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Metabolic Surgery. Abul Fazal Ali Khan Professor of Surgery Allama Iqbal Medical College Lahore. Dr. Abul Fazal Ali Khan Professor of Surgery Allama Iqbal Medical College Lahore. Who would have thought it? An operation proves to be the most effective therapy for T2DM. Background.

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metabolic surgery

Metabolic Surgery

Abul Fazal Ali Khan

Professor of Surgery

Allama Iqbal Medical College Lahore

dr abul fazal ali khan professor of surgery allama iqbal medical college lahore
Dr. Abul Fazal Ali KhanProfessor of Surgery Allama Iqbal Medical CollegeLahore

Who would have thought it?An operation proves to be the most effective therapy for T2DM

  • Obesity and Metabolic Syndrome are serious chronic diseases associated with complex metabolic dysfunctions that increase the risk for morbidity and mortality
  • The dramatic rise in the prevalence of obesity and diabetes has become a major public health issue
  • It demands urgent attention from the government, healthcare systems and the medical community
  • What is Metabolic Syndrome?
  • Current and future clinical applications of metabolic and diabetes surgery
  • How I do it.
  • Recommendations for Family Physicians
metabolic syndrome
Metabolic Syndrome
  • Abdominal obesity 
    • waist circumference > 41” men, 

> 35” women 

  • Fasting blood glucose > 110 mg/dl 
  • Hypertriglyceridemia > 150 mg/dl 
  • Low HDL­cholesterol <40 mg/dl men, 

< 50 mg/dl women 

  • Hypertension (> 130/ >85) 
metabolic surgery1
Metabolic Surgery

Treatment of metabolic derangements 

with alterations of the gut anatomy. 

questions skepticism re ms
Questions & Skepticism Re: MS
  • Is there a good medical therapy which can prevent medical complications
  • How does MS work.
  • Is it effective? Is it durable ?
  • Is MS useful even if DM Relapses
  • In which subset of patients MS is most effective
  • Does it work in non obese patients
  • Does MS prevent T2DM
is there a good medical therapy which can prevent medical complications
Is There A Good Medical Therapy Which Can Prevent Medical Complications

There is now good evidence that while good Med Treatment does benefit :

There are associated problems like:

  • Compliance
  • Not effective in preventing certain complications
  • Cost of TM & unmitigated complications
  • Complications of MT
is ms really effective
Is MS Really effective
  • Improves insulin sensitivity and reduces insulin secretion.
  • Blood glucose levels in diabetic patients improve within a week of MS, in advance of any weight loss.
  • Caloric restriction, independent of adipose tissue mass, is one mechanism.
  • A high proportion of obese patients with diabetes derive substantial metabolic benefit from bariatric surgery.
what is the evidence to support the concept of diabetes surgery
What is the Evidence to Support the Concept of Diabetes Surgery?What is the Evidence to Support the Concept of Diabetes Surgery?
who would have thought it an operation proves to be the most effective therapy for t2dm
Who would have thought it?An operation proves to be the most effective therapy for T2DM

Surgery is more effective than MT in treating T2DM

83% of type 2 diabetic subjects euglycaemic

Pories WJ, Swanson MS, MacDonald KG, et al

Annals of Surgery

adams et al
Adams et al. 
  • 40% reduction in all­cause mortality 
  • 56% reduction in cardiovascular mortality 
  • 56% reduction in cancer mortality 
  • 90% reduction in diabetes­related mortality
ms effects on cvs risk factors
MS: Effects on CVS Risk Factors
  • Gleysteen and colleagues first reported the beneficial effects of GBP on diabetes, hypertension and lipid profiles,
  • SOS study confirmed these findings with both GBP and LGB
  • Regression of LVhypertrophy & reduction of carotid artery intima-media thickness.

Many -although not all - patients with type 2 diabetes are able to reduce or stop their diabetes medication after surgery

subset of patients ms is most effective
Subset of patients MS is most effective
  • Subjects with shortest duration diabetes
  • diet-controlled
  • with greatest weight loss achieved

Schaueret al.

effects of bariatric surgery on type 2 dm are these durable
Effects of Bariatric Surgery on Type 2 DMAre These Durable?
  • Greenville series : 82.9% of 165 patients with T2DM remained in remission after an average of 14 years following RYGB
  • Schaueret al : 83% of subjects undergoing LGBP achieved normal fasting plasma glucose.
  • Even if DM eventually relapses benefits of MS persist
does it work in non obese patients
Does it work in non obese patients

Consider surgery (RYGBS, LAGB, BPD) as a non-primary alternative for inadequately controlled T2DM with BMI 30-35 kg/m2Rubino et al. Annals of Surgery, 2009


Lap RYGBS for BMI 35:A tailored approach Ricardo Cohen, M.D.*, Jose S. Pinheiro, M.D., Jose L. Correa, M.D.,Carlos A. Schiavon, M.D. Surgery for Obesity and Related Diseases 2 (2006) 401–404

  • 37  Diabetic patients on two oral meds 
  • 81% EWL at two years 
  • All patients had normalization of FBG off meds
does ms prevent t2dm
Does MS Prevent T2DM

MS can effectively prevent progression from impaired glucose tolerance to diabetes in severely obese individuals

Sjostrom L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. NEnglJMed. 2004;351:2683-93.


851 bariatric surgery patients 

  • 852 matched controls 
  • 10 year follow­up 
  • Significant reduction in incidence of diabetes in 
  • surgery group   (7% v. 24%, p< 0.001) at 10 years
some more questions
Some More Questions
  • Which procedure is more effective?
  • Is RYGBS safe?
which procedure is more effective rates of remission of diabetes
Which procedure is more effective?Rates of Remission of Diabetes 
ASMBS Bariatric Surgery Center of Excellence Program A total of 235 patients met inclusion criteriaOutcomes of MS to Treat Diabetes
  • Gastric bypass provided superior weight loss and diabetes. More effective for than adjustable gastric banding within 6 to 12 months
  • 90-day complications: 18% vs. 3%, P < 0.05.Most complications were minor: No mortalities
  • Early effectiveness of MS even in patients who did not have morbid obesity.
  • A prolonged period of normalisation of glycaemic control has benefit for diabetes even if there is eventual relapse
obesity surgery mortality risk score
Risk Factors


Male gender


Risk of PE


Obesity Surgery-Mortality Risk Score

DeMaria et al. SOARD 2007

DeMaria et al. Ann Surg 2007

  • Bariatric surgery in obese patients with T2D has a range of health benefits, including a reduction in all-cause mortality
    • Surgery should be considered as complimentary to medical therapies to reduce micro-vascular and cardiovascular risk.
  • When performed within accepted guidelines the morbidity and mortality is generally low, and similar to elective cholecystectomy.
  • Long-term nutritional supplements and support must be provided to patients after surgery
  • Gastrointestinal bypass procedures can improve diabetes by mechanisms beyond changes in food intake and  body weight.
  • Anatomic modification of the GI tract contribute to the amelioration of T2DM through  physiological mechanisms.
  • It is a durable therapy for all the components of the metabolic syndrome.
  • Surgical therapy for Type 2 diabetes is highly effective in  patients with both severe and mild obesity.
duodenal jejunal bypass sleeve
Duodenal­Jejunal Bypass Sleeve
  • 12 patients 
  • 60 cm DJBS placed endoscopically 
  • 23% excess weight loss  at 12 weeks 
  • All 4 diabetic patients had

normal fasting glucose 

  • levels off medication during

DJBS therapy