Metabolic Effects of Bariatric Surgery on Diabetes Mr Paras Jethwa BSc MD FRCS FRCS(Gen Surg)...
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Transcript of Metabolic Effects of Bariatric Surgery on Diabetes Mr Paras Jethwa BSc MD FRCS FRCS(Gen Surg)...
![Page 1: Metabolic Effects of Bariatric Surgery on Diabetes Mr Paras Jethwa BSc MD FRCS FRCS(Gen Surg) Consultant Laparoscopic Surgeon.](https://reader036.fdocuments.net/reader036/viewer/2022062518/56649e8e5503460f94b9217f/html5/thumbnails/1.jpg)
Metabolic Effects of Bariatric Surgery on Diabetes
Mr Paras Jethwa BSc MD FRCS FRCS(Gen Surg)
Consultant Laparoscopic Surgeon
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Definitions
• Body Mass Index = weight/height2
< 20 = underweight20-25 = normal25-30 = overweight30-40 = obese > 40 = morbidly obese
• Excess Weight = Current Weight – Ideal Weight
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BMI > 30 1991
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BMI > 30 1992
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BMI > 30 1993
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BMI > 30 1994
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BMI > 30 1995
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BMI > 30 1996
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BMI > 30 1997
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BMI > 30 1998
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BMI > 30 1999
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BMI > 30 2000
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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 (%)
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Obesity Related Mortality
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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
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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
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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
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Laparoscopic Gastric Bypass
• Mean = 72% EWL• Best for– All BMI– Sweet eaters and grazers– Diabetics
• Mortality risk 1:300• Morbidity risk 1:75
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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
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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
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MGB success
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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
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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
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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
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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
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• 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
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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
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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
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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
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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.
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Diabetes• Bypass:– Type 2 - 87% resolution
• Band– Type 2 - 73% resolution
• 92% mortality risk reduction
• Clinically and cost effective for moderate to severe obesity
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Role of banding?• RCT of 80 patients• 2 year follow up• 87% v 22% excess weight
loss• Significant reduction in
metabolic syndrome
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• 50-77% of obese adolescents carry their obesity into adulthood
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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…
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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