Current Bariatric & Metabolic Surgery Current Bariatric & Metabolic Surgery

HongHongchanchan Lee M.DLee M.D, Ph.D, Ph.D

Division of Laparoscopic & Bariatric Surgery Division of Laparoscopic & Bariatric Surgery Department of Surgery, Department of Surgery, St. MarySt. Mary’’s Hospital, College of Medicine, s Hospital, College of Medicine,

The Catholic University of KoreaThe Catholic University of Korea

TopicTopic•Global Burden of in Morbid obese & Metabolic syndrome

•Basic conceptsSeveral bariatric procedures & GI Hormones

•Mechanisms of Surgical Control of DiabetesCaloric Intake/Weight lossThe role of incretinileal breakUpper intestinal hypothesisAnimal and Surgical Models

Global Burden of in MGlobal Burden of in Morbid obeseorbid obese &&Metabolic syndromeMetabolic syndrome

Major public health problem Major public health problem worldwide worldwide Affects Affects 25% of industrialized world25% of industrialized worldAmerican statistics:American statistics:–– 55% (34 Million) adults are overweight (BMI > 25)55% (34 Million) adults are overweight (BMI > 25)–– 25% of children are overweight25% of children are overweight–– 55--11 million are morbidly obese 11 million are morbidly obese –– 6% of health care expenditures ($238 Billion / 6% of health care expenditures ($238 Billion /

year)year)–– 300,000 deaths annually300,000 deaths annually

JAMA

Obesity in Korea : EpidemiologyObesity in Korea : Epidemiology((Korea National Health and Nutrition Examination Survey III, 1995Korea National Health and Nutrition Examination Survey III, 1995--

2005)2005)Prevalence of obesity in adults: 32.4%Prevalence of obesity in adults: 32.4%Prevalence of obesity in children: 10.2%Prevalence of obesity in children: 10.2%Prevalence of obesity in adolescents: 18%Prevalence of obesity in adolescents: 18%Socioeconomic burden associated with obesity: 4.9% of Socioeconomic burden associated with obesity: 4.9% of total health care expendituretotal health care expenditure

10

15

20

25

30

35

40

1995 1998 2001 2005

Year

%

Male

Female

Total

Obesity (BMI>25 kg/m2) in Korean adults

Treatment of ObesityTreatment of Obesity

Medical treatment ineffective BMI>35Medical treatment ineffective BMI>35Medical treatment ineffective >10kg WLMedical treatment ineffective >10kg WL1992 NIH consensus1992 NIH consensus–– Surgery the only effective method of Surgery the only effective method of

sustainable weight loss sustainable weight loss BMI>40BMI>40BMI>35 with associated coBMI>35 with associated co--morbiditiesmorbidities

for Asian for Asian

1) obese patients with their BMI>37 1) obese patients with their BMI>37 2) obese patients with their BMI>32 in the presence of 2) obese patients with their BMI>32 in the presence of diabetes or two significant obesity related comorbidities diabetes or two significant obesity related comorbidities

3) have been unable to lose or maintain weight loss by 3) have been unable to lose or maintain weight loss by dietary or medical measures dietary or medical measures

4) age of patient > 18 years and < 65 years4) age of patient > 18 years and < 65 years

2005 Asia Pacific Bariatric Surgery Group(APBSG) 2005 Asia Pacific Bariatric Surgery Group(APBSG)

Number of Number of bariatricbariatric surgery performed in surgery performed in Korea is not enough to satisfy the Korea is not enough to satisfy the requirement of obese population from requirement of obese population from 2003 to present2003 to presentMisconception Misconception Patient & doctorPatient & doctor’’s educations educationInsurance reimbursement Insurance reimbursement

Wittgrove AC,Clark GW. Obes Surg 2000.

