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Basic Concepts and Rationale of Metabolic Surgery
Alper Çelik, M.D.Associate Professor of Surgery
Turkish Metabolic Surgery Foundationwww.metabolicsurgeryistanbul.com
1st Question?
• Did initial vertebrates have an appendix epiploica?
HerbivoreVoluminous and hypocaloric dietDistant hindgutLarge and Long GI Tract
CarnivoreHypercaloric dietClose hindgutSmall and Short GI Tract
Who consumes the diet with higher caloric index?
The goat has a bigger stomach that than the dog’s stomach.
And longer intestines also.
the dog is not restricted.
The dog is adapted!
Is Sleeve gastrectomy a restrictive or adaptive procedure? Reflections o the concept of Restriction and Adaptation.
It is the same with Fish !!
Tadpole intestine – transparency vision
It is the same with Amphibians !!
The tadpole gut shortens dramatically during metamorphosis
Schreiber A. M. et.al. PNAS 2005;102:3720-3725
Copyright © 2005, The National Academy of Sciences
Shortening of gut during metamorphosis
Poorer plant food Richer animal food (insects)
Bats with large digestive tract
Bats
Bats with small digestive tract
Herbivore
“vampires"
Folivores & Frugivores
From: Aiello & Wheeler. Current Anthropology 36(2), 1995.
The human abdominal cavity became smaller, when compared to primitive
Australopithecus afarensis (a herbivore)
richer diet
(less fiber)
HumanAustralopitecus
Change in Food Industry
• Refined food• Saccharification• Coca-colanisation!!!• And their metabolic outcomes.
50cm
100cm
Duodenal Switch
150-200cm
“Metabolic” Gastric bypass
The distance dilemma
50cm
100cm
Duodenal Switch
150-200cm
“Metabolic” Gastric bypass
Better metabolic results
50cm
100cm
Duodenal Switch
150-200cm
“Metabolic” Gastric bypass
Worse nutritional results
With richer dietsit seems wise
to diminish the proximal gut and
to bring the ileum closer
But exclusions
might not be the best
solution
because they bring
malabsorption
Hunger Food going fast to the gut
Ghrelin Glp-1PyyOxm
Ghrelin Glp-1PyyOxm
Gastric emptying is blocked Gluttony
Intestinal Satiety
Gastric Satiety
=Full Satiety
Mechanical RestrictionBands, rings, narrow anastomoses
Static and permanentAn obstacle to food passageActive at the first biteLimits ingestion
Functional Restriction
CircumstancialAppears at the end of the mealAt the last biteLimits stocking
Gluttony is not a sin.
It is an instinct present in animals
Gluttony and large stomachs are
adaptations to type of food
and to scarcity
“Functional Restriction”
Why Functional Restriction?
• Because, we the surgeons do not have the right to end one form of addiction and replace it with another (iron, calcium, vitamins, etc.).
There are two options that can provide;
• Ileal Proximalisation without significant malabsorption:
• Ileal Transposition and Transit Bipartition
DSIT By Alper Celik, M.D.
Transit Bipartition
Neuroendocrine component
Easy and safe anastomosis
No bypass or excluded intestinal segmenti!No absorptive or nutritional problem!
Santoro et al. Rev bras videocir 2004; 2(3):130-138.
Obes Surg 2006; 16:1371-79Obes Surg 2008; 18:1343–1345 Ann Surg. 2012;256(1):104-10.
Therefore;
• Our aim in Metabolic Surgery should be to provide:• Ileal Proximalisation
Without Significant Malabsorption
Thank you very much