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Screening and Follow-up in Obese subjects Bariatric Sugery: When?
Gabriella Garruti Department of Emergency and Organ Transplantation
Section of Internal Medicine, Endocrinology , Andrology and Metabolic Diseases
(Chairman: prof. F. Giorgino)
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Bari 27 novembre 2009
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What is Overweight?
Underweight <18.5 Kg/m2
Normal-weight 18.5 - 24.9 Kg/m2
Overweight 25.0 – 29.9 Kg/m2
Obesity category1st 30.0 – 34.9 Kg/m2
2nd 35.0 – 39.9 Kg/m2
3rd > 40.0 Kg/m2
BMIOverweight and Obesity: Overweight and Obesity:
When?When?
WAIST FAT distribution Central obesity
Man: > 9494 (102) cmWoman: > 8080 (88) cm
IDF /(ATPIII)
DietDiet Physical ActivityPhysical Activity
Lifestyle Lifestyle ModificationModification
PharmacotherapyPharmacotherapy
SurgerySurgery
Obesity Treatment Pyramid Obesity Treatment Pyramid
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Guidelines for Selecting Obesity Treatment
Treatment 25-26.9 27-29.9 30-34.9 35-39.9 >40
Diet, Exercise, Behavior Tx + + + + +
Pharmaco-therapy
With co-morbidities + + +
SurgeryWith co-
morbidities
+
The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. October 2000, NIH Pub. No.00-4084 modified by Garruti 2008
+
BMI Category (kg/mBMI Category (kg/m22))
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13.02.05
Gastric Bypass (Roux-en-Y)
Only when Lifestyle is unhealthyOnly when Lifestyle is unhealthy
Gastric banding
Bariatric surgery
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The operations employed for morbid obesity are not to be confused with plastic surgery
Real risk comes with each surgical procedure
Prospective patients should also be thoroughly convinced that they have exhausted all other reasonable avenues of weight loss before selecting surgery
The operations employed for morbid obesity are not to be confused with plastic surgery
Real risk comes with each surgical procedure
Prospective patients should also be thoroughly convinced that they have exhausted all other reasonable avenues of weight loss before selecting surgery
Bariatric surgery: what is?
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Indications1. BMI >40 kg/m2 or
BMI 35–39.9 kg/m2 and life-threatening cardiopulmonary disease, severe DIABETES, orlifestyle impairment
2. Failure to achieve WL with Medical Treatment
Controintraindications1. History of noncompliance with medical care2. Psychiatric illnesses: personality disorder, uncontrolled depression, suicidal
ideation, substance abuse3. elevated ASA risk
NIH Consensus Development Panel. Ann Intern Med 1991;115:956.
Bariatric Surgery: When ?
EAES /ASBS 2005
BMI 30-35 kg/m2 & life-threatening comorbidities
Sauerland et al. Surg Endosc 19:200
Buchwald et al. J Am Coll Surg 200:593
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Obesità di durata superiore a 5 anniObesità di durata superiore a 5 anni BMI BMI >> 40Kg/m 40Kg/m2 2 o BMI o BMI >>35Kg/m35Kg/m22 con comorbidità* con comorbidità* Età: da 18-65 anniEtà: da 18-65 anni Fallimento Tx medica (dietetica, farmacologica, Fallimento Tx medica (dietetica, farmacologica,
comportamentale) per almeno 1 annocomportamentale) per almeno 1 anno Assenza di cause endocrine di obesità Assenza di cause endocrine di obesità Rischio anestesiologico max < ASA 2Rischio anestesiologico max < ASA 2 Assenza di malattie psichiatriche e/o disturbi del Assenza di malattie psichiatriche e/o disturbi del
comportamento alimentare (DCA). comportamento alimentare (DCA). Compliance del paziente (follow-up)Compliance del paziente (follow-up)
NIH 1998- LIGIO 1999 EAES /ASBS 2005
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Indicazioni
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BMI BMI >>35 con 35 con comorbilità* comorbilità*
OSAS/PickwickOSAS/Pickwick Ipertensione arteriosa Ipertensione arteriosa Scompenso cardiacoScompenso cardiaco Diabete mellito tipo 2Diabete mellito tipo 2 OsteoartrosiOsteoartrosi ColelitiasiColelitiasi DislipidemieDislipidemie
Insuff. venosa cronica arti inferiori Insuff. venosa cronica arti inferiori Impotenza/Irregolarità Impotenza/Irregolarità
mestruali /Infertilitàmestruali /Infertilità IperuricemiaIperuricemia IrsutismoIrsutismo NefrolitiasiNefrolitiasi
Indicazioni
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Bariatric Sugery: how important is the multidisciplinary approach?