ObesityObesity

major independent risk factor of the development & major independent risk factor of the development & the prevalence of Type 2 DMthe prevalence of Type 2 DM

total of 80% of individuals with Type 2 DM are total of 80% of individuals with Type 2 DM are obese(30% in Korean) and 50% are morbid obeseobese(30% in Korean) and 50% are morbid obese

BloomgardenBloomgarden ZT Diabetes Care 2000ZT Diabetes Care 2000

McKeigue PM,et al.Lancet 1991;16: 382-6.Deurenberg M, et al.Nutr Rev 2003;61: S80-7.Misra A, et al. Int J Obes Relat Metab Disord 2004;28: 1217-26.

Basic conceptsBasic concepts

Several Several bariatricbariatric & metabolic surgery & metabolic surgery proceduresprocedures

GI HormoneGI Hormone

Bariatric Surgery

Restrictive Mixed Malabsorptive

Several operative procedures are performed for Several operative procedures are performed for treatment of morbid obesitytreatment of morbid obesity

Factors that may play a role in Factors that may play a role in decisiondecision--making processmaking process

AgeAgeMedical HistoryMedical HistorySurgical HistorySurgical HistoryBMIBMIPsychological ProfilePsychological ProfileNutritional ProfileNutritional ProfileLifestyleLifestylePersonal choicePersonal choice

Laparoscopic Sleeve Laparoscopic Sleeve GastrectomyGastrectomy

RestrictiveRestrictiveReduction of the size of Reduction of the size of the stomach, to about the stomach, to about 100 100 -- 120 cc in volume 120 cc in volume Preserves the Preserves the pylorus,actspylorus,acts as "natures as "natures band" band" 45 to 55% EWL 45 to 55% EWL Need long term followNeed long term follow--upup

Vertical banded gastroplasty Minigastric bypass

BariatricBariatric InstrumentsInstruments

As stated clearly in the SAGES & ASBMS As stated clearly in the SAGES & ASBMS guidelines: for surgical guidelines: for surgical traetmenttraetment of Morbid of Morbid Obesity: the Obesity: the multidisciplinary multidisciplinary approachapproachincludes medical includes medical mangementmangement of coof co--morbidities, dietary instruction, exercise morbidities, dietary instruction, exercise training, specialized nursing care & training, specialized nursing care & psychological assistance as needed.psychological assistance as needed.

Total Bariatric cases from April 2006-Sep 2007 Data was reported at ACS 2008(SLRHC)

LRYGBP(N=345, 79.3%)LRYGBP(N=345, 79.3%) LAGB(N=90, 20.7%)LAGB(N=90, 20.7%)

Mean Mean age(yrage(yr)) 3939 4545

Men BMI(kg/m2)Men BMI(kg/m2) 5050 4646

Female: MaleFemale: Male 305:40305:40 77:1377:13

Mean %EWL at 6monthsMean %EWL at 6months 64%64% 28%28%

Post op complicationsPost op complications 30cases(8.6%)30cases(8.6%)leak 3, stricture 7, adhesion 2, leak 3, stricture 7, adhesion 2, SBO 6, marginal ulcer 1, SBO 6, marginal ulcer 1, bleeding 1, uterine bleeding 1, bleeding 1, uterine bleeding 1, UTI 1, DVT 1, pleural effusion UTI 1, DVT 1, pleural effusion 1, malnutrition 1, GE 2, 1, malnutrition 1, GE 2, subphrenicsubphrenic abscess 1, abscess 1, dehydration 1 dehydration 1

3cases(3.3%)3cases(3.3%)improper port positionimproper port position

Readmission rateReadmission rate 26cases(7.5%)26cases(7.5%) 1 case(1.1%)1 case(1.1%)

MortalityMortality 00 00

Obesity Surgery 2008 acceptedObesity Surgery 2008 accepted

Initial evaluation of Laparoscopic RouxInitial evaluation of Laparoscopic Roux--enen--Y Gastric Bypass Y Gastric Bypass and Adjustable Gastric banding in Koreaand Adjustable Gastric banding in Korea: a single institution study: a single institution study

11Hongchan Hongchan Lee,M.DLee,M.D., ., 11Dohyoung Dohyoung Kim,M.DKim,M.D., ., 11Sangkuon Sangkuon Lee,M.DLee,M.D., ., 22Namkwan Namkwan Woo,M.DWoo,M.D., ., 11Eungkook Kim, M.D. Eungkook Kim, M.D.

