Metabolic Surgery compared to Bariatric Surgery

Dr PRAVIN JOHN MS

Dr John Thanakumar MS,MNAMS, FRCS

Dept of Advanced Laparoscopy & Bariatric SurgeryANURAG HOSPITAL, Coimbatore.

•www.anuraghospital.com

Second only to smoking as a preventable cause of death

Major morbidity and mortality

OBESITY

Global Problem - Obesity

Different BMI for Asians and West

Obesity has increased in India in 21 century, with morbid obesity affecting 5% of population

Indians are genetically susceptible to weight accumulation especially around the waist

Obesity in India

NFHS 2007

Obesity statistics Indian States

Impact of Obesity among the Ethnic groups

Abdominal obesity and girth

Decreased high-density lipoprotein

Increased insulin resistance

Increased diabetic state

Increased high blood pressure

Metabolic Syndrome

Diabetes mellitus(Type 2)

Obstructive sleep apnea (OSA)

Coronary ischemic disease

Hypertension

Some cancers

Osteoarthritis

Also early death

Diseases associated with obesity

More in abdominal obesity More in advanced with age( 60 years)

Men commonly than womenSouth Asians appear more susceptible

Metabolic syndrome on drugs e.g. steroids, antidepressants and antipsychotic agents.

Metabolic Syndrome

Common

Metabolic SurgeryWhy the nomenclature?

• Bariatric Surgery is involved with weight loss

• Results and mechanism went beyond weight loss

• Hence the term Metabolic surgery

• 2002 Primary intent to cure Type 2 DM (T2DM)

Francesco Rubino

Term - Metabolic Surgery

• Acceptance after a landmark “Diabetes Surgery Summit” in 2007.

• 2 world congresses dedicated subject and statements of relevant organizations, notably the International Diabetes

Federation in 2011.

Not for Low BMIs

“Metabolic” and “diabetes surgery”, however, incorrectly referred to as a surgical approach to treat diabetes in low

BMI patients, as a set of novel and yet experimental operations.

Differences between bariatric & metabolic surgery

Metabolic surgical patients have a more balanced male/female ratio, showed higher incidence of type 2

diabetes, hypertension, dyslipidemia, higher cardiovascular risk & established cardiovascular disease at onset

Metabolic Surgery is defined as “a set of gastrointestinal operations used with the intent to treat diabetes ("diabetes

surgery") and metabolic dysfunctions (which include obesity)”

• Surgery to treat T2DM in patients with BMI above 35 should be considered “metabolic/diabetes surgery” not

“bariatric surgery”.

Definition of Metabolic Surgery

T2DM & OBESITY

• The primary risk factor for Type 2 Diabetes Mellitus is obesity

• 90% of all patients with type 2 diabetes are overweight or obese.

• Risk of diabetes increases about 42-fold in men as the BMI increases from <23 kg/m2 to >35 kg/m2 & 93-fold in women as BMI increases

from <22 kg/m2 to >35 kg/m2 .

Diabetes Care 1994N Engl J Med 2001

Diabetes improved in more than 85% of patients and cured in more than 75% overall

Cholesterol -70% improved after surgery

Hypertension cured in 60% of patients and improved in more than 18%.

Sleep Apnoea cured in 85.7% of surgical patients.

Benefits of Obesity Surgery

Improvement with fatty infiltration of liver

Improvement in respiratory function and asthmatic symptoms

Reversal of mild cardiomyopathy of obesity

Improvement in joint pain and mobility

Other Advantages of Obesity Surgery

Severe uncontrolled heart disease

Uncontrolled psychiatric disorder, Low IQ

Inability to follow instructions

Drug abuse, and cancer

Who cannot have Obesity surgery?

LaparoscopicAdjustable Gastric Band

Stomach

Laparoscopic Band

Adjustable Gastric Band

Common in Europe, Australia& S.America.

Small gastric pouch(15 mL).

Weight loss is about 50-60% of excess body weight in 2 years.

Injury of the stomach or esophagus

Bleeding

Food intolerance (most common)

Wound infection

Pneumonia

Early Complications of Band

Food intolerance or noncompliance to band (13%)

Band slippage (stomach prolapse) (2.2-8%)

Pouch dilatation

Band erosion into the stomach

Port complications

Re operation rate (2-41%)

Esophageal dilatation

Failure to lose weight

Port infection, band infection

Leakage of the balloon or tubing

Mortality rate (0.5%; 0% in some series)

Late Complications of Gastric Band

Sleeve Gastrectomy

Shape of stomachafter surgery

Sleeve gastrectomy employs subtotal gastric resection to reduce stomach to 15-20% of its original size

The mechanism related to gastric restriction or to Grehlin changes

Initially first of 2-stage op;with simplicity & favorable outcomes

Now a primary, stand-alone procedure.