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Bariatric Sugery: how important is the multidisciplinary approach?
Anesthesiologist, Cardiologist, Dietitian or Nutritionist, Anesthesiologist, Cardiologist, Dietitian or Nutritionist, Endocrinologist , Pneumologist, Psychiatrist, SurgeonEndocrinologist , Pneumologist, Psychiatrist, Surgeon
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Valutazione clinica e strumentale prima della chirurgia
Esami ematochimici Esami ematochimici Inquadramento endocrino-metabolicoInquadramento endocrino-metabolico* e genetico* e genetico Rx torace Rx torace Ecografia addome superiore e inferioreEcografia addome superiore e inferiore Doppler venoso arti inferioriDoppler venoso arti inferiori Emogasanalisi, spirometria, polisonnografiaEmogasanalisi, spirometria, polisonnografia Inquadramento psicologico-nutrizionale (psichiatra e Inquadramento psicologico-nutrizionale (psichiatra e
dietisti)dietisti) Rx baritato (+Trendelenburg per ernia iatale)Rx baritato (+Trendelenburg per ernia iatale) EGDS + biopsia per infezione H. pyloriEGDS + biopsia per infezione H. pylori Consulenza cardio-anestesiologicaConsulenza cardio-anestesiologica
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Inquadramento endocrino-Inquadramento endocrino-metabolico e nutrizionalemetabolico e nutrizionale
Indagine alimentare, variabili antropometricheIndagine alimentare, variabili antropometriche Indici nutrizionaliIndici nutrizionali HOMA/ OGTT per glicemia e insulinemiaHOMA/ OGTT per glicemia e insulinemia Pattern ormonali: Pattern ormonali:
– asse ipofisi-surrene/gonadiasse ipofisi-surrene/gonadi– asse ipofisi-tiroideasse ipofisi-tiroide– asse GH /IGF1asse GH /IGF1
Ecografia tiroideaEcografia tiroidea Mineralometria ossea computerizzata “Total body”Mineralometria ossea computerizzata “Total body”
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• Palatableness (taste receptors)• Geography• Nutrients availability• Economic situation• Culture • Religion
Is Diet dependent on …?Is Diet dependent on …?
Energy needs Environment Genes (metabolism)
Your Gut Has Taste Receptors
ScienceDaily (Aug. 21, 2007)
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Lazar Science 2005 modified by Garruti
In the Pima, survival mechanisms evolved to store fat extremely efficiently (“thrifty genotype”)
This GENETIC MAKE-UP would have served the tribe well in the harsh
desert climes of the southwest Today this so-called "thrifty gene" means 70% of the Arizona Pima
are obese and diabetics
The Desert’s perfect foodsEt lucem sed aliam reddit…
Normalweight
Overweight
Obese
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Indagine alimentare Et lucem sed aliam reddit…
2200
62 99.2 154 41.8
2012% 28% 60%
3X X X
pane, pasta, condimenti, rusticiverdura
Dieta a b.i.g 1200 Kcal/Die Attività fisica (v. piramide attività fisica)
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Giovanna MallardiGiovanna Mallardi
Diet & Energy needsNeuronal circuits in the hypothalamus affect
Satiation (level of fullness during a meal which regulates the amount of food consumed)
Satiety (level of hunger after a meal is consumed which regulates the frequency of eating)
Schwartz et al. 2000 Nature
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Energy density: Volume versus calories
All foods have a certain number of calories within a given amount (volume)Foods with high energy density have a large number of calories in a small volumeAlternatively foods with low energy density provide a larger portion size with a fewer number of calories.