11Division of Laparoscopic & Division of Laparoscopic & BariatricBariatric Surgery, Surgery, Department of Surgery St. MaryDepartment of Surgery St. Mary’’s Hospital, College of Medicines Hospital, College of Medicine22Division of Gastroenterology, Department of Internal MedicineDivision of Gastroenterology, Department of Internal MedicineKang Nam St. MaryKang Nam St. Mary’’s Hospital, College of Medicines Hospital, College of MedicineThe Catholic University of Korea Seoul, Korea The Catholic University of Korea Seoul, Korea

Patients characteristics (Mean ± SD) of Korean 84 bariatric cases

Characteristics LRYGBP (N=31) LAGB(N=53)

GenderM / F(%)

6 / 25 (12% / 88%) 17 / 36(31% / 69%)

Mean Age (year) 29 ± 8 33 ± 12Body Weight(kg) 110.3 ± 16.2 113.1 ± 25.5Height(m) 1.64 ± 0.07 1.68 ± 0.10BMI(kg/m2 ) 41 ± 5 40 ± 8

Pre-operative comorbidities of 84 Bariatric patients

Patient number of pre-existing comorbidities

LRYGBP N(%)N=31

LAGB N(%)N=53

DyslipidemiaSleep apnea

9(29%)8(26%)

8(15%)12(23%)

GERD 9(29%) 13(25%)DJD 8(26%) 17(33%)DM 9(29%) 12(23%)HTN 10(32%) 16(30%)

LRYGBP(N=31,%)LRYGBP(N=31,%) ManagementManagement

AnastomosisAnastomosis site site leak(GJleak(GJ)) 3(9%)3(9%) --GJ leak; open exploration on POD#1 dayGJ leak; open exploration on POD#1 day--2 Esophageal leak on POD#1 day, stopped on 2 Esophageal leak on POD#1 day, stopped on 1 and 2 months 1 and 2 months

Small Bowel ObstructionSmall Bowel Obstruction 1(3%)1(3%) --Roux limb obstruction, Roux limb obstruction, Lap.RevisionLap.Revision

Internal Internal herniationherniation 1(3%)1(3%) --PetersenPetersen’’s s herniation(SBstrangulation)onPODherniation(SBstrangulation)onPOD# # 3weeks,massive bowel resection and 3weeks,massive bowel resection and gastrogastricanastomosis(restorationgastrogastricanastomosis(restoration of of Continuity)Continuity)

IncisionalIncisional herniationherniation 1(3%)1(3%) --Conservative treatmentConservative treatment

AnastomosisAnastomosis site bleedingsite bleeding 1(3%)1(3%) --JJ--J bleeding with obstructing J bleeding with obstructing hematomahematoma & & GJ leak on POD#1day, open exploration GJ leak on POD#1day, open exploration and repairand repair

Overall morbidityOverall morbidity 7(22%)7(22%)

MortalityMortality 0(0%)0(0%)

Post-operative complications and management in LRYGBP

LAGB(N=53,%)LAGB(N=53,%) ManagementManagement

Esophageal dilatationEsophageal dilatation 1(1%)1(1%) --conservative treatmentconservative treatment

Port Port malpositionmalposition 2(1%)2(1%) --access port relocated in left upper access port relocated in left upper quadrant under general anesthesia quadrant under general anesthesia --access port access port flipping,conservativeflipping,conservativetreatmenttreatment

