Mr Paras Jethwa BSc MD FRCS FRCS(Gen Surg)

1
Metabolic Effects of Bariatric Surgery on Diabetes

• Mr Paras Jethwa BSc MD FRCS FRCS(Gen Surg)
• Consultant Laparoscopic Surgeon

2
Definitions

• Body Mass Index weight/height2
• lt 20 underweight
• 20-25 normal
• 25-30 overweight
• 30-40 obese
• gt 40 morbidly obese
• Excess Weight Current Weight Ideal Weight

3
BMI gt 30 1991
4
BMI gt 30 1992
5
BMI gt 30 1993
6
BMI gt 30 1994
7
BMI gt 30 1995
8
BMI gt 30 1996
9
BMI gt 30 1997
10
BMI gt 30 1998
11
BMI gt 30 1999
12
BMI gt 30 2000
13
BMI gt 30 2001
14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
Obesity Related Mortality
19
Type 2 DM

• gt80 have BMI gt25
• 50 obese, 10gt40
• Modest weight loss helps control
• BUT - 95 will fail with diet
• Proposed in mid 90s that T2DM
• Surgical disease
• Foregut hormone stimulation

20
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

21
Laparoscopic Gastric Band

• Mean 47 EWL
• Best for
• BMI lt 47 kg/m2
• Regular meal patterns
• Non sweet eaters
• Mortality risk 1800
• Morbidity risk 1100
• 15 bands need revision

22
Laparoscopic Gastric Bypass

• Mean 72 EWL
• Best for
• All BMI
• Sweet eaters and grazers
• Diabetics
• Mortality risk 1300
• Morbidity risk 175

23
Laparoscopic Sleeve

• Mean 75 EWL?
• Easy maintence
• One long suture line
• Poorer longterm
• Removes Ghrelin producing cells
• Mortality risk 1400
• Morbidity risk 1100

24
Laparoscopic Mini Gastric Bypass

• Mean 80 EWL
• Best for
• All BMI
• Grazers
• T2DM
• Mortality risk 1500
• Morbidity risk 180
• Lower long term risk of metabolic complications
• Extensively practiced in US

25
MGB success
26
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

27
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

28
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

29
Benefits

• 621 studies with 135, 246 patients
• Mean age - 40.2 years
• Mean BMI - 47.9
• 80 Female
• 56 EBWL
• 78 resolution of diabetes
• BPDgtRYBgtLAGB
• Effect static at 2 years

30

• 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

31
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

32
Resolution / improvement of comorbidities
33
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

34
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

35
Metabolic Surgery

• BMI gt 40 or BMI gt35 with Comorbidity
• NICE CG43
• Exhausted non surg methods
• Fit for op
• Willing
• First line for BMIgt50
• Part of MDT
• In young in exceptional circumstances
• psychological factors etc.

36
Diabetes

• Bypass
• Type 2 - 87 resolution
• Band
• Type 2 - 73 resolution
• 92 mortality risk reduction
• Clinically and cost effective for moderate to
  severe obesity

37
Role of banding?

• RCT of 80 patients
• 2 year follow up
• 87 v 22 excess weight loss
• Significant reduction in metabolic syndrome

38

• 50-77 of obese adolescents carry their obesity
  into adulthood

39
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

40
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