Javed Iqbal,Javed Iqbal, FCPS, FRCS FCPS, FRCS

Professor of SurgeryProfessor of Surgery

Quaid-e-Azam Medical College, Quaid-e-Azam Medical College, Bahawalpur, PakistanBahawalpur, Pakistan

What's new in surgery What's new in surgery for the Diabeticsfor the Diabetics

““240 million people worldwide are living with 240 million people worldwide are living with diabetes;diabetes;

380 million by 2025”380 million by 2025” ““It kills one person every 10 seconds”It kills one person every 10 seconds”

The usual domain of the surgeons in Diabetes

Diabetic foot Infections.

Neuropathies. Vascular narrowing

The Surgical Cure of Diabetes

The Key Questions.

Is there a surgical cure?

Can we cut out Diabetes?

Background.

The Historical Perspectives of gastrointestinal anastomosis.

The Rebirth of Bariatric surgery

Metabolic SurgeryMetabolic Surgery

Treatment of metabolic derangements withTreatment of metabolic derangements with

alterations of the gut anatomyalterations of the gut anatomy

remission of diabetesremission of diabetes

The Evidence The Evidence

There is overwhelming evidence indicating that several types of There is overwhelming evidence indicating that several types of bariatric operations promote profound weight loss and cause complete bariatric operations promote profound weight loss and cause complete remission of type 2 diabetes. remission of type 2 diabetes.

Pories and Swanson, Ann surg 222:339-350

Sjostrom and Larsonet al NEJM 357: 741-752

Association of Diabetes and Obesity

DIABETES + OBESITY = DIABESITY

DIABETES OBESITY 90%

WEIGHT LOSS

T 2 D

WEIGHT GAIN T 2 D

How can we correct it ?

Dietary control Lifestyle changes.

Medical management

Why Surgery ? Non Surgical methods of weight loss are

associated with higher failure rates.

NIH consensus Panel 1991 recommendation:

“Surgery is the only long term sustainable weight loss method”

*American Diabetic association has also recommended weight loss surgery in Diabetics with BMI 35 or above.

*ADA clinical practice recommendations 2008

Benefits of surgical weight loss(morbidity and mortality improvement)

Weight loss is associated with resolution of co morbidities. DM=>80% Hypertension=>60% Hyperlipidemia=>60-95% Obstructive Sleep Apnoea => 80-80% Pories and Swanson, Ann surg 222:339-350

Swedish obese subjects study shows clear benefit of survival for surgery patients from cardiovascular events.(24%)

Sjostrom and Larsonet al NEJM 357: 741-752

BARIATRIC SURGERY AND DIABETES

Bariatric patients would have a sustained weight loss and thus would have a complete resolution of diabetes

T2D even if are not obese still would achieve resolution after SG or GBP

Schauer&Burguera AnnalsSurgery 2003;238:467-84

Gann ss& Horgensen ANZ J Surgery 2007;77:958-62

BARIATRIC SURGERY

Gastric BandingGastric BandingSleeve GastrectomySleeve GastrectomyGastro-Biliary BypassGastro-Biliary Bypass

Bariatric Surgeries

Mechanisms of Diabetes ResolutionMechanisms of Diabetes Resolutionafter Gastrointestinal Bypassafter Gastrointestinal Bypass

SurgerySurgery

Enhanced secretion of something good forglucose homeostasis ?

Reduced production of something bad for glucosehomeostasis ?

What is The Mechanism?

Sudden reduction in caloric intake Reduced Ghrelin Levels Increased production of bile acids

BA + TGR 5 c AMP dependant THAE Increased Energy Expenditure

The QueryThe Query

Weight loss surgery patients experience a Weight loss surgery patients experience a reduction in or resolution of diabetic reduction in or resolution of diabetic symptoms immediately following surgery, symptoms immediately following surgery, before weight loss has had a chance to take before weight loss has had a chance to take place. place.

THE ANSWER

The Immediate control The Entero insular Axis

The Francesco Rubino Experiment. The Foregut Hypothesis

The Hindgut Hypothesis The role of GLP-I& GIP

The exclusion of the The exclusion of the duodenal nutrient duodenal nutrient passage may offset anpassage may offset anabnormality of abnormality of gastrointestinalgastrointestinalphysiology responsible physiology responsible for insulin resistance for insulin resistance and type 2 diabetesand type 2 diabetes

Nutrients reach the distal Nutrients reach the distal ileum within 5 min of the ileum within 5 min of the ingestion of food and this ingestion of food and this stimulates the secretion of stimulates the secretion of GLP1 by L cellsGLP1 by L cellslocated in this arealocated in this area

The Entero Insular Axis

Anti-Incretins

IncretinsGLP-1

GIP

PYY

Insulin Production

b-cell Neogenesis

Statiety.

DPP-4

INCREASED INSULIN AVAILABILTY

THE ANSWER

Long Term ResolutionDecreased adipose tissue leads to

modulation of the Adipo Insular Axis

Adipocytokines.

Leptin.Adiponectin.

Resistin.Decreased Insulin Resistance

The Net Effect

Decreased insulin destruction Increased Insulin Production

Decreased Insulin Resistance

WHO WOULD HAVE THOUGHT IT?

An Operation Can be The most effective Therapy For Adult Onset

Diabetes Mellitus

Where do we stand?Where do we stand?

Workshop in RomeWorkshop in Rome Workshop with Mufazzal LakhdawalaWorkshop with Mufazzal Lakhdawala Spent some time with Prof. Mumtaz MaherSpent some time with Prof. Mumtaz Maher Extensive hands of course with Prof Karl MillerExtensive hands of course with Prof Karl Miller Acquired all necessary equipmentsAcquired all necessary equipments Extensive training hand-swen gut surgeryExtensive training hand-swen gut surgery Developed a teamDeveloped a team Regularly performing sleeve gastrectomyRegularly performing sleeve gastrectomy

How much it costs?How much it costs?

Nothing is more costly than a healthy Nothing is more costly than a healthy lifelife