Screening and Follow-up in Obese subjects Bariatric Sugery: When? Gabriella Garruti Department of Emergency and Organ Transplantation Section of Internal Medicine, Endocrinology , Andrology and Metabolic Diseases (Chairman: prof. F. Giorgino) Et lucem sed aliam reddit… Bari 27 novembre 2009
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Screening and Follow-up in Obese subjects Bariatric Sugery: When? Gabriella Garruti Department of Emergency and Organ Transplantation Section of Internal.
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Screening and Follow-up in Obese subjects Bariatric Sugery: When?
Gabriella Garruti Department of Emergency and Organ Transplantation
Section of Internal Medicine, Endocrinology , Andrology and Metabolic Diseases
(Chairman: prof. F. Giorgino)
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Bari 27 novembre 2009
Bari 27 novembre 2009
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What is Overweight?
Underweight <18.5 Kg/m2
Normal-weight 18.5 - 24.9 Kg/m2
Overweight 25.0 – 29.9 Kg/m2
Obesity category1st 30.0 – 34.9 Kg/m2
2nd 35.0 – 39.9 Kg/m2
3rd > 40.0 Kg/m2
BMIOverweight and Obesity: Overweight and Obesity:
The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. October 2000, NIH Pub. No.00-4084 modified by Garruti 2008
+
BMI Category (kg/mBMI Category (kg/m22))
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13.02.05
Gastric Bypass (Roux-en-Y)
Only when Lifestyle is unhealthyOnly when Lifestyle is unhealthy
Gastric banding
Bariatric surgery
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The operations employed for morbid obesity are not to be confused with plastic surgery
Real risk comes with each surgical procedure
Prospective patients should also be thoroughly convinced that they have exhausted all other reasonable avenues of weight loss before selecting surgery
The operations employed for morbid obesity are not to be confused with plastic surgery
Real risk comes with each surgical procedure
Prospective patients should also be thoroughly convinced that they have exhausted all other reasonable avenues of weight loss before selecting surgery
Bariatric surgery: what is?
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Indications1. BMI >40 kg/m2 or
BMI 35–39.9 kg/m2 and life-threatening cardiopulmonary disease, severe DIABETES, orlifestyle impairment
2. Failure to achieve WL with Medical Treatment
Controintraindications1. History of noncompliance with medical care2. Psychiatric illnesses: personality disorder, uncontrolled depression, suicidal
ideation, substance abuse3. elevated ASA risk
NIH Consensus Development Panel. Ann Intern Med 1991;115:956.
Bariatric Surgery: When ?
EAES /ASBS 2005
BMI 30-35 kg/m2 & life-threatening comorbidities
Sauerland et al. Surg Endosc 19:200
Buchwald et al. J Am Coll Surg 200:593
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Obesità di durata superiore a 5 anniObesità di durata superiore a 5 anni BMI BMI >> 40Kg/m 40Kg/m2 2 o BMI o BMI >>35Kg/m35Kg/m22 con comorbidità* con comorbidità* Età: da 18-65 anniEtà: da 18-65 anni Fallimento Tx medica (dietetica, farmacologica, Fallimento Tx medica (dietetica, farmacologica,
comportamentale) per almeno 1 annocomportamentale) per almeno 1 anno Assenza di cause endocrine di obesità Assenza di cause endocrine di obesità Rischio anestesiologico max < ASA 2Rischio anestesiologico max < ASA 2 Assenza di malattie psichiatriche e/o disturbi del Assenza di malattie psichiatriche e/o disturbi del
comportamento alimentare (DCA). comportamento alimentare (DCA). Compliance del paziente (follow-up)Compliance del paziente (follow-up)
NIH 1998- LIGIO 1999 EAES /ASBS 2005
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Indicazioni
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BMI BMI >>35 con 35 con comorbilità* comorbilità*
OSAS/PickwickOSAS/Pickwick Ipertensione arteriosa Ipertensione arteriosa Scompenso cardiacoScompenso cardiaco Diabete mellito tipo 2Diabete mellito tipo 2 OsteoartrosiOsteoartrosi ColelitiasiColelitiasi DislipidemieDislipidemie
Insuff. venosa cronica arti inferiori Insuff. venosa cronica arti inferiori Impotenza/Irregolarità Impotenza/Irregolarità
Valutazione clinica e strumentale prima della chirurgia
Esami ematochimici Esami ematochimici Inquadramento endocrino-metabolicoInquadramento endocrino-metabolico* e genetico* e genetico Rx torace Rx torace Ecografia addome superiore e inferioreEcografia addome superiore e inferiore Doppler venoso arti inferioriDoppler venoso arti inferiori Emogasanalisi, spirometria, polisonnografiaEmogasanalisi, spirometria, polisonnografia Inquadramento psicologico-nutrizionale (psichiatra e Inquadramento psicologico-nutrizionale (psichiatra e
dietisti)dietisti) Rx baritato (+Trendelenburg per ernia iatale)Rx baritato (+Trendelenburg per ernia iatale) EGDS + biopsia per infezione H. pyloriEGDS + biopsia per infezione H. pylori Consulenza cardio-anestesiologicaConsulenza cardio-anestesiologica
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Inquadramento endocrino-Inquadramento endocrino-metabolico e nutrizionalemetabolico e nutrizionale
Indagine alimentare, variabili antropometricheIndagine alimentare, variabili antropometriche Indici nutrizionaliIndici nutrizionali HOMA/ OGTT per glicemia e insulinemiaHOMA/ OGTT per glicemia e insulinemia Pattern ormonali: Pattern ormonali:
All foods have a certain number of calories within a given amount (volume)Foods with high energy density have a large number of calories in a small volumeAlternatively foods with low energy density provide a larger portion size with a fewer number of calories.
