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Bariatric Surgery and Metabolism

Bariatric Surgery and Metabolism. Goal: to review 4 important and clinically relevant papers from 2010 on Bariatric Surgery and Metabolism. 10/4/2014. 1. Disclosures. I am still pissed we’re not at Vail. Ethicon: Advisory board. Whistler 2004. Objective.

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Bariatric Surgery and Metabolism

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  1. Bariatric Surgery and Metabolism Goal: to review 4 important and clinically relevant papers from 2010 on Bariatric Surgery and Metabolism 10/4/2014 1

  2. Disclosures • I am still pissed we’re not at Vail. • Ethicon: Advisory board

  3. Whistler 2004

  4. Objective • Metabolic surgery to treat type 2 diabetes mellitus in patients who do not meet body weight criteria for morbid obesity (BMI 30-35) • Comparing LRYGB and LAGB in this patient population

  5. Methods • Bariatric Outcomes Longitudinal Database (BOLD) • 66264 bariatric procedures • 794 with BMI 30-35 kg/m2 • 235 with diabetes requiring medication • 109 LAGB ; 109 LRYGB • 92% Laparoscopic

  6. Results More severe DM in bypass group More complications in bypass group

  7. Results • Both procedures resulted in significant decrease in BMI, DM severity and # of DM medications • Gastric bypass showed better results than gastric band

  8. Results BMI # DM Meds.

  9. Results

  10. Conclusion • Both LAGB and LRYGB achieve significant, favorable impact on type 2 diabetes in the moderately obese (BMI 30-35) • Both procedures demonstrate a significant reduction in diabetes co-morbidity score and # of diabetes medication • Gastric bypass provides more effective treatment at the price of higher complication rates (mostly minor)

  11. Objective • Evaluation of bariatric surgery as secondary prevention in obese patients with ischemic heart disease (IHD)

  12. Methods • 4047 subjects in the Swedish Obese Subjects (SOS) group • 35 with IHD • 21 treated with bariatric surgery ; 14 treated conventionally • Mean follow-up 10.8 years

  13. Methods • SOS study:

  14. Results Mean weight change At 2 and 10 years bariatric surgery resulted in significantly greater weight loss compared to the control group

  15. Results

  16. Results

  17. Results

  18. Conclusion • Bariatric surgery appears to be a safe and feasible treatment to achieve long-term weight loss and improvement in cardio-vascular risk factors, symptoms and quality of life in obese subjects with IHD

  19. Objective • To present the longest follow-up report of any lipid-atherosclerosis interventional trial

  20. Methods • 25 years of follow-up in the POSCH study: Overall mortality Specific cause of death Prediction for increase in life expectancy

  21. Results

  22. Results

  23. Results

  24. Results

  25. Conclusion • A 25 year mortality follow-up in POSCH shows statistically significant gains in overall survival, cardio-vascular disease free survival and life expectancy in the surgery group compared to the controlled group

  26. Objective • To investigate the rate of type 2 diabetes remission after gastric bypass and banding and establish the mechanism leading to remission of type 2 diabetes after bariatric surgery

  27. Study 1: 34 obese type 2 diabetics Gastric bypass or banding 3 year follow-up Study 2 41 obese type 2 diabetics Gastric bypass, banding or very low calorie diet 42 day follow-up

  28. Results Study 1

  29. ResultsStudy 2

  30. ResultsStudy 2

  31. ResultsStudy 2

  32. Conclusion

  33. Methods • Trials comparing bariatric surgery vs. no surgery in patients with morbid obesity with the following end-points: • Non-CV mortality • CV mortality • Global mortality – CV + non-CV

  34. Results Small (<3000 pts.) vs. Large (>3000 pts.)

  35. Results LAGB Vs. RYGB

  36. Conclusion • Bariatric surgery reduces the risk of global mortality, CV mortality and all-cause mortality compared to participants not undergoing surgery • Risk reduction is lower in large studies than in small studies • Both gastric bypass and gastric band seem to reduce mortality risk

  37. Bariatric surgery and metabolism Other papers of interest

  38. 10/4/2014 43

  39. SUMMARY: Diabetes • Both restrictive (AGB) and malabsorptive (RGBP) procedures improve diabetic control • Improvement and remission of DM is significantly greater with malabsorptive (largely GBP), even with equivalent weight loss in some studies • Postprandial increase in GLP-1, insulin secretion and improvement in insulin resistance occurs only with GBP, even before weight loss; mechanisms (duodenal exclusion, incretin effects, neural, etc.) still incompletely explained • Restrictive and malabsorptive procedures both improve DM in patients with BMI <35, although less dramatically than in patients with BMI > 35

  40. SUMMARY: Mortality • Partial ileal bypass for hyperlipidemia improves 25 year survival, > in patients with baseline EF ≥ 50% (survival  by 1.7 years; 100,000 less deaths per million patients at 25 years) • Reduced mortality after both AGB and GBP compared to controls (global and all-cause) • ? Greater reduction in CV mortality with GBP reported in diabetics • Bariatric surgery can be performed safely in patients with IHD, but no reduction in CV events or deaths compared to controls (limitations of study: low BMI, small sample size, primarily restrictive procedures (VBG))

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