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RECENT ADVANCES:

SURGICAL MANAGEMENT OF METABOLICSYNDROME

 Avidip De

PGT, GeneralSurgery

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WHAT IS METABOLIC SYNDROME???

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TREATMENTS OF METABOLIC SYNDROME

1. Traditional:

Diet, Exercise, Medication

No more than 5-10% reduction in body weight

2. Bariatric surgery:

Only effective long-term treatment for morbid

obesity

NIH Consensus Conference Statement, 1991

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AIMS OF BARIATRIC SURGERY 

Reduce the excess morbidity & mortality of 

obesity

Measured by percentage excess weight loss

or BMI change

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ROUX-EN-Y GASTRIC BYPASS

Commonest bariatric surgery

 Access is increasingly Laparoscopic: Shorter hospital stay

Less pain & complications

Improved PFT

Quicker improvement in quality of life

Mechanism: Changing the gut hormones that control appetite & satiety (

PYY & GLP-1)

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ROUX-EN-Y GASTRIC BYPASS (CONTD.)

Excess weight loss= 60 – 70%

Weight loss is faster than banding

Lower failure rates Better improvements in type 2 D.M. &

dyslipidaemia

Iron & Vit. B12 deficiency > 30%

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GASTROPLASTY 

Vertical stapling along lesser curvature

Outlet is banded by a mesh strip or silastcring to prevent enlargement

Superseded by gastric banding

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BILIOPANCREATIC DIVERSION

Excess weight loss= 70 - 80%

Significant (7%) long-term risk of malnutrition

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DUODENAL SWITCH

Modification of biliopancreatic diversion

Excess weight loss is typically 80% or more

Diarrhoea, anemia, calcium & protein mal-absorption, bone demineralisation

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GASTRIC BANDING

2nd most common bariatric surgery

Least peri-operative complication & mortality

(0.1%) Perigastric or Pars flaccida approach

Mechanism: Small ‘virtual’ gastric pouch

above the band leads to early satiety & lossof appetite, without much change in the gutsatiety hormones

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GASTRIC BANDING (CONTD.)

Excess weight loss= 55 – 65%

Long-term results are largely unknown

Success rate < 50% & failure rate about 40%

after 7 years

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SLEEVE GASTRECTOMY 

 Alternative to RYGB in higher risk patients,

especially with BMI >60 kg/sq. mtr.

Excess weight loss appears similar to RYGB

but no long-term reports are available

Can be followed by other bariatric operations

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INTRAGASTRIC BALLOONS

To make patients fitter for surgery after initial

weight loss

Licensed for 6 months, weight regain occurs

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EFFECTS ON CO- MORBIDITY 

Diabetes & HTN improve in vast majority of 

patients within 1-2 yrs.

Improvements also seen in dyslipidaemia,

sleep apnea & quality of life

Remission of type 2 D.M. is 83% after RYGB

& 47% after banding (Buchwald)

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BARIATRIC SURGERY: A CURE FOR TYPE 2 D.M.

???

Mechanism of remission of DM.:

Improved insulin resistance due to wt. loss per 

se

Production of incretins (GLP-1)

Changes in gut hormones

Bariatric surgery should be considered as a

treatment option for diabetics with BMI < 35kg/sq. mtr. (Diabetes Surgery Summit in

Rome, March 2007 )

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WHICH OPERATION IS BEST???

Based on:

1. Local culture

2. Surgeon & patient preference

3. Balance of risk & benefit

4. Expertise

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COST EFFECTIVENESS & LONG-TERM SURVIVAL

BENEFITS

Cost of surgery is recouped within 3-4 yrs

 After surgery: More paid work

More productive ife Fewer sick days

Bariatric surgery patients have better long-

term survival than obese controls (Swedish

Obese Subject Study & Utah Study)

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