Sleeve Gastrectomy The Metabolic Choice. Why Sleeve Gastrectomy? “We need a bariatric procedure...
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Sleeve Gastrectomy The Metabolic Choice
Sleeve Gastrectomy The Metabolic Choice. Why Sleeve Gastrectomy? “We need a bariatric procedure that does not cause as much morbidity and does not need
Why Sleeve Gastrectomy? We need a bariatric procedure that does
not cause as much morbidity and does not need as much follow up as
the current ones E.E. Mason Presidential Address 2007 ASMBS
Slide 3
Mechanism of action 1. Restriction 2. Natural Band Formation 3.
Hormonal
Slide 4
1. Restriction LSG reduces the size of the gastric reservoir to
60-100 ml permitting intake of only small amounts of food and
imparting a feeling of satiety earlier during a meal
Slide 5
2. Natural Band The pylorus functions as a natural band in this
procedure facilitating further restriction
Slide 6
3. Ghrelin hormone produced mainly by P/D1 cells lining the
fundus of the human stomach and epsilon cells of the pancreas that
stimulates hunger Ghrelin levels increase before meals and decrease
after meals. the counterpart of the hormone leptin, produced by
adipose tissue, which induces satiation when present at higher
levels
Slide 7
3. Ghrelin By resecting the fundus in a LSG, the majority of
ghrelin producing cells are removed reducing plasma ghrelin levels
and subsequently hunger.
Slide 8
Current Weight loss Evidence 35 Studies between 1/03 and 1/09
2,570 patients Pre-op BMI 35 69 kg/m 2 (mean 50) Post-op BMI 26 53
kg/m 2 ( mean 37) Follow-up 3 months to 5 years 33 83% EWL (mean
55%) Complication rate 0 24% 0 15% in 11 studies with n> 100 5
postoperative mortalities (0.19%)
Slide 9
Sleeve Gastrectomy Good Excess Weight loss Technically feasible
Safe
Slide 10
Sleeve Gastrectomy and Diabetic Control
Slide 11
Resolution, Remission or Cure It is generally accepted that
effective medical or surgical diabetes therapy results in remission
of the disease and not cure This generally means that the patient
is off all hypoglycemic medications and/or insulin and that they
have normal fasting plasma glucose, normal post prandial glucose
excursions and normal HbA 1c
Slide 12
| Bariatric Surgery Efficacy Buchwald H. JAMA, 2004 Procedure%
EWLT2DM (Remission) Gastric Banding47% (n=1848)48% Gastric
Bypass62% (n=4204) 84% BPD70% (n=2480)98%
Slide 13
| Bariatric Surgery is Effective, But Not Equal-Where does
sleeve fit in? 30 Day Mortality Adapted from Buckwald H, et al,
Bariatric surgery, a systematic review and meta- analysis, JAMA.
2004;292:1724-1737 and Maggard M, et al, Meta-Analysis: Surgical
Treatment of Obesity, Ann Intern Med. 2005;142:547-559. Risk
Benefit 0.0010.010.1110 Banding Roux-en-Y Switch 10% 50% 100%
Diabetes Resolution Rate Excess Weight Loss
Slide 14
14 | Diabetes Surgical Interventions (DSI) Technical Complexity
Low MediumHigh Low Medium High Efficacy
Slide 15
How does a Sleeve Gastrectomy impart its Diabetic
Remission?
Slide 16
1. Hormonal Changes 2. Hindgut theory
Slide 17
1. Hormonal Changes-Ghrelin Effect Marked Reduction of fasting
ghrelin levels post- operatively Karamkos et al. 2008 Ghrelin is a
hormone produced primarily by the gastric fundus Ghrelin : suppress
the insulin sensitizing hormone adiponectin Blocks hepatic insulin
signaling Inhibits insulin secretion By gastric fundus removal, the
reduced circulating ghrelin level and its insulinostatic effect
will increase the maximal captacity of glucose induced insulin
release and enable the islet to secrete more insulin Abbatini et
al. 2009
Slide 18
| 2. The Hindgut Theory The more rapid delivery of undigested
nutrients to the distal bowel upregulates the production of L-cell
derivatives like GLP-1, Peptide YY Rubino et.al, Ann Surg, 2006
Mason E. Obes Surg 2005 15, 459-461
Slide 19
The But we are not making any new anastamosis like a BPD or a
RNYGB so how does this happen with a SG??? Melissas et al. Obes
Surg 2007 gastric emptying half-time (T1/2) accelerated (47.6 +/-
23.2 vs 94.3 +/- 15.4, P