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0 1 2 3 4 5 6 7 8
Energy Density of Selected Foods
Energy Density (kcal/g)
LettuceVegetable soup
Skim milkApple
Black beansWhite fish
YogurtVegetable lasagna
Roast chickenWhite bread
PretzelsCheddar cheese
Salad dressingPotato chips
BaconButter
Klein S, et al. Gastroenterology. 2002
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HEALTHY PYRAMID FOOD (Harvard Medical School)
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ClassificationGastric restriction
Primarily restrictive and partially malabsorptive
Primarily malabsorptive and partially restrictive
Procedure
Adjustable Gastric Banding
Roux-en-Y Gastric Bypass Sleeve Gastrectomy
Biliopancreatic diversion with duodenal switch
Biliopancreatic diversion
Distal gastric bypass
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Restrictive Gastric Surgery
Vertical gastroplasty
Adjustable gastric banding
Intragastric balloon
(BIB)
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Laparoscopic Adjustable Gastric Banding
Silicone band placed around upper stomach to create a small pouch. Outlet diameter can be changed by infusing or withdrawing saline from port.
Gastric BandConnection tubing
Access port (reservoir)
American Society for Metabolic and Bariatric Surgery, www.asbs.org
LapBandTM
Puglisi 2008
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Roux-en-Y gastric bypass Et lucem sed aliam reddit…
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Sleeve gastrectomy with rerouting of small intestine through “nutrient limb” and “biliopancreatic limb”
Digestion and absorption are limited to 100 cm “common channel” of terminal ileum
Causes marked weight loss, but can lead to significant nutritional deficiencies
Biliopancreatic Diversion with Biliopancreatic Diversion with Duodenal SwitchDuodenal Switch
Marceau P. et al. World J Surg 1998;22:947-54
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Follow-up (post- LAGB and post-GBP)
0 1 3 6 9 12 15 18 21 24 0 1 3 6 9 12 15 18 21 24 months
EGDS Calibration
Rx ?Rx ?
Cardiologist, Dietitian or Nutritionist, Cardiologist, Dietitian or Nutritionist, Endocrinologist , Pneumologist, PsychiatristEndocrinologist , Pneumologist, Psychiatrist
surgeonsurgeon
……?
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Energy Metabolism in mammalsEnergy Metabolism in mammals
Basal Metabolic Rate[Obbligatory Thermogenesis (Th)]
Exercise-induced ThDiet-induced Th
Major effects of
Bariatric Surgery Weight
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Indagine alimentare Et lucem sed aliam reddit…
1000
99.2 154 41.8
3015% 28% 57%
3X X X
?
Dieta a b.i.g 1000-1200 Kcal/Die Attività fisica (v. piramide attività fisica)
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Maria A. Lucafo’ & Giovanna MallardiMaria A. Lucafo’ & Giovanna Mallardi
X X
Life-style modifications :
Anti-atherogenic Diet
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Suggested Energy Deficit based on Initial BMI
Initial BMI
(Kg/m2)
Suggested Energy Intake
(kcal/d)
Approximate Initial Energy Deficit
(kcal/d)
25-29.925-29.9 ?? 500500
30-34.930-34.9 ?? 500500
35-39.935-39.9 ?? 500-1000500-1000
>>4040 ?? 500-1000500-1000
>>50 50 ?? ??National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults – The Evidence Report. Obes Res. 1998;6(suppl 2):51S-209S
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Obrien et al. Ann Intern Med. 2006
Wei
ght L
oss,
%
Baseline
