Metabolic Surgery

Metabolic SurgeryAbul Fazal Ali KhanProfessor of Surgery Allama Iqbal Medical College Lahore

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

BackgroundObesity 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 issueIt demands urgent attention from the government, healthcare systems and the medical community

ObjectivesWhat is Metabolic Syndrome?Current and future clinical applications of metabolic and diabetes surgeryHow I do it. Recommendations for Family Physicians

Metabolic SyndromeAbdominalobesitywaistcircumference>41men,> 35womenFastingbloodglucose>110mg/dlHypertriglyceridemia>150mg/dlLowHDLcholesterol85)

Metabolic SurgeryTreatmentofmetabolicderangementswith alterationsofthegutanatomy.

Questions & Skepticism Re: MSIs there a good medical therapy which can prevent medical complicationsHow does MS work.Is it effective? Is it durable ?Is MS useful even if DM RelapsesIn which subset of patients MS is most effectiveDoes it work in non obese patientsDoes MS prevent T2DM

Is There A Good Medical Therapy Which Can Prevent Medical ComplicationsThere is now good evidence that while good Med Treatment does benefit :There are associated problems like: ComplianceNot effective in preventing certain complications Cost of TM & unmitigated complicationsComplications of MT

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.

WhatistheEvidencetoSupporttheConceptofDiabetesSurgery?

Who would have thought it? An operation proves to be the most effective therapy for T2DM

SurgeryismoreeffectivethanMTin treating T2DM83%oftype2diabeticsubjects euglycaemic

PoriesWJ,SwansonMS,MacDonaldKG,etal Annals of Surgery

Adamsetal.40%reductioninallcausemortality56%reductionincardiovascularmortality56%reductionincancermortality90%reductionindiabetesrelatedmortality

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

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

Subset of patients MS is most effectiveSubjects with shortest duration diabetesdiet-controlledwith greatest weight loss achievedSchauer et al.

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 RYGBSchauer et al : 83% of subjects undergoing LGBP achieved normal fasting plasma glucose. Even if DM eventually relapses benefits of MS persist

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

LapRYGBS for BMI 35:A tailored approachRicardoCohen,M.D.*,JoseS.Pinheiro,M.D.,JoseL.Correa,M.D.,CarlosA.Schiavon,M.D.SurgeryforObesityandRelatedDiseases2(2006)40140437 Diabetic patientsontwooralmeds81%EWLattwoyearsAllpatientshadnormalizationofFBGoffmeds

Does MS Prevent T2DMMS 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. NEngl JMed. 2004;351:2683-93.

851bariatricsurgerypatients852matchedcontrols10yearfollowupSignificantreductioninincidenceofdiabetesinsurgerygroup(7%v.24%,p95% (Immediate)

ASMBS Bariatric Surgery Center of Excellence Program A total of 235 patients met inclusion criteria Outcomes of MS to Treat DiabetesGastric 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

23Obesity Surgery-Mortality Risk ScoreRisk FactorsBMI50kg/m2Male genderHypertensionRisk of PEAge45y

CategoryNo. of factorsReported MortalityA46-49%0-10.2-0.3%B48%2-31.2-1.9%C3-5%4-52.4-7.6%DeMaria et al. SOARD 2007DeMaria et al. Ann Surg 2007

RecommendationsBariatric 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

ConclusionsGastrointestinalbypassprocedurescanimprove diabetesbymechanismsbeyondchangesinfoodintakeand bodyweight.AnatomicmodificationoftheGItractcontributetotheameliorationofT2DMthrough physiologicalmechanisms.It is a durabletherapyforallthecomponentsofthemetabolicsyndrome.SurgicaltherapyforType2diabetesishighlyeffectivein patientswithboth severeand mildobesity.

Thank YouDuodenalJejunalBypassSleeve12patients60cmDJBSplaced endoscopically23%excessweightlossat12weeksAll4diabeticpatientshad normalfastingglucoselevelsoffmedicationduringDJBStherapy