Transcript surgical treatment of diabetes for wasiem

The Surgical Treatment
of Diabetes
Fahad Bamehriz, MD
Centre for Minimal Access Surgery
King Faisal Specialist Hospital and Research Centre
Riyadh
Introduction
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Obesity:
- it is ≥ 20% than the ideal weight
- Body Mass Index (BMI) ≥ 30 kg/m²
. BMI 25- 27 = normal subject
28-30 = over-weight
31- = obese
40- 50 = morbid obesity
50-60 = super MO
Introduction
Obesity and Diabetes
Type 2 DM
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Men
Women
18.1
12.9
BMI>= 40 kg/m2 and age< 55 years
Prevalence ratios generally were greater in younger than
in older adults.
Must et al. The Disease Burden Associated With Overweight and Obesity
JAMA. 1999;282:1523-1529.
How obesity will cause DM
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Ballantyne GH et al (Obes Surg. 2005),
(adipoinsular axis theory). The fat mass
participates in the regulation of glucose and
insulin metabolism through the release of
adipocytokines in a mechanism called the
adipoinsular axis. Putative adipocytokines include
leptin, adiponectin and resistin.
How
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Frezza EE (Obes Surg. 2004 ), Intra-abdominal
fat deposition is associated with increased plasma
concentration of free fatty acids, which reduce
insulin sensitivity at both muscular and hepatic
sites. The progression of diabetes is heralded by
the inability of the beta-cells to maintain their
previously high rate of insulin secretion in
response to glucose, in the face of insulin
resistance.
How
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Patriti A (Obes Surg. 2004 ), (Enteroinsular axis
theory), Both GLP-1 and GIP have an impaired
secrtion effect in type 2 diabetics. GIP is a peptide
secreted by the duodenal K-cells in response to
ingested fat and carbohydrate. In obese type 2
diabetes patients, its receptor on beta-cells is
down-regulated. GLP-1 is a peptide secreted by
the gut L-cells, and, in type 2 diabetes, its
secretion is impaired.
Not known
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At this point, we are unable to correlate the different
findings of the many questions that arise, such as: 1) Does
the decrease in sensitivity to insulin result from
rearrangement of the insulin receptor? 2) Is weight loss
the trigger for decrease of insulin resistance? 3) Is
rearrangement of part of the intestine a mechanism to
trigger the secretion of hormones (incretins) that help in
insulin response? 4) Which mechanism controls the
insulin resistance?
The Epidemic of Obesity
Obesity, Metabolic Syndrome
and [US]
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The prevalence of obesity increases from an average of 6% in
healthy children to 20% in adolescent males and to a further 32% in
elderly patients.
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“The prevalence of MS in In the Middle East, as pointed out by pilot
observational projects, is estimated to be anywhere between 1525%. The medical system is unprepared to deal with this epidemic.”
Source: Elabbassi WN, Haddad HA.Department of Cardiology, University of Ottawa Heart
Institute, Ottawa, Canada.
Medical Complications of obesity
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Type 2 diabetes
Hypertension
Hyperlipidemia
CAD, CHF, CVA
PVD
DVT and pulmonary
embolism
SLEEP APNEA
Pulmonary HTN
Edema, skin breakdown
Venous stasis, ulcers
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Osteoarthritis
Gastroesophageal reflux
Gallbladder Disease
Fatty Liver
Menstrual irregularities
Infertility
Hypogonadism, ED,
anorgasmia
Urinary stress
incontinence
Pseudotumor cerebri
The Changing concept
Bariatric Surgery: Indications
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1991 NIH Consensus
 BMI
> 40 kg/m2
 BMI > 35 kg/m2 but with a serious co-morbidity:
Diabetes, severe hypertension, obstructive sleep
apnea, etc…
 Several failed attempts at dieting: “patients seeking
treatment for the first time should be considered” for
a non-surgical program.
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ASBS, SAGES, SSAT, EAES
How surgery can treat DM
The mechanism by which weight loss surgery
improves glucose metabolism and insulin
resistance remains controversial.
