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Mr Paras Jethwa BSc MD FRCS FRCS(Gen Surg) Consultant Laparoscopic Surgeon

Mr Paras Jethwa BSc MD FRCS FRCS(Gen Surg) Consultant Laparoscopic Surgeon. Metabolic Effects of Bariatric Surgery on Diabetes. Definitions. Body Mass Index = weight/height 2 < 20 = underweight 20-25 = normal 25-30 = overweight 30-40 = obese > 40 = morbidly obese

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Mr Paras Jethwa BSc MD FRCS FRCS(Gen Surg) Consultant Laparoscopic Surgeon

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  1. Mr Paras Jethwa BSc MD FRCS FRCS(Gen Surg) Consultant Laparoscopic Surgeon Metabolic Effects of Bariatric Surgery on Diabetes

  2. Definitions • Body Mass Index = weight/height2 < 20 = underweight 20-25 = normal 25-30 = overweight 30-40 = obese > 40 = morbidly obese • Excess Weight = Current Weight – Ideal Weight

  3. BMI > 30 1991

  4. BMI > 30 1992

  5. BMI > 30 1993

  6. BMI > 30 1994

  7. BMI > 30 1995

  8. BMI > 30 1996

  9. BMI > 30 1997

  10. BMI > 30 1998

  11. BMI > 30 1999

  12. BMI > 30 2000

  13. BMI > 30 2001

  14. Obesity Related Mortality

  15. 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

  16. 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

  17. 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

  18. Laparoscopic Gastric Bypass • Mean = 72% EWL • Best for • All BMI • Sweet eaters and grazers • Diabetics • Mortality risk 1:300 • Morbidity risk 1:75

  19. 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

  20. 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

  21. MGB success

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. Resolution / improvement of comorbidities

  29. 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

  30. 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

  31. Metabolic Surgery BMI > 40 or BMI >35 with Comorbidity NICE: CG43 Exhausted non surg methods Fit for op Willing First line for BMI>50 Part of MDT In young in exceptional circumstances psychological factors etc.

  32. Diabetes • Bypass: • Type 2 - 87% resolution • Band • Type 2 - 73% resolution • 92% mortality risk reduction • Clinically and cost effective for moderate to severe obesity

  33. Role of banding? • RCT of 80 patients • 2 year follow up • 87% v 22% excess weight loss • Significant reduction in metabolic syndrome

  34. 50-77% of obese adolescents carry their obesity into adulthood

  35. 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…

  36. 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

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