Wat kan bariatrische heelkundebijbrengen in de therapie bij

diabetes mellitus type 2

M. Lannoo

Surgical procedures:

LAP GASTRIC BANDING

Surgical procedures: GASTRIC BYPASS

Surgical procedures: SLEEVE GASTRECTOMIE

Surgical procedures: Biliopancreatische diversie

scopinaro Duodenal switch

Surgical procedures:

Biliopancreatische diversie

- elongation common limb ( 150 – 180 cm )

- conversion to gastric bypass

ALBPL

CL

RESULTATEN: BARIATRIESjöström et al.

The Swedisch Obesity Study (SOS trial)• Prospective, controlled Swedish Obese

Subjects study.

• 2010 underwent bariatric surgery (surgery group)

• 2037 received conventional treatment (matchedcontrol group).

• But not randomized,

treatment of the control group not well defined,more pre-baseline cardiovascular events in

controlsN Engl J Med. 2007 Aug 23;357(8):741-52.)

RESULTATEN: BARIATRIE

SOS study, N Engl J Med 2004

RESULTATEN: BARIATRIE

Buchwald et al. conducted a large meta-analysis

163 studies

22,094 patients

Surgical proceduresGastric Banding

Gastric Bypass (Roux en Y)

Gastroplasty

Bilio-pancreatic Diversion

Assesment of comorbities Diabetes

Hypertension

Hypercholesterolemia

Obstructive Sleep Apnea

N Engl J Med. 2007 Aug 23;357(8):741-52.)

RESULTATEN: BARIATRIE

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Diabetes AHT Hyperchol OSAS

Resolution or improvement (% of patients)

OBSERVATIONS: mortality

Adams et al.N Engl J Med 357;8 august 2007

RESULTATEN: BARIATRIE

author N%EWL 1y IDDM 2 AHTSleep

apnoea

Moon Han 130 83 100% 93% 100%

Cottam 126 45 75% 75% 80%

Sillechia 41 77% 63% 56,2%

Vidal 39 63 85%

Kasalicky 61 72 71% 65%

Tagaya 30 67% 56%12

Akkary Obes Surg 2008 18:1323-1329

Surgical procedures:

LAP GASTRIC BANDING

• focus is niet

gewichtsverlies maar

gezondheid

• verhouding is recht

evenredig

• na lap gastric banding

vaak dissociatie

RESEARCH ARTICLE

Differential Changes in Dietary Habits after Gastric Bypass

Versus Gastric Banding OperationsBarbara Ernst, Bernd Schultes et al.

OBES SURG (2009) 19:274–280

Conclusion Collectively, data clearly point to distinct

changes in dietary habits after bariatric operations which

markedly differ between gastric bypass and gastric banding

patients. Overall, it is tempting to conclude that gastric

bypass operations lead to a healthier and a more balanced

diet than gastric band implantations.

Compliantie

• lap band resultaten (= RYGBP) lange termijn

qua G-verlies• 6 weken interval

• regelmatige band aanpassing

• multidisciplinair consultatie

O'Brien PE, Dixon JB, Brown W, Schachter LM, Chapman L, Burn AJ, Dixon ME, Scheinkestel C, Halket C,

Sutherland LJ, Korin A, Baquie P. The laparoscopic adjustable gastric band (Lap-Band): a prospective

study of medium-term effects on weight, health and quality of life. Obes Surg 2002;12(5): 652-660.

Faling

• gewichtstoename of onvoldoende gewichtsreductie gaat tot 30%

Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5-year results of a prospective randomized

trial. Angrisani L, Lorenzo M, Borrelli V

Surg Obes Relat Dis. 2007 Mar-Apr;3(2):127-32; discussion 132-3.

• oplossing is vaak RYGBP & is gecompromitteerd door voorgaande lap gastric banding!• meer lekken?

• langere OP-tijd

• meer complicaties?

Physiology of weight loss after

RYGBMechanical view

Hormonal view

1. Isolation of the gastric cardia

2. Exclusion of the distal stomach from food

3. Enhanced exposure of undigested food

to distal jejunum to

Fast delivery of food

GLP-1, PYY

Early satiety&satiation

Physiology of weight loss after

RYGBMechanical view

Gut talks to the brain view

BANDING

RYGBP

Endoscopic stoma size reduction shouldn’t have potential

TYPE 2 DIABETES IS A SURGICAL

DISEASE

Walter Pories claimed in 1992

RESULTATEN: DIABETES

THE FIRST OBSERVATIONS

W. Pories

500 patients

Long term sufficient weight loss

Adequate follow up

RESULTATEN: DIABETES

RESULTATEN: DIABETES

Buchwald et al. conducted a large meta-analysis(Buchwald H, Avidor Y,Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric

surgery: a systematic review and meta analysis. Jama. 2004 Oct 13;292(14):1724-37)

