bariatric/metabolic surgery and type 2 diabetes september 2015 deron ludwig md/erik simchuk md north...
TRANSCRIPT
![Page 1: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/1.jpg)
Bariatric/Metabolic Surgery and Type 2 Diabetes
September 2015Deron Ludwig MD/Erik Simchuk MD
North Valley Surgical AssociatesChico, CA.
![Page 2: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/2.jpg)
Disclosures
• None
![Page 3: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/3.jpg)
Scope of the Problem
• 50% of Americans Diabetic (12-14%) or Pre-Diabetic (38%)
• Most T2, Most common cause Obesity
JAMA Sept 2015
![Page 4: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/4.jpg)
Obesity Epidemic
![Page 5: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/5.jpg)
Obesity Epidemic
![Page 6: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/6.jpg)
What We Eat
![Page 7: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/7.jpg)
How Much We Eat
![Page 8: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/8.jpg)
How Much We Eat
![Page 9: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/9.jpg)
Hidden Danger in Our Food
![Page 10: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/10.jpg)
Hidden Danger in our Food
![Page 11: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/11.jpg)
WLS Procedure Type
![Page 12: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/12.jpg)
WLS Procedure Type
![Page 13: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/13.jpg)
Health Outcome: WLS
![Page 14: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/14.jpg)
Long-Term effects Of RYGB
• Ave f/u 6.9 years• EWL 60%• Insulin use 40% to 6%• HTN 73% to 54%• DL 71% to 54%
Obesity Surg. 2014
![Page 15: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/15.jpg)
LRYGB 10 YEARS
• EWL 57%• T2DM 83%• HTN 87%• DL 67%• OSA 76%
Soard June 2009
![Page 16: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/16.jpg)
LSG 5 year Results
• 30 Patients• EWL Year 1: 65%• Year 3: 62%• Year 5: 56%
• No Deaths or Major Morbidity
Am J Surg 2014
![Page 17: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/17.jpg)
Long-Term outcome after LSG
• 161 PT– EWL at 5 years: 63%– DL 81% – T2DM 85%– New GERD 27%
Soard Apr 2014
![Page 18: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/18.jpg)
LRYGB vs LSG prospective 5 yr results
• EWL LRYGB: 69%
• EWL LSG: 67%
• WL failures no different/Comparable effectiveness
Obesity Surg July 2014
![Page 19: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/19.jpg)
LRYGB vs LSG
• Retrospective: 200 Pt. each
• EWL same at 12 and 18 months
• Similar resolution comorbidities except slightly higher DM resolution of LRYGB
Soard July 2011
![Page 20: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/20.jpg)
LRYGB and LSG
• Both very effective and comparable for both weight-loss and improvement in health in short and long-term
![Page 21: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/21.jpg)
DIABESITY
• A direct relationship exist between the obesity epidemic and an emerging epidemic of diabetes in America.
• In the past two decades the rate of obesity has doubled in America.
• In the past two decades the rate of diabetes has doubled in America.
Source: Diabesity, Dr. Katherine Kaufman, former ADA president, Bantam Books, 2005
![Page 22: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/22.jpg)
DIABESITY• Diabetes is the sixth leading cause of death in the USA.• 2002: 71,000 Americans died from diabetes, but another
186,000 died from diabetes related conditions.• Diabetes increases the risk for heart disease sixfold and
multiplies the risk of stroke by four.
Source: Diabesity, Dr. Katherine Kaufman, former ADA president, Bantam Books, 2005
![Page 23: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/23.jpg)
DIABETES
![Page 24: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/24.jpg)
DIABESITY
• Diabetes is the most costly disease in America, consuming one out of every 7 dollars.– Today 1 in 5 dollars
• $137.7 billion per year with $92 billion spent on medical care and the remainder on lost wages, lost productivity.
Source: Diabesity, Dr. Katherine Kaufman, former ADA president, Bantam Books, 2005
![Page 25: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/25.jpg)
T2 Diabetes
![Page 26: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/26.jpg)
DIABESITY
• Cost of Diabetes 2012: 245 billion
Am Diabetes Assoc
![Page 27: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/27.jpg)
DIABESITY
• The annual cost of diabetes medical care was $10,683 in 2002 and $13,700 in 2012
• http://www.diabetes.org/diabetes-statistics/cost
![Page 28: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/28.jpg)
Cost of Diabetes 2012
![Page 29: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/29.jpg)
Who Would Have Thought It? An Operation Proves to Be the Most Effective Therapy for Adult-Onset Diabetes Mellitus, Pories WJ, Swanson MS, MacDonald KG et al. Annals of Surgery, 222:3, 1995
Could an Operation Cure Type II Diabetes?
