Javed Iqbal, Javed Iqbal, FCPS, FRCS FCPS, FRCS Professor of Surgery Professor of Surgery Quaid-e-Azam Medical Quaid-e-Azam Medical College, Bahawalpur, College, Bahawalpur, Pakistan Pakistan
Jun 12, 2015
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