For all surgical procedures combined type 2 diabetes

Resolved in 76.8% Resolved or improved in 86% of patients

Complete remission by type of surgery 48% after gastric banding (operative mortality 0.1%) 84% after Roux en Y (operative mortality 0.5%) >95% after bilio-pancreatic diversion (operative

mortality 1.1%)

Remission of diabetes after gastric banding occurs over several weeks or month, whereasafter gastric bypass it can occur within days

RESULTATEN: DIABETES

Sjöström et al.

The Swedisch Obesity Study (SOS trial)• Prospective, controlled Swedish Obese

Subjects study.

• 2010 underwent bariatric surgery (surgery group)

• 2037 received conventional treatment (matchedcontrol group).

• But not randomized,

treatment of the control group not well defined,more pre-baseline cardiovascular events in

controlsN Engl J Med. 2007 Aug 23;357(8):741-52.)

Effect= mainly

✚ CVD of DM

pat

RESULTATEN: DIABETES

• The Swedisch Obesity Study (SOS trial)

Sjostrom L et al. n engl j med; 351;26, 2004

RESULTATEN: DIABETES

author N%EWL 1y IDDM 2 AHTSleep

apnoea

Moon Han 130 83 100% 93% 100%

Cottam 126 45 75% 75% 80%

Sillechia 41 77% 63% 56,2%

Vidal 39 63 85%

Kasalicky 61 72 71% 65%

Tagaya 30 67% 56%24

Akkary Obes Surg 2008 18:1323-1329

RESULTATEN: DIABETES

• R

Rosenthal et al Surg Obes Relat Dis

2009 Epub corrected proof

DURATION OF DIABETES IS IMPORTANT

REMARKABLE ANALOGY WITH RYGBP

Surgical procedures:

LAP GASTRIC BANDING

• gewichtsverlies

– vergelijkbaar in beste geval

– door meer falingen in realiteit 20% lager

• minder effect op co-morbiditeit

• Diabetes

Tice JA, Feldman MD. et al.

Am J Med 2008;121(10):

885-893.

Adapted from Buse JB et al. In Williams Textbook of Endocrinology. 10th ed. Philadelphia, Saunders, 2003:1427–1483;

Buchanan TA Clin Ther 2003;25(suppl B):B32–B46; Powers AC. In: Harrison’s Principles of Internal Medicine.

16th ed. New York: McGraw-Hill, 2005:2152–2180; Rhodes CJ Science 2005;307:380–384.

MECHANISMEN: DIABETES

Hyperglycemia

Liver

Insulin deficiency

Excess glucose output Insulin resistance (decreased glucose uptake)

Pancreas

Muscle and fat

Excess

glucagon

Islet

Diminished

insulin

Diminished

insulin

Alpha cellproduces excess glucagon

Beta cellproduces less insulin

Adapted from Brubaker PL, Drucker DJ Endocrinology 2004;145:2653–2659; Zander M et al Lancet 2002;359:824–830;

Ahrén B Curr Diab Rep 2003;3:365–372; Buse JB et al. In Williams Textbook of Endocrinology. 10th ed. Philadelphia,

Saunders, 2003:1427–1483.

MECHANISMEN: DIABETES

Active

GLP-1 and GIP

Release of

incretin gut

hormones

Pancreas

Blood

glucose control

GI tract

Glucagon from alpha cells

(GLP-1)

Glucose dependent

Alpha cells

Increased insulin

and decreased

glucagon

reduce

hepatic

glucose output

Glucose dependent

Insulin from beta cells

(GLP-1 and GIP)

Beta cells

Insulin

increases

peripheral

glucose

uptake

Ingestion

of food

MECHANISMEN: DIABETES

Hypothesis of the distal bowel: Expedited of nutrients to the distal bowel

enhances a physiologic signal that improvesglucose metabolism (GLP-1)

Hypothesis of the proximal bowel: Exclusion of duodenum and proximal jejunum

may prevent secretion of a putative signal thatpromotes insuline resistance (involvement of the proximal small intestine in the physiology of IR.

MECHANISMEN: DIABETES

HypoglycemiaNesidioblastosis

Insulin resistance

MECHANISM: sleeve gastrectomy

RYGBP

SLEEV

E

Karamanakos et al Ann of Surg 2008;247(3):401-7

Mechanisms Sleeve gastrectomy

32

Early Postoperative Insulin-Resistance Changes

After Sleeve Gastrectomy

Nicola Basso OBES SURG (2010) 20:50–55

INDICATIONS : Lower BMI in type 2 DM

Quote of Professor Scopinaro

Why should you treat a disease

When you can cure it!!!!

