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Metabolic Surgery Abul Fazal Ali Khan Professor of Surgery
Allama Iqbal Medical College Lahore
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Dr. Abul Fazal Ali Khan Professor of Surgery Allama Iqbal
Medical College Lahore Who would have thought it? An operation
proves to be the most effective therapy for T2DM
Slide 4
Background Obesity 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 issue It demands urgent attention from the government,
healthcare systems and the medical community
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Objectives What is Metabolic Syndrome? Current and future
clinical applications of metabolic and diabetes surgery How I do
it. Recommendations for Family Physicians
Metabolic Surgery Treatment of metabolic derangements with
alterations of the gut anatomy.
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Questions & Skepticism Re: MS Is there a good medical
therapy which can prevent medical complications How does MS work.
Is it effective? Is it durable ? Is MS useful even if DM Relapses
In which subset of patients MS is most effective Does it work in
non obese patients Does MS prevent T2DM
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Is There A Good Medical Therapy Which Can Prevent Medical
Complications There is now good evidence that while good Med
Treatment does benefit : There are associated problems like: 1.
Compliance 2.Not effective in preventing certain complications
3.Cost of TM & unmitigated complications 4.Complications of
MT
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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.
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What is the Evidence to Support the Concept of Diabetes
Surgery?
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Who would have thought it? An operation proves to be the most
effective therapy for T2DM Surgery is more effective than MT in
treating T2DM 83% of type 2 diabetic subjects euglycaemic Pories
WJ, Swanson MS, MacDonald KG, et al Annals of Surgery
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Adams et al. 40% reduction in allcause mortality 56% reduction
in cardiovascular mortality 56% reduction in cancer mortality 90%
reduction in diabetesrelated mortality
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MS: Effects on CVS Risk Factors Gleysteen and colleagues first
reported the beneficial effects of GBP on diabetes, hypertension
and lipid profiles, SOS study confirmed these findings with both
GBP and LGB Regression of LVhypertrophy & reduction of carotid
artery intima-media thickness.
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Many -although not all - patients with type 2 diabetes are able
to reduce or stop their diabetes medication after surgery
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Subset of patients MS is most effective Subjects with shortest
duration diabetes diet-controlled with greatest weight loss
achieved Schauer et al.
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Effects of Bariatric Surgery on Type 2 DM Are These Durable?
Greenville series : 82.9% of 165 patients with T2DM remained in
remission after an average of 14 years following RYGB Schauer et al
: 83% of subjects undergoing LGBP achieved normal fasting plasma
glucose. Even if DM eventually relapses benefits of MS persist
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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/m 2 Rubino et al. Annals of Surgery,
2009
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Lap RYGBS for BMI 35: A tailored approach Ricardo Cohen, M.D.*,
Jose S. Pinheiro, M.D., Jose L. Correa, M.D.,Carl os A. Schiavon,
M.D. Surgery for Obesity and Related Diseases 2 (2006) 401404 37
Diabetic patients on two oral meds 81% EWL at two years All
patients had normalization of FBG off meds
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Does MS Prevent T2DM MS 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.
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851 bariatric surgery patients 852 matched controls 10 year
followup Significant reduction in incidence of diabetes in surgery
group (7% v. 24%, p< 0.001) at 10 years
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Some More Questions Which procedure is more effective? Is RYGBS
safe?
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Which procedure is more effective? Rates of Remission of
Diabetes Adjustable Gastric Banding RouxenY Gastric Bypass
Biliopancreatic Diversion 48% (Slow) 84% (Immediate)>95%
(Immediate)
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ASMBS Bariatric Surgery Center of Excellence Program A total of
235 patients met inclusion criteria Outcomes of MS to Treat
Diabetes Gastric 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
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Obesity Surgery-Mortality Risk Score Risk Factors 1.BMI50kg/m2
2.Male gender 3.Hypertension 4.Risk of PE 5.Age45y CategoryNo. of
factors Reported Mortality A 46-49% 0-10.2-0.3% B 48% 2-31.2-1.9% C
3-5% 4-52.4-7.6% DeMaria et al. SOARD 2007 DeMaria et al. Ann Surg
2007
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Recommendations Bariatric 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
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Conclusions Gastrointestinal bypass procedures can improve
diabetes by mechanisms beyond changes in food intake and body
weight. Anatomic modification of the GI tract contribute to the
amelio ration of T2DM through physiological mechanisms. It is a
durable therapy for all the components of the metabolic syndr ome.
Surgical therapy for Type 2 diabetes is highly effective in
patients with both severe and mild obesity.
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Thank You
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DuodenalJejunal Bypass Sleeve 12 patients 60 cm DJBS placed
endoscopically 23% excess weight loss at 12 weeks All 4 diabetic
patients had normal fasting glucose levels off medication during
DJBS therapy