Port site infectionPort site infection 1(1%)1(1%) removal and access port relocated removal and access port relocated on left on left subcostalsubcostal areaarea

Wound infectionWound infection 1(1%)1(1%) conservative treatmentconservative treatment

OveralOveral morbiditymorbidity 5(9%)5(9%)

MortalityMortality 0(0%)0(0%)

-Post operative complications and management in LAGB

LRYGBP(nLRYGBP(n=31)=31) LAGB(nLAGB(n=53)=53) PP

6months6months 68.2 68.2 ±± 18.718.7 32.7 32.7 ±± 13.113.1 <0.05<0.05

12months12months 76.9 76.9 ±± 19.019.0 46.8 46.8 ±± 21.021.0 <0.05<0.05

24months24months 79.7 79.7 ±± 18.218.2 55.1 55.1 ±± 19.719.7 <0.05<0.05

36months36months 85.8 85.8 ±± 18.618.6 63.3 63.3 ±± 18.418.4 <0.05<0.05

LRYGBP(nLRYGBP(n=7/31)=7/31) LAGB(nLAGB(n=12/53)=12/53)

Duration of Duration of preoppreopDM(yearsDM(years))

6.4 6.4 ±± 6.46.4 3.5 3.5 ±± 3.23.2

PreopPreop BldBld GlcGlc level(mglevel(mg/dl)/dl) 220.1 220.1 ±± 41.141.1 204.1 204.1 ±± 21.921.9

PostopPostop BldBld GlcGlc level(mglevel(mg/dl /dl at 1month after procedure)at 1month after procedure)

*72.7 *72.7 ±± 16.416.4 *101.3 *101.3 ±± 21.221.2

PreopPreop HbA1C(%)HbA1C(%) 9.6 9.6 ±± 2.12.1 9.4 9.4 ±± 1.31.3

PostopPostop HbA1C at 1 HbA1C at 1 month(%)month(%)

*5.7 *5.7 ±± 2.02.0 *5.5 *5.5 ±± 1.21.2

* : significant different between pre and post op level

-Follow-up of fasting blood glucose and HbA1C level after two procedures

-Percent(%) of excess weight loss(EWL) between two procedures

121.8 kg 66.8 kgEWL 94%

10 months later

Roux-en-Y Gastric Bypass

14 months later

72 kg

134.8 kg 69 kgEWL 87%

27 months later

Laparoscopic Adjustable Gastric Banding

214.5 kg 89 kgEWL 91%

22 months later

Laparoscopic Adjustable Gastric Banding

After conventional access port insertion method.

Minimal-scar LAGB

After “Minimal-scar LAGB”

St. LukeSt. Luke’’ss--Roosevelt Hospital Center Roosevelt Hospital Center Department of SurgeryDepartment of Surgery

Columbia University College of Physicians & SurgeonsColumbia University College of Physicians & Surgeons

114th street & Amsterdam 59th street & 8Av

GastroIntestinalGastroIntestinal Hormones ?Hormones ?

GI HormonesGI Hormones

David E. Cummings and Joost Overduin, J Clin Invest. 2007 January 2; 117(1): 13–23

GI HormoneGI Hormone

““secretinsecretin”” was first used to define factors was first used to define factors regulating pancreas secretionregulating pancreas secretion““incretinincretin”” was later introduced in the 1920was later introduced in the 1920’’s to s to describe these potential mediatorsdescribe these potential mediatorsThe connection between the gastrointestinal The connection between the gastrointestinal tract and the endocrine pancreas was confirmed tract and the endocrine pancreas was confirmed in the 1960s, when insulin became measurable in the 1960s, when insulin became measurable in plasma.in plasma.