Surgical (LapBand)
Nonsurgical
*VLCD, behavioral modification, and pharmacotherapy
6 mo 12 mo 18 mo 24 mo
Weight Loss after Bariatric Surgery Weight Loss after Bariatric Surgery or Mor Medical edical TTherapyherapy**
BMI between
30 and 35 Kg/m2
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MesiMesi WL(Kg)/SEMWL(Kg)/SEM WE(Kg)/SEMWE(Kg)/SEM %EWL/SEM%EWL/SEM
1° mese 9.5/1.1 46.5/7.4 20.2/4.2
2° mese 14.4/2.5 48.5/7.2 23.6/3.8
3° mese 13.6/2.5 45.1/6.6 24.6/5.0
Parametri antropometrici dopo BIB
6° mese 18.0/8.0 40.0/5.6 27.0/7.8
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Parametri antropometrici dopo LapGB
Mesi WL(Kg)/SEM
WE(Kg)/SEM
%EWL/SEM
1° mese 6.0/1.0 46.0/7.7 13.0/2.3
3° mese 9.7/2.1 40.5/6.4 19.8/3.8
4° mese 9.3/3.7 39.6/5.3 19.7/3.3
8° mese 13.1/1.3 37.1/3.5 28.3/3.2
12° mese 11.8/2.3 38.8/3.76 26.2/5.4
18° mese 23.1/6.5 32.5/3.8 30.0/5.3
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% of subjects with low or high compliance
Excess Weight Excess Weight Loss (EWL) and Compliance to (EWL) and Compliance to CComprehensive omprehensive MMedical edical TTherapyherapy* * after Gastric Bandingafter Gastric Banding
lowhigh
low high
Lucafo’ MA, Rotelli MT, De Tullio A. 2008 unpublished
*[life-style modifications (diet, exercise) + pharmacotherapy]
%EWL in subjects with low or high compliance
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Procedure ApproximateLoss of Excess
Weight (%)
Laparoscopic gastric banding 45–65
Gastric bypass procedure 55–65
Biliopancreatic diversion (DS) 60–75
Effect of Different Bariatric Surgical Procedures on Weight Loss
Klein et al. Gastroenterology. 2002;123:882-932
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Comorbidity outcomes after Bariatric surgery
Comorbidity Improved/Resolved
Diabetes 100%
Coronary artery disease 100%
Hypercolesterolemia 96%
Gastroesophageal reflux d. 96%
Sleep apnea 93%
Hypertension 88%
Osteoarthritis 88%
Hypertriglyceridemia 86%
Depression 55%
Adapted from Schauer et al. Ann Surg 2000
Busetto et al. Obes Surg 2000 10: 569Busetto et al. Obes Surg 2000 10: 569
Pontiroli et al JCEM 2002 87:3555Pontiroli et al JCEM 2002 87:3555
Scopinaro et al. Diabetes Care 2005; 28:2406Scopinaro et al. Diabetes Care 2005; 28:2406
Busetto et al. NMCD 2008; 18:112Busetto et al. NMCD 2008; 18:112
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THE EFFECTS OF GASTRIC BANDING ON RED BLOOD CELL AGGREGATION & DEFORMABILITY IN MORBIDLY OBESE SUBJECTS
Puglisi Francesco, Capuano Palma, Giorgio Catalano, Garruti Gabriella, Trerotoli Paolo, Tedeschi Michele, De Fazio Michele, Cicco Giuseppe, Giorgino Francesco, Memeo Vincenzo
Total M FN 20 9 (45%) 11 (55%)Mean age (SD) 40.8 (12.2) 36.4 (11.3) 44.4 (12.3)Range 22-60 22-51 23-60
Mean Baseline weight (SD) 132.3 (23.4) 142.4 (26.9) 124 (17.3)Range 100-195 112-195 100-161
Mean Baseline BMI (SD) 45.8 (5.9) 45.6 (6.5) 45.9 (5.8)Range 37.4-58.6 37.4-55.7 38.9-58.6
Arterial hypertension 9 (45%) 3 (33.3%) 6 (54.5%)Hypertryglyceridemia 8 (40%) 5 (55.6%) 3 (27.3%)Smoke 7 (35%) 3 (33.3%) 4 (36.4%)Diabetes 7 (35%) 3 (33.3%) 4 (36.4%)Vascular dis. 5 (25%) 2 (22.2%) 3 (27.3%)Joint diseases 4 (20%) 1 (11.1%) 3 (27.3%)Hypoventilation syndrome 3 (15%) 1 (11.1%) 2 (18.2%)Heart diseases. 3 (15%) 2 (22.2%) 1 (9.1%) Anxiety-depression 3 (15%) 0 (0%) 3 (27.3%)Thyroid dysfunction 2 (10%) 0 (0%) 2 (18.2%)Gallbladder stones 1 (5%) 0 (0%) 1 (9.1%)
Box plot comparing EI 3 PA at baseline and 3 and 6 months after surgery.