 Reduce food intake,
 Weight loss and
 Modifications of the enteroinsular axis
 Reduce certain GI hormonal level
Types of surgery
Adjustable gastric banding
Sep/1993= first
laparoscopic AGB
(Belachew M)
 Types of Adjustable
Bands:
1-Bioenterics = LapBand=Silicone
2-Swedish adjustable
gastric band
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Lap. Band
VS
SAGB
Indications for AGB
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Compliance ….compliance to follow dietary and sport instructions
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Strong and motivated patient
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history of significant weight loss by dieting program
Better: - lower BMI
- Non-sweet eater
- close to follow-up
General OR information
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OR time is almost 1 hr
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Excess weight loss is 30-40% in 6 months
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Can be day- surgery case
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Need 1-2cc filling every 4-6 weeks
LAGB complications
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Mortality rate is 1 in 2000 (0.05%)
Overall morbidity rate is 11.3%
Major complications requiring reoperation are 1%
to 4%
Complication of LAGB
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Gastric prolapse (2.2% to 24%)
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Reflux esophagitis
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Dysphagia
Stoma obstruction
Esophageal and pouch dilatation (10%)
Erosion (1%)
Gastric necrosis (0.25%)
Symptomatic gallstone disease (5%)
Psychological intolerance
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Outcome of LAGB and DM
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Ponce J et al (Obes Surg. 2004),
53/413 patients were taking medications for type 2
diabetes preoperatively
Had LAGB
Resolution of diabetes was observed in 66% at 1-year and
80% at 2-year follow-up.
HbA1c dropped from 7.25% (5.6-11.0, n=53)
preoperatively to 5.58% (5.0-6.2, n=15) at 2 years after
surgery.
Outcome of LAGB and DM
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Fielding G et al ( Obes Surg. 2003 )
88 patients had DM and underwent LAGB
37 of patients had all medication stopped at a median of
6.5 months following LAGB
Two-thirds of the diabetic patients have had remission of
diabetes following LAGB. LAGB is an effective
treatment for diabetes in obese patients.
Gastric bypass
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First Laparoscopic
gastric bypass was in
1993 by Wittgrove,
Clark, and Tremblay.
Surgical indications
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Sweet eater
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Older patients, less activity and motivation
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Better: - bigger BMI ( BMI ≥ 50)
- DM
General OR information
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OR time is almost 3-4 hours
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Excess weight loss is 60-70% in 6 months
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Important points :
- leakage rate is 5%
- close follow-up for vitamins, Ca level
Complications of LRYGBP
Anastomotic leakage
(2%-5%)
(2%-9%)
(0.5%-2%)
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Wound infection
Incisional hernia
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Mortality
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Bowel obstruction
GI bleeding
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(0.3%-3%)
(3.5%-20%)
(2%-4%)
Stomal stenosis
(4%-27%)
Conversion to open
(2.2%)
Pulmonary embolism
(0.5%)
Gastric perforation
( 1%)
Marginal ulcer
(1%-10%)
Symptomatic cholelithiasis (2%-4%)
Internal hernia
(0.7%-3.3%)
Pulmonary complication
(6%)
Malabsorpative complications
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Dumping syendrom
Diarreah
Hair loss
Anemia
Vitamines deficiency
Outcome of LROYGB and DM
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Stubbs RS et al (Obes Surg. 2005)
62/342 patients had type 2 diabetes
Follow-up was 10 years
85% of those with type 2 diabetes were cured and
10% had improved. No patients with impaired
glucose tolerance had progressed to diabetes.
Outcome of LROYGB and DM
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Goodman GN et al (Obes Surg. 1996 )
46/133 (35%) patients were on insulin preoperatively,
only 11/133 (8%) have remained on insulin and 9/11 at
lower doses
64/133 (48%) were on oral hypoglycemics, but only
8/133 (6%) continue their use
23/133 (17%) were on diet alone or no treatment before
surgery
91/133 (68%) claimed diet alone or no treatment after
surgery
Outcome of LROYGB and DM
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Wittgrove AC et al (Obes Surg. 1996 )
24/100 had DM who underwent LROYGB
Follow-up was for 30 months
Diabetes mellitus was normalized in 22 of 24
patients
RYGB and DM: Results
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68 patients with type II DM underwent RYGBP (66
laparoscopic, 2 open). One conversion to open
There were 24 women and 44 men with an average
age of 50 years. Average weight was 150 kg and average
BMI was 49.2 kg/m2.
Mortality:zero
Major morbidity within 30 days 5%.
%EWL 3, 6, and 12 months was 30, 50, and 70%.
DM resolved in 82.3% and improved in 16.7% at a mean
follow up of 6 months.