GI HormoneGI Hormone

In humans, two peptide hormones have been identified In humans, two peptide hormones have been identified as being responsible for the as being responsible for the incretinincretin effect effect Glucose dependent Insulin releasing Glucose dependent Insulin releasing Polypeptide(Polypeptide(GIPGIP, , formerly called gastric inhibitory polypeptide) and formerly called gastric inhibitory polypeptide) and GlucagonGlucagon--Like PeptideLike Peptide--1(1(GLPGLP--11))

GIP and GLPGIP and GLP--1 are both secreted in response to food 1 are both secreted in response to food ingestion and both ingestion and both potentiatepotentiate the glucose induced insulin the glucose induced insulin response.response.

IncretinsIncretins : GIP & GLP: GIP & GLP--11

JF Gautier,et al. Diabete Metab 2005: 31: 233-242

GIP & GLPGIP & GLP--1 in T2 DM1 in T2 DM

GIPGIP GLPGLP--11

SecretionSecretion NormalNormal ↓↓

ResponseResponse ↓↓ NormalNormal

JF Gautier,et al. Diabete Metab 2005: 31: 233-242

Insulin & Glucose MetabolismInsulin & Glucose Metabolism

JF Gautier,et al. Diabete Metab 2005: 31: 233-242

IncretinsIncretins: GIP & GLP: GIP & GLP--11

Biological actions of the Biological actions of the incretinsincretins (GIP & GLP(GIP & GLP--1) 1) and therapeutic perspectives in patients with and therapeutic perspectives in patients with type 2 diabetestype 2 diabetes

DiabtesDiabtes Med 2005: 31; 233Med 2005: 31; 233--242242

IncretinsIncretins : GLP: GLP--11

JF Gautier,et al. Diabete Metab 2005: 31: 233-242

(Exenatide®)

Peptide Tyrosine Peptide Tyrosine TyrosineTyrosine(PYY)(PYY)

36 amino acid36 amino acidStraight chain polypeptideStraight chain polypeptideMember of NPY familyMember of NPY familyActs primarily through Y2 receptorActs primarily through Y2 receptorLL--type endocrine cellstype endocrine cellsCoCo--localized with GLPlocalized with GLP--11Released by : Released by : glucose,fattyglucose,fatty acids & bile saltsacids & bile salts

PYYPYY

ActionsActionsInhibits Inhibits cAMPcAMP mediated actionsmediated actions

Gastric acid secretionGastric acid secretionGastric Gastric pepsinogenpepsinogen secretionsecretionGastric emptyingGastric emptyingSmall bowel Small bowel motility(ilealmotility(ileal brake mechanism)brake mechanism)VIP stimulated VIP stimulated cIcI-- secretionsecretion

Inhibits NPY in Inhibits NPY in ArcuateArcuate NucleusNucleusCause satietyCause satietyDecreases food intakeDecreases food intake

PYYPYY

ClinicalClinicalDecreased levels in obesityDecreased levels in obesity

fasting & postprandial PYY levels are depressed in fasting & postprandial PYY levels are depressed in obese subjects though tissue levels are elevatedobese subjects though tissue levels are elevated

No No ““PYY ResistancePYY Resistance”” in obesityin obesityinfusion in obese patients at infusion in obese patients at physiological levels quenches appetite physiological levels quenches appetite & cause weight loss& cause weight loss

Increased fasting levels & peak Increased fasting levels & peak postprandial levels after LRYGBP & BPDpostprandial levels after LRYGBP & BPD

GhrelinGhrelin

Appetite StimulantAppetite StimulantLigandLigand of Growth Hormone Receptorof Growth Hormone ReceptorGut peptideGut peptideFound in Stomach & Found in Stomach & Duodenum(XDuodenum(X/A like cell)/A like cell)Increases before mealsIncreases before mealsWeight loss increase Weight loss increase GhrelinGhrelin

GhrelinGhrelin

ActionsActionsDecreased insulin releaseDecreased insulin releaseDecreased energy expenditureDecreased energy expenditureIncreased appetiteIncreased appetiteIncreased Growth hormone secretionIncreased Growth hormone secretionIncreased acid secretion & gastric motilityIncreased acid secretion & gastric motilityIncreased sleep & memoryIncreased sleep & memory