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AI: aggregation index; EI: elongation index AI: aggregation index; EI: elongation index
T0 T3 T6p-values
T3 vs T0 T6 vs T0AI % 0.74 (0.04) 0.72 (0.05) 0.67 (0.06) 0.013 0.000AI t1/2 1.34 (0.36) 1.38 (0.3) 1.49 (0.29) 0.3447 0.189EI 0.03 Pa 0.042 (0.016) 0.039 (0.016) 0.043 (0.023) 0.32 0.757EI 3 Pa 0.379 (0.065) 0.412 (0.056) 0.449 (0.067) 0.049 0.0001EI 30 Pa 0.584 (0.128) 0.646 (0.043) 0.669 (0.064) 0.11 0.0274
Weight132.305 (23.446)
117.85 (25.775)
109.75 (25.007) 0.0001 0.0001
BMI 45.813 (5.977) 40.813 (6.867) 37.965 (6.792) 0.0001 0.0001
Tot Chol 207.8 (23.305) 196.6 (16.529)185.15
(18.883) 0.0045 0.0001HDL Chol 48.25 (11.201) 50.15 (10.277) 53.5 (8.918) 0.197 0.0048
LDL Chol 132.05 (21.197)128.21
(26.388) 122.2 (23.294) 0.086 0.0042
Tryglicerides 154.75 (51.759)138.85
(38.232) 129.7 (37.542) 0.0161 0.0038Glycaemia 103.7 (15.058) 99.65 (10.937) 97.65 (7.436) 0.16 0.38
Insulin 33.66 (17.155)27.171
(13.507) 24.29 (12.446) 0.001 0.0001
AI: aggregation index; EI: elongation index
THE EFFECTS OF GASTRIC BANDING ON RED BLOOD CELL AGGREGATION & DEFORMABILITY IN MORBID OBESE PATIENTS
Puglisi Francesco et al.
Box plot comparing AI% 3 at baseline and 3 and 6 months after surgery
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Bs 3M 6M
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BMI DISTRIBUTION IN A COHORT BMI DISTRIBUTION IN A COHORT OF TYPE 2 DIABETIC SUBJECTSOF TYPE 2 DIABETIC SUBJECTS
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GARRUTI G., VITA MG, GIAMPETRUZZI F et al. 2008 unpublished
LapGBLIMITILIMITI Anestesia Anestesia (vs Tx medica integrata)(vs Tx medica integrata) Limitato calo ponderale Limitato calo ponderale (vs Tx chirurgica malassorbitiva)(vs Tx chirurgica malassorbitiva) Obbligatorio “counseling” Obbligatorio “counseling” Alimentazione semiliquida per ~ 1 settimana Alimentazione semiliquida per ~ 1 settimana (600 - 800Kcal/die) (vs Terapia medica ed chirurgica malassorbitiva)(600 - 800Kcal/die) (vs Terapia medica ed chirurgica malassorbitiva) Durata del pasto:> 40 min Durata del pasto:> 40 min Intervallo tra cena e bed-time: 2 hIntervallo tra cena e bed-time: 2 h
VANTAGGI Dieta ipocalorica bilanciata (proteine 19,4%;
glucidi 56,2% ; lipidi 24,4%) + integratori Graduali modificazioni dell’immagine corporea
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Complications after Gastric Bypass The bypassed portion of intestine is where the majority of calcium and iron absorption takes place
LONG-TERM COMPLICATIONS
anemia osteoporosis
Other clinically important deficiencies
Vitamin B 1 (thiamine) Vitamin B 12 lack of gastric intrinsic factor
(GIF)
Lifelong follow-up with a daily multi-vitamins and mineral supplementation are strongly recommended to prevent nutritional complications
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GBP & Dumping syndromeGastric bypass operations may also cause "dumping syndrome" food or liquids travel too rapidly through the small intestine (sweets are often the culprit) Dumping symptoms include
nausea weakness sweating faintness diarrhea Symptoms dissipate after the patient rests???
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BraiBrainn
NPYAGRPgalanin
Orexin-Adynorphin
StimulateStimulateα-MSHCRH/UCNGLP-I
CARTNE5-HT
InibitInibit
Central SignalsCentral Signals
Glucose
CCK, GLP-1 Apo-A-IVVagal afferents
Insulin
Ghrelin
Leptin
Cortisol
Peripheral Peripheral signalssignals
Peripheral Peripheral organsorgans
+
+
Gastrointestinaltract
Adiposetissue
FoodIntake
Adrenal glands
External factorsEmotionsFood characteristicsLifestyle behaviorsEnvironmental cues
Regulation of Food IntakeRegulation of Food Intake
Schwartz et al. 2000 Nature
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ANP
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Adipose Tissue depots are a marvelous source of adipocyte
precursors stem cells
Any surgical procedureAny surgical procedure normalizes hyperglycemianormalizes hyperglycemia restores insulin sensitivityrestores insulin sensitivity prevents progression from IGT to DMprevents progression from IGT to DM reduces mortality from DMreduces mortality from DMGastric bypass and Biliopancreatic diversionGastric bypass and Biliopancreatic diversion restores euglycemia and normal insulin restores euglycemia and normal insulin long before any significant weight losslong before any significant weight loss
Changes in hormones secretion from the GI tract
Bariatric surgery and GlycaemiaBariatric surgery and GlycaemiaEt lucem sed aliam reddit…
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Bariatric Surgery in DM2:When?
