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Daniel Tat-ming ChungPrincess Margaret Hospital
16th April 2011JHSGR
for weight Surgical procedures
designed to produce substantial weight loss.
Most effective therapy for severe obesity Reduction of morbidity
and mortality Quality of life
improvement
Oriental Daily 15th April 2011
In 2000: >171 million people worldwide suffer from diabetes = 2.8% of the population
Doubled by 2030
Narayan et al. Diabetic Care 2006
Greatest increase in prevalence:
Asia and AfricaWdiabetes: estimates for 2000 and projections ild et al. "Global prevalence of for 2030". Diabetes Care 2004
http://www.keyvive.com
Gaede et al. NEJM 2008
Insulin levels / HbA1c / Fasting glucose declined significantly postoperatively
No. ofStudy
No. of Patient
CompletelyResolved
Resolved orImproved
Buchwald et al. JAMA 2004 136 22094 76.8% 86.0%
Buchwald et al. Am J Med 2009
621 135,246
78.1% 86.6%
Buchwald et al. Am J Med 2009
Sjostrom et al. N Engl J Med 2004
0.1% - 2% Gastric banding: 0.1%
Released on 28 March 2011
“Bariatric surgery may be considered for adults with BMI 35 kg/m2 and type 2 diabetes, especially if the diabetes or associated comorbidities are difficult to control with lifestyle and pharmacologic therapy.’’ ADA Standard of Medical Care in Diabetes 2011
Pories et al. Ann Surg 1995
Wickremesekera et al. Loss of Insulin Resistance after Roux-en-Y Gastric Bypass Surgery: a Time Course Study. Obesity Surg 2005
“The changes in in insulin resistance seen after gastric bypass, which are responsible for the resolution or improvement of type 2 diabetes occur within 6 days of the surgery, before any appreciable weight loss has occurred “
WEIGHT LOSS RELATEDWEIGHT LOSS INDEPENDENCE
Morbidly obese subjects with normal glucose tolerance
Studied at 4 and 14 months
Insulin-mediated glucose disposal improved in proportion to the degree of weight loss
Pereira et al. 2003
Type 2 diabetic individuals improves glucose disposal much more significantly than in a comparable group where weight loss was induced by diet
Equivalent weight loss by RYGB or by diet in two groups of matched morbidly obese patients with type 2 diabetes produced changes in incretin levels which were strikingly different
Laferrere et al 2008
? Anatomical rearrangement
? Decreased caloric intake
? Malabsorption
Rubino et al. Effect of Duodenal–Jejunal Exclusion in a Non-obese Animal Model of Type 2 Diabetes - A New Perspective for an Old Disease. Ann Surg 2004
Early delivery of nutrients to the distal intestine enhances the incretin hormone effect Glucagon-like
peptide-1 (GLP-1) secreted by L-cell in distal ileum and colon
Distal ileum and Colon
Weight loss through ileal transposition is accompanied by increased ileal hormone secretion and synthesis in rats
Strader et al. 2005
After 3 weeks, all 5 patients with T2DM preoperatively had normal blood glucose levels without medication.
No conclusive evidence that RYGB increases the production of GLP-1
GLP-1 incraeses after RYGB: ? late adaptive phenomenon
Role in early improvement of DM remission is questionable
Prevention of duodeal passage of nutrient improve glucose tolerance only in diabetic patients
Glucose tolerance may actually deteriorate if the procedure is performed in non-diabetics
Schwarz et al. 1996 Rubino et al. 2006
Aberrant gastrointestinal signaling unique to the diabetic state
Possibly removed when the proximal intestine is bypassed
Rubino et al. The Mechanism of Diabetes Control After Gastrointestinal Bypass Surgery Reveals a Role of the Proximal Small Intestine in the Pathophysiology of Type 2 Diabetes. Ann Surg 2006.
27 < BMI < 33 25 < BMI < 35
Chiellini et al. 2009
EFFECTS OF BILIOPANCERATIC DIVERSION ON TYPE 2 DIABETES IN PATIENTS WITH BMI 25 TO 35
Scopinaro et al. 2011
Buchwald et al. JAMA 2004:Hyperlipidemia improved in 70% or more of patients
Hypertension was resolved in 61.7% of patients and resolved or improved in 78.5%.
Lower with LAGB (43%, 27% respectively)
Buchwald et al. JAMA 2004
Placed in the stomach to mimic restriction
Placed in the trans-pyloric area to delay or regulate gastric emptying
Endoscopically placed devices hysically fixed to the upper GI tract to mimic proximal gastric restriction of the LAGB
Endoluminal impervious sleeves to bypass the gastro-duodenal upper jejunal area to mimic the RYGB, or bypass the duodenum and proximal jejunum to mimic the DJB
Laparoscopic procedures to place novel electronic gastric or gastro-duodenal motility stimulators, and vagal nerve blocking devices
Bariatric metabolic surgery Distal vs Anti-incretin hypothesis Pathophysiology of type 2 DM Application on non-obese DM patient