Mr Paras Jethwa BSc MD FRCS FRCS(Gen Surg) Consultant Laparoscopic Surgeon
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Transcript of Mr Paras Jethwa BSc MD FRCS FRCS(Gen Surg) Consultant Laparoscopic Surgeon
Metabolic Effects of Bariatric Surgery on Diabetes
Mr Paras Jethwa BSc MD FRCS FRCS(Gen Surg)
Consultant Laparoscopic Surgeon
Definitions
• Body Mass Index = weight/height2
< 20 = underweight20-25 = normal25-30 = overweight30-40 = obese > 40 = morbidly obese
• Excess Weight = Current Weight – Ideal Weight
BMI > 30 1991
BMI > 30 1992
BMI > 30 1993
BMI > 30 1994
BMI > 30 1995
BMI > 30 1996
BMI > 30 1997
BMI > 30 1998
BMI > 30 1999
BMI > 30 2000
BMI > 30 2001
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USA MEXICO UK SLOVAKIA GREECE AUSTRALIA NZ HUNGARY SPAIN IRELAND TURKEY SWEDEN FRANCE J APAN
Worldwide Obesity Prevalence (%)
Obesity Related Mortality
Type 2 DM
• >80% have BMI >25
• 50% obese, 10%>40%
• Modest weight loss helps control
• BUT - 95% will fail with diet
• Proposed in mid 90’s that T2DM– “Surgical disease”
– Foregut hormone stimulation
Surgical Options
• Restrictive vs. malabsorption• Restrictive:– Generating saiety signals
• Malabsorpative:– Gastric restriction– Duodenal and upper jejunal bypass
• Extreme (BPD & Switch)– Only last 50cm of SB used for digestion
Laparoscopic Gastric Band
• Mean = 47% EWL• Best for– BMI < 47 kg/m2
– Regular meal patterns– Non sweet eaters
• Mortality risk 1:800• Morbidity risk 1:100• 15% bands need revision
Laparoscopic Gastric Bypass
• Mean = 72% EWL• Best for– All BMI– Sweet eaters and grazers– Diabetics
• Mortality risk 1:300• Morbidity risk 1:75
Laparoscopic Sleeve
• Mean = 75% EWL?• Easy maintence• One long suture line• Poorer longterm• Removes Ghrelin producing cells• Mortality risk 1:400• Morbidity risk 1:100
Laparoscopic Mini Gastric Bypass• Mean = 80% EWL• Best for
– All BMI– Grazers– T2DM
• Mortality risk 1:500• Morbidity risk 1:80• Lower long term risk of metabolic
complications• Extensively practiced in US
MGB success
What mechanisms are at work?Bypass factors
• Foregut vs. Hindgut theories– Gherlin– Glucagon like peptide – Gut derived glucadonotropic signalling
• Diabetic effect seen before weight loss– Clear division contributes– RYB vs. Banding for speed of control
Weight loss factors
• Improvements insulin action/reduced resistance
• Relieve secretory pressure on ß cells• Early effect:– Calorific reduction - increase insulin sensitivity
• Later effect:– Absolute weight loss glycaemic control
Are the effects longlasting?
• Maximum wt loss is at 1-2 years• 30-50% excess wt loss at 6/12• 10-14 years post op - more favourable levels
of :– Cholesterol– DM– HT
Benefits
• 621 studies with 135, 246 patients• Mean age - 40.2 years• Mean BMI - 47.9• 80% Female
• 56% EBWL • 78% resolution of diabetes• BPD>RYB>LAGB• Effect static at 2 years
• Case controlled prospective study
• Surgery v control• 4047 patients• 99.9% follow up• Average 10.9 year follow up• Prospective SOS trial:
– Glucose/lipids/BP• 10.9 year FU - 30%
mortality
Non T2DM effects• SOS study
• 50% reduction in IHD• 85% reduction in sleep apnoea• Life expectancy improves up to 89%• Up to 40% reduction in premature death• 60% reduction in cancer deaths• Fatal IHD halved
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DM Lipids HT SleepApnoea
% amelioration
Resolution / improvement of comorbidities
Prognostic factors for DM remission
• Type of op• Pro:
– Early rapid weight loss– Preoperative insulin dose
• Against:– Diabetes dutation (B cell mass)– High HbA1c– Insulin vs. oral therapy– Diabetic complications (retinopathy etc.)
• Unsure:– FH– Late onset type 1
Risks
• Remarkably safe• Mortality 0.1% to BPD 1.1%• 5-10% acute comps– Bleeds– Int. hernia– Anastomotic issues– Nutrition– Emotional
• Hypoglycaemia if medication unaltered
Metabolic SurgeryBMI > 40 or BMI >35 with ComorbidityNICE: CG43
Exhausted non surg methodsFit for opWillingFirst line for BMI>50 Part of MDTIn young in exceptional circumstances psychological factors etc.
Diabetes• Bypass:– Type 2 - 87% resolution
• Band– Type 2 - 73% resolution
• 92% mortality risk reduction
• Clinically and cost effective for moderate to severe obesity
Role of banding?• RCT of 80 patients• 2 year follow up• 87% v 22% excess weight
loss• Significant reduction in
metabolic syndrome
• 50-77% of obese adolescents carry their obesity into adulthood
Adolescents
• Rapidly growing group in US– Sequential family members
• Extremely obese teen– Treatment of choice?
• Radical step BUT…….– T2DM not uncommon in teens now– Given that we are following US trends…
Summary
• Obesity plays a key role in pathophysiology• Roux en Y bypass most effective• Effects not just related weight related• Useful adjunct in obesity esp. when DM difficult
to control• Surgical diversion leads to release of incretin • Type 2 DM evaluated at MDT