““Should surgeons treat diabetes in severely obese people ?”Should surgeons treat diabetes in severely obese people ?”
J.H. Pinkney, SjJ.H. Pinkney, Sjööstrströöm C.D., Gale E.A.M. Lancet 2001 357: 1357m C.D., Gale E.A.M. Lancet 2001 357: 1357..
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Rubino et al 2004 Ann Surg 240(2): 236–242
Incretins and anti-incretins in DM2Et lucem sed aliam reddit…
Rubino et al. Ann Surg. 2004; 240(2): 236–242
Incretins and anti-incretins in DM2 after GBP
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[A] Simple gastro-jejunostomy
Enhanced delivery of nutrients to the hindgut without excluding
nutrient flow through the proximal intestine
No improvement of Diabetes in diabetic GK animals.
[B] DJB creates similar shortcuts of
nutrients as in gastro-jejunostomy
- includes the exclusion of the proximal intestine from the flow
of nutrients- improves glucose tolerance and
fasting glycemia in diabetic GK rats
Exclusion of the duodenum is critical for the effect on diabetes
Duodeno-jejunal bypass (DJB) and Diabetes
Rubino et al. Diab. Care 2008
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• Swiss pharmaceutical firm, Novartis, demonstrated in clinical studies that its investigational drug vildagliptin improves the function of pancreatic islets in both animals and humans.
• Vildagliptin, a novel investigational Incretin Enhancer, previously known as LAF237, inhibits DPP-4, resulting in an increase of circulating levels of GLP-1, a crucial incretin hormone.
Gastric inhibitory polypeptide (GIP), also known as the glucose-dependent insulinotropic peptide
Drucker, D. J. J. Clin. Invest. 2007;117:24-32
Dipeptidyl peptidase IV (DPP4) enzyme that breaks down gut peptides especially GLP-1
DPP-4 Inhibitors or Incretin Enhancers
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Different effect of GBP on GIP in diabetic and nondiabetic
patients
Rubino et al. Ann Surg. 2004; 240(2): 236–242
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Bariatric Surgery in DM2 & MbS:When?
IndicationsBMI >40 kg/m2 or BMI 35–39.9 kg/m2 and
life-threatening cardiopulmonary diseases
severe DIABETES
EAES /ASBS 2005
BMI 30-35 kg/m2 & life-threatening comorbidities
Sauerland et al. Surg Endosc 19:200
Buchwald et al. J Am Coll Surg 200:593
Systematic comparative studies with new therapeutic compounds
- CB1 antagonists
- CCK enhancers
- DPP4 inhibitors
- Incretin enhancers
- Glitazones
SurgerySurgeryV. MEMEOF. PUGLISI
P. CAPUANO M. TEDESCHI
M. A. LUCAFO’
PsychiatryPsychiatry L. ZAVOIANNI
Internal Medicine & Internal Medicine & EndocrinologyEndocrinology
F. GIORGINOG.MALLARDI
A. BELLOMO DAMATO F. BRESCIA
G.STEFANELLIG. MALLARDIA. DE TULLIO
Clinical NurtitionClinical NurtitionG. DE PERGOLA
L. MANDOI A. RAFFO
Anesthesia Anesthesia P. CARAVETTA
Acknowledgements
EndoscopyEndoscopyO. CAPUTI IAMBRENGHI
Laboratory of D.E.T.OLaboratory of D.E.T.O..M. T. ROTELLI
CardiologyCardiologyA. VENEZIANI
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Internal MedicineInternal MedicineR. GIORGINO
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PneumologyPneumology N. PALUMBO
O. RESTA