Dieta a b.i.g 1000-1200 Kcal/Die Attività fisica (v. piramide attività fisica)
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Maria A. Lucafo’ & Giovanna MallardiMaria A. Lucafo’ & Giovanna Mallardi
X X
Life-style modifications :
Anti-atherogenic Diet
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Suggested Energy Deficit based on Initial BMI
Initial BMI
(Kg/m2)
Suggested Energy Intake
(kcal/d)
Approximate Initial Energy Deficit
(kcal/d)
25-29.925-29.9 ?? 500500
30-34.930-34.9 ?? 500500
35-39.935-39.9 ?? 500-1000500-1000
>>4040 ?? 500-1000500-1000
>>50 50 ?? ??National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults – The Evidence Report. Obes Res. 1998;6(suppl 2):51S-209S
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Obrien et al. Ann Intern Med. 2006
Wei
ght L
oss,
%
Baseline
Surgical (LapBand)
Nonsurgical
*VLCD, behavioral modification, and pharmacotherapy
6 mo 12 mo 18 mo 24 mo
Weight Loss after Bariatric Surgery Weight Loss after Bariatric Surgery or Mor Medical edical TTherapyherapy**
Excess Weight Excess Weight Loss (EWL) and Compliance to (EWL) and Compliance to CComprehensive omprehensive MMedical edical TTherapyherapy* * after Gastric Bandingafter Gastric Banding
lowhigh
low high
Lucafo’ MA, Rotelli MT, De Tullio A. 2008 unpublished
Complications after Gastric Bypass The bypassed portion of intestine is where the majority of calcium and iron absorption takes place
LONG-TERM COMPLICATIONS
anemia osteoporosis
Other clinically important deficiencies
Vitamin B 1 (thiamine) Vitamin B 12 lack of gastric intrinsic factor
(GIF)
Lifelong follow-up with a daily multi-vitamins and mineral supplementation are strongly recommended to prevent nutritional complications
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GBP & Dumping syndromeGastric bypass operations may also cause "dumping syndrome" food or liquids travel too rapidly through the small intestine (sweets are often the culprit) Dumping symptoms include
nausea weakness sweating faintness diarrhea Symptoms dissipate after the patient rests???
Regulation of Food IntakeRegulation of Food Intake
Schwartz et al. 2000 Nature
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ANP
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Adipose Tissue depots are a marvelous source of adipocyte
precursors stem cells
Any surgical procedureAny surgical procedure normalizes hyperglycemianormalizes hyperglycemia restores insulin sensitivityrestores insulin sensitivity prevents progression from IGT to DMprevents progression from IGT to DM reduces mortality from DMreduces mortality from DMGastric bypass and Biliopancreatic diversionGastric bypass and Biliopancreatic diversion restores euglycemia and normal insulin restores euglycemia and normal insulin long before any significant weight losslong before any significant weight loss
Changes in hormones secretion from the GI tract
Bariatric surgery and GlycaemiaBariatric surgery and GlycaemiaEt lucem sed aliam reddit…
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Bariatric Surgery in DM2:When?
““Should surgeons treat diabetes in severely obese people ?”Should surgeons treat diabetes in severely obese people ?”
J.H. Pinkney, SjJ.H. Pinkney, Sjööstrströöm C.D., Gale E.A.M. Lancet 2001 357: 1357m C.D., Gale E.A.M. Lancet 2001 357: 1357..
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Rubino et al 2004 Ann Surg 240(2): 236–242
Incretins and anti-incretins in DM2Et lucem sed aliam reddit…
Rubino et al. Ann Surg. 2004; 240(2): 236–242
Incretins and anti-incretins in DM2 after GBP
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[A] Simple gastro-jejunostomy
Enhanced delivery of nutrients to the hindgut without excluding
nutrient flow through the proximal intestine
No improvement of Diabetes in diabetic GK animals.
[B] DJB creates similar shortcuts of
nutrients as in gastro-jejunostomy
- includes the exclusion of the proximal intestine from the flow
of nutrients- improves glucose tolerance and
fasting glycemia in diabetic GK rats
Exclusion of the duodenum is critical for the effect on diabetes
• Swiss pharmaceutical firm, Novartis, demonstrated in clinical studies that its investigational drug vildagliptin improves the function of pancreatic islets in both animals and humans.
• Vildagliptin, a novel investigational Incretin Enhancer, previously known as LAF237, inhibits DPP-4, resulting in an increase of circulating levels of GLP-1, a crucial incretin hormone.
Gastric inhibitory polypeptide (GIP), also known as the glucose-dependent insulinotropic peptide
Drucker, D. J. J. Clin. Invest. 2007;117:24-32
Dipeptidyl peptidase IV (DPP4) enzyme that breaks down gut peptides especially GLP-1