Transcript Bariatric Surgery as a Treatment for Diabetes

BARIATRIC SURGERY AND
TREATMENT OF TYPE 2
DIABETES
Bradley Schwack, MD
Assistant Professor, Surgery
NYU School of Medicine
NYU Weight Management Program
BARIATRIC SURGERY
Definition of obesity
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determined by height and weight
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Body Mass Index (BMI)= kg/m2
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100 lbs overweight
Degrees of Obesity
NORMAL
BMI 18.5 – 24.9
OVERWEIGHT
BMI 25 – 29.9
OBESE
BMI 30 – 34.9
SEVERE OBESE
BMI 35 – 39.9
MORBIDLY
OBESE
BMI  40
What does it mean to be obese?
Medical Implications:
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hypertension
hyperlipidemia
diabetes mellitus
respiratory
insufficiency
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obesityhypoventilation
sleep apnea
asthma
cardiomyopathy/MI
GERD
PE/DVT
CVA
 stress incontinence
 DJD wt-bearing joints
 low back pain
 venous stasis/ulcers
 cholelithiasis
 amenhorrhea
 infertility problems
 skin
infections/inflammation
 accident proneness
- cancer (uterus, breast,
colon, prostate)
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Obesity is a U.S. public health epidemic:
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64% Americans overweight
30% Americans obese
10% morbidly obese
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400,000 deaths /year from obesity related
causes
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[90,000 deaths/yr from colon + breast ca]
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#2 cause of preventable deaths
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#1 is smoking
Bariatric Surgery
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Bariatrics: The study of Obesity and its
Treatments
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Surgery: The science of operations
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Bariatric surgery: A therapeutic
intervention to understand and treat the
cause and sequelae of morbid obesity.
Rising Use of Weight Loss Surgery
Steinbrook, N Engl J Med, 2004
Bariatric Surgery and Diabetes
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Meta-analysis (Buchwald et al – 2009)
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Overall remission rate of 78%
< 2 years since surgery 80%
 >2 years since surgery 75%
 Results seen with all operations, yet most dramatic
with the gastric bypass
 Not much data beyond 5 years
**If treated within 5 years of DM diagnosis—
higher long term remission rates (Brethauer et
al, 2013) – possible progressive loss of beta cell
function
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Bariatric Surgery and Diabetes
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International Diabetes Federation (2011)
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Journal of Diabetes (3(2011): 261-264)
“Bariatric surgery is an appropriate
treatment of people with T2D and obesity
who are not achieving recommended
treatment targets with existing medical
therapies, especially in the presence of
other major comorbidities”
<1% of those eligible actually have WLS for
diabetes
What do you do when you have
100 lbs to lose?
1991 NIH Consensus Statement
Bariatric Surgery
At BMI 40:
risk of surgery < risk of morbid obesity
CONSENSUS STATEMENT*
Bariatric Surgery for Morbid Obesity: Health Implications for
Patients, Health Professionals, and Third-Party Payers
H. Buchwald, J Am Coll Surg 2005; 200:593
Criteria for surgery
BMI > 40 kg/m2
-ORBMI > 35 kg/m2 and major medical
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complications of obesity
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Failure of other approaches to long-term
weight loss
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no substance abuse, psychoses or
uncontrolled depression
How does surgery work?
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Restrictive - restrict amount of food ingested
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Decreases appetite/hunger
Early satiety
Behavior modification
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Malabsorptive- limits digestion and absorption
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Decreases length of intestine exposed to digested food
25% of fat is absorbed
Behavior modification
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Gastric Banding (Lap Band)
Roux-en Y Gastric bypass (RYGB)
Sleeve Gastrectomy
Biliopancreatic Diversion, Duodenal Switch (BPD/DS)
All operations can be performed open or laparoscopically
Laparoscopic Roux en Y Gastric
Bypass
Laparoscopic Roux en Y Gastric
Bypass
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1960s invented by Drs. Mason and Ito
Restrictive: small gastric pouch (15-20cc)
Intestinal anatomy:
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Redirect the alimentary tract so that the
gastric contents are directed 75-150cm distal
to the ligament of Treitz .