T Akamizu & K Kangawa. Enocr J. 2006 Jul 28

Mechanisms of Surgical Control of DiabetesMechanisms of Surgical Control of Diabetes

•Caloric Intake/Weight loss

•The role of incretin

•The role of the forgut

•The role of the hindgut

•Animal and Surgical Models

SurgSurg ObesObes RelatRelat Dis. 2007;3(2):109Dis. 2007;3(2):109--1515

DE. Cummings, et alDE. Cummings, et al

a metaa meta--analysis of 22,094 patients of RYGBPanalysis of 22,094 patients of RYGBP

83% to 86% remission of DM83% to 86% remission of DMnormalized blood glucose & HgA1Cnormalized blood glucose & HgA1Cafter discontinuation of all DM after discontinuation of all DM medicationmedication

Weight loss effectWeight loss effect

Improving glucose homeostasisImproving glucose homeostasis--physiologic changephysiologic changeincreases in muscle insulin receptor density & increases in muscle insulin receptor density & adiponectinadiponectin levelslevelsdecrease in the intramuscular & decrease in the intramuscular & intrahepaticintrahepatic content of total content of total lipids and longlipids and long--chain fatty chain fatty acylacyl--CoACoA moleculesmolecules

Many months to years after RYGBPMany months to years after RYGBP

Most dramatic observationMost dramatic observation

Complete remission of DM within days to Complete remission of DM within days to weeks after RYGBPweeks after RYGBP

Key roleKey role

““ilealileal brakebrake””

GLPGLP--1, 1, PYY,oxyntomulinPYY,oxyntomulin in response to ingested in response to ingested nutrients,nutrients,

decreased food intake,decreased food intake,

decreased UGI motilitydecreased UGI motility

““ Upper Intestinal hypothesisUpper Intestinal hypothesis””

Marked accentuate GLPMarked accentuate GLP--1, PYY1, PYY

: accentuating glucose: accentuating glucose--dependent insulin secretion,dependent insulin secretion,increasing increasing ββ cell mass and heightening insulin sensitivitycell mass and heightening insulin sensitivity

improve glucose improve glucose homeostasis(greaterhomeostasis(greater impact on DM impact on DM than medical; GLPthan medical; GLP--1 agonist such as 1 agonist such as exenatideexenatide))

Metabolic SurgeryMetabolic Surgery

Metabolic SurgeryMetabolic Surgery

Metabolic SurgeryMetabolic Surgery

Metabolic SurgeryMetabolic Surgery

Changes in Regulatory PeptidesChanges in Regulatory PeptidesDecreased Decreased GhrelinGhrelinIncreased PYYIncreased PYYIncreased GLPIncreased GLP--11Decreased Decreased LeptinLeptinDecreased Decreased LeptinLeptin resistanceresistanceDecreased InsulinDecreased InsulinDecreased Insulin ResistanceDecreased Insulin Resistance

SurgSurg ObesObes RelatRelat Dis. 2007;3(2):195Dis. 2007;3(2):195--197197

Ricardo V. Cohen,Francesco Rubino et al.

Ileal Trasposition, Sleeve Gastrectomy + Entrectomy, Omentectomy, Intraluminal Duodenal Sleeve

ConclusionsConclusionsBariatricBariatric & Metabolic Surgery produce & Metabolic Surgery produce maintaining of weight loss & durable remission maintaining of weight loss & durable remission of Type 2 DMof Type 2 DMReduce the mortality from the disease & Reduce the mortality from the disease & reduce health care costsreduce health care costsNot just Not just bariatricbariatric surgeons but also metabolic surgeons but also metabolic surgeonssurgeons

Thank you !Thank you !

Division of Laparoscopic & Bariatric Surgery Department of SurgerySt. Mary’s Hospital, College of MedicineThe Catholic University of Korea