benefits, including a reduction in all-cause mortality • Surgery should be considered as complimentary to medical therapies to reduce micro-vascular and cardiovascular risk. • When performed within accepted guidelines the morbidity and mortality is generally low, and similar to elective cholecystectomy. • Long-term nutritional supplements and support must be provided to patients after surgery

  26. Conclusions  • Gastrointestinal bypass procedures can improve diabetes by mechanisms beyond changes in food intake and  body weight. • Anatomic modification of the GI tract contribute to the amelioration of T2DM through  physiological mechanisms. • It is a durable therapy for all the components of the metabolic syndrome. • Surgical therapy for Type 2 diabetes is highly effective in  patients with both severe and mild obesity.

  27. Thank You

  28. Duodenal­Jejunal Bypass Sleeve • 12 patients  • 60 cm DJBS placed endoscopically  • 23% excess weight loss  at 12 weeks  • All 4 diabetic patients had normal fasting glucose  • levels off medication during DJBS therapy

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