Redirection of intestines has 2 fold impact:
Avoid the reflux of bile and pancreatic juices into
the gastric pouch
 Variable malabsorbtive effect.
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-Gastric pouch: 15-20 ml
•Food bypasses 95% stomach
and duodenum
•2 anastomoses
•12 mm stoma
•Inaccessible gastric remnant
•Require life-long vitamin
supplements
•Side effects:
•dumping,
•stomal stricture
•Deficiencies- iron, calcium
•Theoretically reversible, but
very difficult.
Gastric Bypass
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The gastric bypass has been a recognized treatment of morbid
obesity for over 40 years.
Laparoscopic:
 1994 Wittgrove and Clark
 5-6 small abdominal incisions (0.5-2.0cm)
 Inflate the peritoneal cavity with gas to create space to work
 Reduces trauma, operative exposure, surgical insult, and postoperative pain.
 Proven an equally safe and effective means of weight loss.
 Level of comfort with procedure is a matter of surgeon opinion,
training, and experience.
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Wittgrove et al. 1994
Higa et al., 2001.
Lugan et al, 2004.
Gastric Bypass
Gastric Bypass
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1.5-2 years
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60-68% excess weight loss
Majority of weight loss in first 9 months
Plateau at 1.5 years
5 years
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may regain 15%-20% excess wt
Gastric Bypass Complications
Pneumonia
Blood clots in legs
Bleeding
Infection
Perotinitis
intestinal leakage (2-3%)
Popped staples
Death: 1 in 200
Nutritional Risks
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Lifelong vitamins (Calcium, Fe, B-12)
Daily multivitamin
Bi-annual labs
Watch for anemia
Wait >18months before pregnancy
Dehydration
Bypass and Diabetes
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Pories et al (1995)-Greenville, NC (ECU)
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>600 patients
83% w/ T2DM—normal glc, HbA1c, insulin
99% w/ glc intolerance—normal
“No other therapy has produced such durable
and complete control of diabetes mellitus.”
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Ann Surg (1995; 222: 339-52)
Bypass and Diabetes
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Bypass shows more promising resolution of diabetes
than the sleeve or band.
Parikh et al (2013)—Meta-analysis (1389pts)
 Remission rates (1 year):
 33% Lap band
 54% Sleeve
 64% Gastric Bypass
Buchwald et al (2009)
 Resolution of T2DM
 57% Lap band patients
 80% Gastric bypass patients
Bypass and Diabetes
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Unique to bypass—DM resolution can
come before weight loss
Rubino et al (2006) – animal studies
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Bypassing a short segment of proximal
intestine directly ameliorates T2DM,
independent of food intake, body weight, etc.
Potentially undiscovered factors from proximal
small bowel contributing to pathophysiology of
DM
Bypass and Diabetes
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Theories as to “why” (and factors unique
to bypass?)
