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Outcome of Diabetes Mellitus after Metabolic Surgery

Outcome of Diabetes Mellitus after Metabolic Surgery. Joint Hospital Surgical Grand Round 11 th August 2018. Dr. Chui Ka-ho, Tommy Prince of Wales Hospital. Outline. What is metabolic surgery? What is the long term DM outcome after metabolic surgery? How to predict DM remission rate?

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Outcome of Diabetes Mellitus after Metabolic Surgery

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  1. Outcome of Diabetes Mellitus after Metabolic Surgery Joint Hospital Surgical Grand Round 11th August 2018 Dr. Chui Ka-ho, Tommy Prince of Wales Hospital

  2. Outline • What is metabolic surgery? • What is the long term DM outcome after metabolic surgery? • How to predict DM remission rate? • Updated approach in DM management

  3. Outline • What is metabolic surgery? • What is the long term DM outcome after metabolic surgery? • How to predict DM remission rate? • Updated approach in DM management

  4. Obesity is a global epidemic

  5. The number of people with diabetes has risen from 108 million in 1980 to 422 million in 2014 • The global prevalence of diabetes among adults over 18 years of age has risen from 4.7% in 1980 to 8.5% in 2014 • In 2015, an estimated 1.6 million deaths were directly caused by diabetes (WHO Nov 2017)

  6. Foregut hypothesis Exclusion of duodenum and proximal jejunum from the transit of nutrients may interrupt signals that lead to insulin resistance and Type 2 DM

  7. Hindgut hypothesis • Enhanced delivery of nutrients to distal ileum alters secretion of hormones and improves glucose metabolism • Increased release of GLP-1 and PYY(Peptide YY) • -Anorectic • -Incretin effect -Triggers the ileal brake mechanism

  8. Outline • What is metabolic surgery? • What is the long term DM outcome after metabolic surgery? • How to predict DM remission rate? • Updated approach in DM management

  9. Swedish Obese Subjects (SOS) Trial • First long-term, non-randomized, prospective, controlled study • Recruitment date 1/9/1987 – 31/1/2001 • 2010 patients having bariatric surgery • 2037 patients matched obese controls receiving usual care • 250 surgical departments Sjostrom et al. JAMA 2012

  10. Sjostrom et al. JAMA 2012

  11. Sjostrom et al. JAMA 2014

  12. Sjostrom et al. JAMA 2014

  13. SOS trial – Cardiovascular Events Sjostrom et al. JAMA 2012

  14. SOS trial – Death rate Sjostrom et al. JAMA 2012

  15. Swedish Obese Subjects (SOS) Trial By 15 – 20 years of FU, Bariatric surgery is associated with • More substantial and durable weight loss • Better DM remission • Lower cardiovascular complications, cancers and mortality Sjostrom et al. JAMA 2012

  16. JAMA 2014

  17. Comorbidity Resolution JAMA 2014 In contrast to medical therapy, bariatric surgery - Result in significantly higher rate of DM resolution

  18. Long Term T2DM Outcomes of Metabolic Surgery Evidence from RCT

  19. Italian Trial (Rubino Group) Rubino et al. Lancet 2016

  20. Rubino et al. Lancet 2016

  21. Rubino et al. Lancet 2016

  22. STAMPEDE Trial Schauer et al, NEJM 2017

  23. Schauer et al, NEJM 2017

  24. Outline • What is metabolic surgery? • What is the long term DM outcome after metabolic surgery? • How to predict DM remission rate? • Updated approach in DM management

  25. Parameter to predict DM remission rate • 15 studies • Prospective (5) • Retrospective (9) • Observational (1) • 1753 patients Wang. Obes Surg 2015

  26. Gender • Not association • Predictors of DM remission • Age • DM duration • HbA1c • Not on insulin • BMI • C-peptide Wang. Obes Surg 2015

  27. 2. Scoring system to predict DM remission • DiaRem Score • For RYGB • ABCD Bariatric Surgery Score • For RYGB and sleeve gastrectomy • Validated in Asian population • Indian Diabetes Remission score • Validated in Indian population

  28. ABCD Diabetes Surgery Score Lee. Surg Obes Relat Dis 2013 & 2015

  29. Relation of ABCD score and DM remission rate after bypass (LRYGB, LMGB, LDJB +SG) Lee. Surg Obes Relat Dis 2013 & 2015

  30. DiaRem Score Still, Lancet Diabetes Endocrinol 2013

  31. DiaRem Score vs ABCD Score • Both score can predict the success of DM remission after gastric bypass • ABCD score – better at differentiating patients with poorer score Lee, 3rd World Congress for Interventional Therapies for T2DM and Diabetic Summit-II 2015

  32. Outline • What is metabolic surgery? • What is the long term DM outcome after metabolic surgery? • How to predict DM remission rate? • Updated approach in DM management

  33. Rubino, Diabetes Care 2016

  34. Conclusion • Metabolic surgery aims at treating metabolic derangements of obesity by alterations of GI anatomy • Metabolic surgery is significantly more effective than intensive medical therapy in treating T2DM related to obesity

  35. Conclusion • Multiple parameters and scoring system can predict the change of DM remission • If ABCD score ≤3 or DiaRem score ≥8: DM remission rate < 10% • Metabolic surgery is recommended as an option to Type 2 diabetes in: • Class III obesity regardless of glycemic control or complexity of glucose lowering regimens • Class II obesity with inadequately controlled hyperglycemia despite lifestyle and optimal medical therapy.

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