September 15-16th 2008

1ste World Congress on Interventional therapies for type

2 Diabetes; September 15-16th 2008

INDICATIONS : <35 BMI type 2 DM

Rubino et al.:

Effect of Duodenal–Jejunal Exclusion in a Non-obese Animal Model of Type 2 Diabetes

Rubino F. Ann Surg. 2004 Jan;239(1):1-11.

LEAN

TYPE 2 DIABETIC

RATS

% resolution 3-6 months 6-12 months BMI 3-6 months 6-12 months

RYGBP 50 55,2 27,2 27,1

Lap Banding 31,8 27,5 31 30,9

P 0,0579 0,0199 <0,0001 0,0002

LAGB vs RYGBP BMI 30<>35 DM TYPE

2Early Postoperative Outcomes of Metabolic Surgery to Treat Diabetes

From Sites Participating in the ASMBS BSCOE Program as Reported in the BOLD

Eric J. DeMaria, MD, Walter J. Pories, MD¶ Annals of Surgery • Volume 252, Number 3, Sept. 2010

INDICATIONS : <35 BMI type 2 DM

Unhealthy lifestyle and

environmental factors

Insulin resistance

Metabolic syndrome

Increased risk of cardiovascular disease

MECHANISM: Diabetes

Healthy beta-cells

+

Unhealthy lifestyle and

environmental factors

Type 2 diabetes

Hyperglycaemia

MECHANISM: diabetes

+

Genes

Environment

Inflammation

Free fatty acid

Glucose

Failing beta-cells

WEIGHT LOSS is IMPORTANT

Rubino

WEIGHT LOSS is IMPORTANT

W. PORIES

Walter J. Pories , G. Lynis Dohm, Obes Surg. 2010 Nov 18. Epub ahead of print

COULD NOT REPRODUCE THE RESULT ON DM

WEIGHT LOSS is IMPORTANT

Insulin resistance did not change either

Walter J. Pories , G. Lynis Dohm, Obes Surg. 2010 Nov 18. Epub ahead of print

Possible mechanisms:

-Increased calory intake

-Increased fat mass

-Adaptation of the gut

Further research is needed

WEIGHT REGAIN IS STRONGLY ASSOCIATED WITH RELAPSE OF DM

Lower preoperative BMI is also contributing factor

WEIGHT LOSS is IMPORTANT

Surg Obes Relat Dis. 2010 DiGiorgi M, Bessler M.

WEIGHT LOSS is IMPORTANT

CALORIC RESCTRICTION is IMPORTANT

JAMES M. ISBELL, NAJI N. ABUMRAD,DIABETES CARE, VOLUME 33, NUMBER 7, JULY 2010

BYPASS VERSUS NO OPERATION DIET ONE WEEK IDENTICAL FOR BOTH

RYGBP CHANGES HORMONES

INSULINE RESISTANCE IS CHANGED BY CALORY

RESTRICTION

NEW DEVICES

NEW DEVICES

NEW OPERATIONS

NEW OPERATIONS

An ileal interposition with a diverted sleeve gastrectomyis an effective operation for the treatment of type 2 diabetes mellitus patients with BMI 21-29.

Depaula AL, Surg Endosc 2008 Oct 2.

Indicaties

• BMI 35 + DM2 of hypertension with 3 R/

of OSAS

Dyslipidemia/hypertension/GERD/ orthopedic/psy

• BMI 40

• One year diet

• Multidiscplinary intake: psy, DIT,surgeon,

physician

* NIH statement 1991 + RIZIV

CAVEAT

• IDF statement: Bariatric surgery: an IDF

statement for obese Type 2 diabetes

J.B. Dixona, P. Zimmeta, , and International Diabetes Federation Taskforce

on Epidemiology and Prevention

Surgery should be an accepted option in people who have

Type 2 diabetes and a BMI of 35 kg ⁄m2 or more.

Surgery should be considered as an alternative treatment

option in patients with a BMI between 30 and 35 kg ⁄m2

when diabetes cannot be adequately controlled by optimal

medical regimen, especially in the presence of other major

cardiovascular disease risk factors.

CAVEAT

• Operatie noopt tot een volledige

verandering van levenstijl en

voedingsgewoonte.

• Patiënt moet dit weten en willen!

• Patiënt verliest een chronische ziekte

maar niet de behandeling!

• DUS NIET FORCEREN MAAR

INFORMEREN