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Weight loss
Ghrelin suppression (bypassed stomach)
Metabolic due to exclusion of the proximal
small intestines (unsure of reasons why)
Sleeve Gastrectomy
Sleeve Gastrectomy
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Purely restrictive
Partial gastrectomy of
greater curvature
Leaves tube of
stomach sized to 32
French Bougie
No long term data
Sleeve Gastrectomy
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1-2% risk of leak at upper stomach from
staple line
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Possible re-operation
Death
Lengthy hospitalization
Possible re-operation for completion
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Gastric bypass or malabsorbtive procedure
Lap Band
Re-sleeve gastrectomy
Sleeve Gastrectomy and Diabtes
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“New Kid on the Block”
Mechanism most likely related to acute
weight loss
? Ghrelin suppression
No part of GI tract is bypassed
Sleeve Gastrectomy and Diabetes
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Sleeve has been done as a primary
operation for a few years
Small studies showing improvement of
diabetes with weight loss
Some show equal remission to and some
show a bit less remission than with bypass
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Factors may be higher vs lower BMI
Insulin insensitivity vs low insulin production
The Laparoscopic Adjustable
Gastric Band System
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A silicone band is placed
around the upper part of the
stomach
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A small pouch is created
Slows down gastric pouch
emptying
Early feeling of satiety
Surgical appetite suppressant
Purely restrictive
Quick recovery
Adjustable restriction
through mediport
Reversible (if necessary)
Depends on surgeon and
patient commitment (much
f/u)
LAP-BAND Adjustability
Unfilled Band
Filled Band
Adjustments are made in the office
% Excess Weight Loss
90
80
70
60
LapBand
50
GB
40
BPD
30
20
10
0
0
1 yr
2 yrs
3 yrs
4 yrs
5 yr
1
Pories 1995
2
Marceau, 1998; Hess 1998; Scopinaro 1998
3
O’Brien 1999; Cadiere 2000; Fielding1999; Dargent 1999; Belachew 1998
Advantages
Disadvantages
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No intestinal surgery
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No stapling/cutting
of stomach
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No nutritional risks
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Adjustable
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Reversible
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Safe
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Foreign body
Frequent follow-up
visits
Needs more
commitment
Easy to cheat
Complications of the Band
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Slippage (5%)—gastric prolapse
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Erosion (0.1%)—band erodes into lumen
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Antibiotics
Weight loss failure (5%)
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Replace in day surgery
Port infection (0.5%)
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Need laparoscopic removal
Tubing breakage (1%)
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Need reoperation laparoscopically
Remove laparoscopically and do a RNY
Death: 1 in >3000
LAGB and Diabetes
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Dolan and Fielding. Obes Surg, 2004
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88 patients, BMI 45, Type II DM
2 years after surgery
51% EWL
 65% patients off all medications (insulin, oral)
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30% EWL by 6 months after surgery--> more likely
to be off all DM medications
Lap Band and Diabetes
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Sultan et al (2010: SOARD 6:373-376.)
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102 patients LAGB (5 year mean EWL 48.3%)
88% preop on meds for DM, 46.5% on @5yrs
14.9% preop on insulin for DM, 8.5% @ 5yrs
HbA1c: 7.53 avg preop; 6.58 avg 5 yrs later
DM resolved—no meds, glc, HbA1c—in 40%
of LAGB 5 years out
Combined improvement/remission rate was
80% at 5 years
Lap Band and Diabetes
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Dixon et al (2012: Obesity Reviews 13:5767)
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Remission improvement rates varied from 5370% within 2 years after LAGB placement
Look at success of weight loss in lap band
populations as well
Varied results
Surgery Deters Progression of Illness
Incidence (%)
50
45
40
35
30
25
20
15
10
5
0
49
41
29
27
24
24
22
Control
17
8
8
7
1
2 YR
10 YR
DM
Sjöström et al., NEJM 2004,352:2683
2 YR
HTN
10 YR
2 YR
TG
10 YR
Surgery
Surgery Decreases Long-term
Mortality
Study
Mortality
with Surgery
Mortality
without Surgery
MacDonald, 1997
9%
28%
Christou, 2004
0.7%
6.1%
O’Brien, 2006
0.3%
10.6%
Restrictive Bariatric Surgery
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A tool against obesity
Not a magic bullet
Patient follow up and compliance is
necessary
Restrictive Bariatric Procedures and
Diabetes
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BARIATRIC PROCEDURES HAVE
BEEN SHOWN TO BE SUPERIOR TO
CONSERVATIVE THERAPY IN THE
MANAGEMENT OF TYPE 2 DIABETES
Schauer et al (2012: N Engl J Med 366: 15671576)
 Dixon et al (2011: SOARD 7: 433-447)
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“Internation Diabetes Federation taskforce”
The Conclusion. . . .?
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Type 2 Diabetes
BMI < 35
Moderate response to
conservative/medical treatment
Will Bariatric Surgery be a treatment
option and will insurance companies cover
such a procedure??
This is not necessarily the goal of
Bariatric Surgeon
The Goal is to be Healthy
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55 – 70% of the excess weight off
Feeling less tired and sick
Off high blood pressure meds
Control and possible remission of
Diabetes