1 TERAPIA CHIRURGICA DELL’OBESITA’: SCELTA DELL’INTERVENTO Luca Busetto Servizio Terapia Medica e Chirurgica dell’Obesità Università degli Studi di Padova “GESTIONE TERAPEUTICA DEL PAZIENTE OBESO” Verona, 25-26 gennaio 2008 Indications to bariatric surgery Indications to bariatric surgery (NIH Consensus Development Conference Statement) (NIH Consensus Development Conference Statement) Bethesda, March 25 Bethesda, March 25- 27, 1991. 27, 1991. BMI > 40 kg/m 2 (BMI > 35 kg/m 2 if complicated obesity). Age : 18-60 years. Longstanding obesity (> 5 years). Previous failure of medical therapy. Able to participate to long-term follow-up. Am J Clin Nutr 1992;55:615S
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Luca Busetto Servizio Terapia Medica e Chirurgica dell’Obesità
Università degli Studi di Padova
“GESTIONE TERAPEUTICA DEL PAZIENTE OBESO”Verona, 25-26 gennaio 2008
Indications to bariatric surgery Indications to bariatric surgery (NIH Consensus Development Conference Statement) (NIH Consensus Development Conference Statement)
Bethesda, March 25Bethesda, March 25--27, 1991.27, 1991.
� Assigning a patient to a particular bariatric procedure:
“At this moment, there is insufficient evidence-based data to suggest how to assign a patient to any particular bariatric procedure”.
Int J Obesity 2007;31:569-77
6
BARIATRIC SURGERY
Individualised Treatment
Sequential Treatment
• Prader-Willi S. →→→→ Malabsorption
• MC4R variants →→→→ Gastric By-pas
• Sweet Eating →→→→ Gastric By-pass
• Binge Eating →→→→ Gastric By-pass
• Type 2 diabetes →→→→ Gastric By-pass
• Hyperlipidemia →→→→ Malabsorption
• Super-obesity →→→→ Gastric By-pass
or Malabsorption
BARIATRIC SURGERY Individualised Treatment
7
• Lower weight loss in VBG patients (Sugerman 1987). • No differences in weight loss in the SOS study (Lindroos 1996).
Individualised Treatment:Sweet Eaters
0,5
1
1,5
SUCCESS FAILURE REGAIN
Rela
tiv
e R
isk
Busetto et al. Obes Surg 2002:12:83
“Grazing: A High-Risk Behaviour”. Saunders R. Obes Surg 2004;14:98-102.
♦ Patients with disturbed eating patterns (BED or “grazing”) identified before surgery.→ “Many who had been binge eaters before surgery reported a shift to “grazing”
Although this eating was often perceived as a binge, it involved the intake ofsmaller amount of food”.
Individualised Treatment:Binge Eaters
0
10
20
30
40
50
60
0 1 2 3 4 5
anni
%E
WL
Busetto et al. Obes Surg 2005;15:195
26,2 25,4
10,0
0,8
26,1
17,7
4,81,2
0
20
STENOSIS POUCH
DILATATION
ESOPHAGEAL
DILATATION
EROSION
% o
f p
ati
en
ts
BED NO - BED
8
Remission of type II diabetes after gastric bypassRemission of type II diabetes after gastric bypass
% Changes of AT volumes in 6 morbid obese women before and 6 months after LAGB.
Busetto et al. Int J Obes 2000;24:60
13
Reduction of Liver Volume in the early weight loss period after LAGB.
1,79 1,54 1,51
1
1,5
2
Liv
er v
olu
me
(L)
BEFORE 2 MONTHS 6 MONTHSBEFORE 2 MONTHS 6 MONTHS
**
Busetto et al. Obes Res 2002;10:408
+ 10 cm+ 10 cm
+ 10 cm+ 10 cm + 20 cm+ 20 cm
+ 20 cm+ 20 cm
14
Oxygen Saturation in 17 super-obese patients before and after BIB™ Intragastric Balloon.
88
90
92
94
96
98
100
orthostatic clinostatic
%
**
Busetto et al. Chest 2005;128:618
0
20
40
60
80
BMI 55,8 >>> 48,6 kg/m2Events/h
***
AHI in 17 AHI in 17 morbidmorbid obese obese patientspatients withwith OSA OSA beforebefore and after and after intraintra--gastricgastric balloonballoon. .
Busetto et al. Chest 2005;128:618
***
15
0
0,5
1
1,5
2
2,5
3
OPJ PHAR GLOT
cro
ss-s
ec
tio
na
l a
rea
(cm
2)
*
***
††
†**
*
*
Busetto et al. Chest 2005;128:618
Pharyngeal area in 17 morbid obese patientswith OSA before and after BIB and in 20 controls.
Sequential treatment: 2° step procedure
Busetto et al. Obes Surg 2002;12:83
16
Remission of diabetes, dyslipidaemia and hypertension after LAGB, according to quartiles of percent weight loss.
0
20
40
60
80
100
DM H-CT L-HDL H-TG HPT
I (0.7-11.0%)
II (11,0-16,8%)
III (16,8-24,5%)
IV (24,5-56,8%)
** **
** ****
**
Busetto et al. Obes Res 2004;12:1256
AHI in 25 obese patients withOSA before and after LAGB.
Dixon et al. Int J Obes 2005;29:1048
0
20
40
60
80
100
BMI 52,7 >>> 37,2 kg/m2Events/h
***
0
20
40
60
80
BMI 55,8 >>> 48,6 kg/m2Events/h
******
AHI in 17 obese patients withOSA before and after BIB.
Busetto et al. Chest 2005;128:618
17
Comparative long-term mortality after LAGB versus non surgical controls.
Busetto et al. SOARD 2007; 3:496
Adj. HR of death in LAGB group: 0.36 (95%CI: 0.16-0.79)