Daniel Tat-ming ChungPrincess Margaret Hospital

16th April 2011JHSGR

for weight Surgical procedures

designed to produce substantial weight loss.

Most effective therapy for severe obesity Reduction of morbidity

and mortality Quality of life

improvement

Oriental Daily 15th April 2011

In 2000: >171 million people worldwide suffer from diabetes = 2.8% of the population

Doubled by 2030

Narayan et al. Diabetic Care 2006

Greatest increase in prevalence:

Asia and AfricaWdiabetes: estimates for 2000 and projections ild et al. "Global prevalence of for 2030". Diabetes Care 2004

http://www.keyvive.com

Gaede et al. NEJM 2008

Insulin levels / HbA1c / Fasting glucose declined significantly postoperatively

No. ofStudy

No. of Patient

CompletelyResolved

Resolved orImproved

Buchwald et al. JAMA 2004 136 22094 76.8% 86.0%

Buchwald et al. Am J Med 2009

621 135,246

78.1% 86.6%

Buchwald et al. Am J Med 2009

Sjostrom et al. N Engl J Med 2004

0.1% - 2% Gastric banding: 0.1%

Released on 28 March 2011

“Bariatric surgery may be considered for adults with BMI 35 kg/m2 and type 2 diabetes, especially if the diabetes or associated comorbidities are difficult to control with lifestyle and pharmacologic therapy.’’ ADA Standard of Medical Care in Diabetes 2011

Pories et al. Ann Surg 1995

Wickremesekera et al. Loss of Insulin Resistance after Roux-en-Y Gastric Bypass Surgery: a Time Course Study. Obesity Surg 2005

“The changes in in insulin resistance seen after gastric bypass, which are responsible for the resolution or improvement of type 2 diabetes occur within 6 days of the surgery, before any appreciable weight loss has occurred “

WEIGHT LOSS RELATEDWEIGHT LOSS INDEPENDENCE

Morbidly obese subjects with normal glucose tolerance

Studied at 4 and 14 months

Insulin-mediated glucose disposal improved in proportion to the degree of weight loss

Pereira et al. 2003

Type 2 diabetic individuals improves glucose disposal much more significantly than in a comparable group where weight loss was induced by diet

Equivalent weight loss by RYGB or by diet in two groups of matched morbidly obese patients with type 2 diabetes produced changes in incretin levels which were strikingly different

Laferrere et al 2008

? Anatomical rearrangement

? Decreased caloric intake

? Malabsorption

Rubino et al. Effect of Duodenal–Jejunal Exclusion in a Non-obese Animal Model of Type 2 Diabetes - A New Perspective for an Old Disease. Ann Surg 2004

Early delivery of nutrients to the distal intestine enhances the incretin hormone effect Glucagon-like

peptide-1 (GLP-1) secreted by L-cell in distal ileum and colon

Distal ileum and Colon

Weight loss through ileal transposition is accompanied by increased ileal hormone secretion and synthesis in rats

Strader et al. 2005

After 3 weeks, all 5 patients with T2DM preoperatively had normal blood glucose levels without medication.

No conclusive evidence that RYGB increases the production of GLP-1

GLP-1 incraeses after RYGB: ? late adaptive phenomenon

Role in early improvement of DM remission is questionable

Prevention of duodeal passage of nutrient improve glucose tolerance only in diabetic patients

Glucose tolerance may actually deteriorate if the procedure is performed in non-diabetics

Schwarz et al. 1996 Rubino et al. 2006

Aberrant gastrointestinal signaling unique to the diabetic state

Possibly removed when the proximal intestine is bypassed

Rubino et al. The Mechanism of Diabetes Control After Gastrointestinal Bypass Surgery Reveals a Role of the Proximal Small Intestine in the Pathophysiology of Type 2 Diabetes. Ann Surg 2006.

27 < BMI < 33 25 < BMI < 35

Chiellini et al. 2009

EFFECTS OF BILIOPANCERATIC DIVERSION ON TYPE 2 DIABETES IN PATIENTS WITH BMI 25 TO 35

Scopinaro et al. 2011

Buchwald et al. JAMA 2004:Hyperlipidemia improved in 70% or more of patients

Hypertension was resolved in 61.7% of patients and resolved or improved in 78.5%.

Lower with LAGB (43%, 27% respectively)

Buchwald et al. JAMA 2004

Placed in the stomach to mimic restriction

Placed in the trans-pyloric area to delay or regulate gastric emptying

Endoscopically placed devices hysically fixed to the upper GI tract to mimic proximal gastric restriction of the LAGB

Endoluminal impervious sleeves to bypass the gastro-duodenal upper jejunal area to mimic the RYGB, or bypass the duodenum and proximal jejunum to mimic the DJB

Laparoscopic procedures to place novel electronic gastric or gastro-duodenal motility stimulators, and vagal nerve blocking devices

Bariatric metabolic surgery Distal vs Anti-incretin hypothesis Pathophysiology of type 2 DM Application on non-obese DM patient