Wt loss 33-83% of excess weight. Physiologic operation

Laparoscopic Sleeve Gastrectomy

Laparoscopic Roux en Y Gastric Bypass

Gastric pouch ( 20 ml) and small outlet cause sensation of satiety & grehlin.

Malabsorption is adjusted by length of the alimentary and bilio pancreatic limbs.

The malabsorptive element bypasses the distal stomach, duodenum, and some of the jejunum.

The standard Roux limb is 75cm. Long gastric bypass is150cm and the last is a very long-limb (distal gastric bypass).

Lap Roux en Y Gastric Bypass

Weight loss 65-70% of excess body weight

Long-limb bypasses give comparable weight reductions in super obese (BMI >50 kg/m2) pts.

Weight loss generally levels off in 1-2 years.

Result of Gastric Bypass

Anastomotic leak (1-3%)

Pulmonary embolism, deep vein thrombosis (<1%)

Wound infection (more common with open approach)

Gastrointestinal hemorrhage, bleeding (0.5-2%)

Respiratory insufficiency, pneumonia

Acute distention of the distal stomach

Early Complications of Roux en Y Gastric Bypass

Stomal stenosis, most common (20%)Bowel obstruction, small bowel obstruction (1%)

Internal herniaCholelithiasis

Micronutrient deficienciesMarginal ulcer

Staple line disruptionVentral hernia formation

Late Complications of Gastric Bypass

Marginal Ulcer

Operative (30-day) mortality is about 0.5%.

Less the experience, more the complications

Compared with open procedures, laparoscopy has a higher rate of intra-abdominal complications

Mortality of Gastric Bypass

Mini Gastric Bypass

Robert Ruthledge, 2009

Meta analysis- DM +Obesity

135,246 pts in 621 studies

Mean age 40.2 yrs BMI 47.9

10.5% bariatric procedures

78.1% DM improved

86.6% DM resolved

Buchwald et al 2009

Predictors for Resolution of T2DM in Obesity Surgery

T2DM < 5 years 95%

T2DM 6-10 yrs 74%

T2DM >10 yrs 54%

BMI > 37

Hb A1c >7.5

C peptide > 3 ng/mL

Buchwald et al 2009

Dixon et al 2008

Dangers of Obesity

• CAD mortality 3 times > in the obese

• Cancer higher in the obese.

• CAD and Cancer mortality is significantly reduced in the surgical group

Swedish Obese Subjects Study, Lancet, 2009

RYGB and MGB compared

RYGB- Gastric BypassMGB - Mini Gastric Bypass

RYGB- Gastric BypassMGB - Mini Gastric Bypass

RYGB vs MGB Selection of cases

Lap RYGB vs MGB for morbid obesity, Ann Surg, 2005RYGB- Gastric BypassMGB - Mini Gastric Bypass

RYGB and MGB Post Surgery Results

Lap RYGB vs MGB for morbid obesity, Ann Surg, 2005RYGB- Gastric BypassMGB - Mini Gastric Bypass

LSG vs RYGB on Co morbidities

50 Indian patients on each arm

Resolution of co morbidities equal on both lap sleeve and RYGB - T2DM,HT, dyslipedemias, sleep apneas, jt pains

Mild increase of GERD in LSV

Asian studies better results with LSG

Lakdawala, Obes Surg, 2010LSG-Lap Sleeve GastrectomyRYGB- Gastric Bypass

DM resolution in RYGB, SG & Band

Diabetic resolution 81.2 % for RYGB

Diabetic resolution 80.9 % for SG

Diabetic resolution 60.8 % for Banding

Greatest improvement in Blood sugars occurred in SG group

60 pts with T2DM morbidityAbbatini, Surg Endos 2010

LSG-Lap Sleeve GastrectomyRYGB- Gastric Bypass

Potential Benefits of Single incision laparoscopic surgery

• Superior cosmesis

• Possibly shorter operating time

• Less Pain

• ? Lower costs

• Shortened time to full recovery

Evangelos C, Surg Endos 2010

Evangelos C, Surg Endos 2010

LONGER Andrew Chow, JAMA surgery, 2010

Problems of Single incision laparoscopic surgery

Loss of triangulation

Crossing of instruments

Larger access port

Not for adhesions or redo surgery

Hernia of the port site

Future

• Careful selection in choice and method of Metabolic Surgery

• Multiple studies needed for comparison of SILS to standard laparoscopic surgery

ANURAG HOSPITAL,

8, Krishna Nagar

Sowripalayam Main Road

Coimbatore - 641028.

www.anuraghospital.com

Tel: 0422 6587871

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