Clinical Observations: RYGB &
DM
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Improvement in DM is immediate and
precedes weight loss
Patients are less hungry and have different
taste threshold to sugar (less craving)
despite weight loss
Why: ?gastric restriction ?dumping
?Mechanical ?Hormonal
RYGB as a metabolic operation
Biliopancreatic diversion ± DS
Sleeve gastrectomy
Sleeve gastrectomy
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First introduced by Ganger Micheal in 2002
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It is the first step when you do Biliopancreatic diversion
with Duodenal switch procedure (BPD+DS)
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It is temporary step to reduce weight before the
permanent procedure which is BPD+DS (when BPD+DS
is difficult to be done duo to excessive fat or huge Lt.
liver lobe)
Indications for SG
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Super-super obese (BMI >65)
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First step to reduce weight before attempting
BPD+DS
General OR information
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OR time is 2-3 hours
Excess weight loss is 80% but can not be
maintained for longer than 3 years
It is a temporary procedure, which it need to be
completed later on
Stable line leakage is 5%
It may be even difficult to do or finish (duo to a
lot of fat or huge Lt. liver lobe
Vertical Banded Gastroplasty
Indications for VBG
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Big…big size single meal eater
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Non-sweet eater
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Non-compliance patients
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± motivated patients
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Does not loss significant by dieting history
General information VBG
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60% a mean excess weight loss
Less than 10% early morbidity rate
Less than 1% perioperative mortality
Nearly 80% failure rate (long term follow-up
Poor weight loss maintenance
15% to 20% reoperation rate duo to stomal outlet stenosis
or severe reflux
Outcome of VBG and DM
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Arribas del Amo D et al (Obes Surg. 2002 Jun )
9/80 patients had diabetes
follow-up > 5 years in 52 patients
Diabetes resolved in 55.55% (5 of 9 )
Bariatric Surgery: Impact on Mortality
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RCT: None
observational 2-cohort study:
SOS Trial: ? survival advantage at 10-years
?RYGB
 McGill (Christou): 0.68% vs. 6.17% 5-years
 Washington State (Flum): 16.3% vs. 11.8% at
15-years
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Age, gender, race
No DM HTN
HTN
DM
White female
18.5-24.9
5.2
20.8
29.8
25.0-29.9
6.3
16
30.5
30.0-34.9
6
13.3
27.4
35.0-39.9
5.4
12.4
24.4
≥ 40
4.7
11.8
21.1
18.5-24.9
7.9
27.1
35.9
25.0-29.9
6.9
17.8
31
30.0-34.9
6.8
14.3
27.2
35.0-39.9
6.5
13.9
29.1
≥ 40
8.7
18.6
28.1
18.5-24.9
4.5
19
33
25.0-29.9
4.6
13.7
22
30.0-34.9
4.7
12.8
19.3
35.0-39.9
5.8
15.2
17.2
≥ 40
5.4
10
24.3
18.5-24.9
8.6
30.5
39.3
25.0-29.9
6.9
18.7
27.2
30.0-34.9
7.3
13.8
26.4
35.0-39.9
7.4
22.3
21.3
≥ 40
9.4
22.3
20.8
White male
Black female
Black male
Age, gender, race
No DM HTN
HTN
DM
White female
18.5-24.9
5.2
20.8
29.8
25.0-29.9
6.3
16
30.5
30.0-34.9
6
13.3
27.4
35.0-39.9
5.4
12.4
24.4
≥ 40
4.7
11.8
21.1
18.5-24.9
7.9
27.1
35.9
25.0-29.9
6.9
17.8
31
30.0-34.9
6.8
14.3
27.2
35.0-39.9
6.5
13.9
29.1
≥ 40
8.7
18.6
28.1
18.5-24.9
4.5
19
33
25.0-29.9
4.6
13.7
22
30.0-34.9
4.7
12.8
19.3
35.0-39.9
5.8
15.2
17.2
≥ 40
5.4
10
24.3
18.5-24.9
8.6
30.5
39.3
25.0-29.9
6.9
18.7
27.2
30.0-34.9
7.3
13.8
26.4
35.0-39.9
7.4
22.3
21.3
≥ 40
9.4
22.3
20.8
White male
Black female
Black male
Conclusion
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Bariatric surgery is the only available effective
treatment for diabetes in patients with morbid
obesity.
Bariatric surgery should be viewed as metabolic
surgery.
We have to better refine indications for surgery.
Bariatric surgery should be performed in high
volume specialized centers.
Thank You
Q and A