![Page 30: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/30.jpg)
Traditional: Maximize diabetic control through strict diet, oral medications, insulin, or even insulin pump to slow the progression of diabetes and its sequela
Paradigm Shift
Bariatric Surgery today: If a patient has T2 Diabetes and Morbid Obesity (BMI ≥35)
Bariatric Surgery in ideal world: WLS for T2 diabetics with BMI ≥30
![Page 31: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/31.jpg)
T2 Diabetes
![Page 32: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/32.jpg)
International Diabetes FederationPosition Statement 2010/2011
• Bariatric surgery appropriate if T2DM and BMI >35
• Surgery should be prioritized if BMI >35 and T2DM– Previous wording surgery an “option”– That group often refractory to medical mgt
• Surgery considered for BMI >30 if not meeting medical treatment targets
![Page 33: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/33.jpg)
T2 Diabetes
![Page 34: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/34.jpg)
Case Study
• 62 y/o M: 404 lb. (BMI 63.3): MI/CAGB, CHF, Severe T2DM on 3 pills and >150 u insulin-10 YR duration, Diabetic ulcer, DL, OSA on BIPAP and O2, edema, CKD, narcotics for LBP/JT pain
• LRYGB 2006: Today: Wt. 200 lb.(BMI 27): OSA, DL, Renal, edema-resolved
• T2DM: improved with 35 u insulin/d
– WLS effects: DURATION/INSULIN
![Page 35: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/35.jpg)
Results of Bariatric SurgeryDiabetes
• 240 patients with T2DM• F/U mean 20 months, 80%• Clinical resolution: 83% (NL FBG and
HGBa1C and no meds)• Marked improvement 17%
– 100% response rate!
• Predictors of remission: duration less than 5 years, no insulin
Schauer PR,Burguera B. Effect of Lap r-y gastric bypass on Type II diabetes. Annals of Surgery Oct 2003.
![Page 36: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/36.jpg)
Results of Bariatric SurgeryDiabetes
• 117 patients with T2DM• Remission: 72 (74%)• Improvement: 25 (26%)
• Predictors of remission: Waist circumference (odds ration 2.4), absence of insulin treatment
Torquati. Is Roux-enY gastric bypass surgery the most effective treatment for Type 2 diabetes in morbidly obese patients? Journal of gastrointestinal surgery 2005.
![Page 37: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/37.jpg)
Results of Bariatric SurgeryDiabetes
• 608 Patients (open RYGB)• 14 year follow-up• 50% EBW loss• 83% clinical resolution diabetes• Ave 108 lb weight loss
Pories WJ. Ann Surg 1995.
![Page 38: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/38.jpg)
Results of Bariatric SurgeryDiabetes
• 154 patients with T2DM
• 1 year postop: 83% resolution
• 5 years postop: 86% resolution
Sugerman HJ, Wolfe LG. Ann Surg, Jun 2003
![Page 39: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/39.jpg)
Long-Term T2 DM remission LSG
• 88% off meds at 3 months
• 85% at 3 years
• 77% at 5 years
Soard July 2013/Dr Abbatini
![Page 40: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/40.jpg)
Bariatric Surgery vs Intensive Medical NEJM 2012
• Randomized controlled, 1 center (STAMPEDE), 1 year, 150 pt: Medical/LSG/RYGB
• Target A1c(6.0%) Medical 12%, Surgical 40% • Insulin use 38% in Med grp at 12 mo. /
4%RYGB-8%LSG surgery grp• EWL 88% RYGB/81% LSG/13% Med• AVE PRE A1C 9%/Duration 9 yr.
NEJM 2012/Dr Schauer
![Page 41: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/41.jpg)
Bariatric Surgery vs Medical treatment 3 year Outcomes NEJM 2014
• Primary End point A1C <6.0% 150 pt RCT– WLS: bypass 38%, Sleeve: 24%– Medical Group: 5%
• Secondary End points: QOL, WT, glucose lowering meds all significantly greater in surgical group
NEJM 2014/Dr Schauer
![Page 42: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/42.jpg)
Metabolic surgery vs. Conventional Medical
• 5yr RCT medical vs. Surgery (RYGB/BPD)– 40% CR at 5 yr (A1C <6.5%)-surgical grp (RYGB)
– 27% of medical had DM complic vs. none
– Wt loss, Lower lipids, CV risk, Med use in surg
The LANCET, Dr Mingrone, Sept 2015
![Page 43: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/43.jpg)
LSG vs Medical mgt
• At 2 years 76% surgical able to stop or reduce meds vs 26%– VA group with intense medical “MOVE” pgm
• 52% in medical group needed more meds
Dr Malbotra
![Page 44: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/44.jpg)
T2DM Class 1 Obesity
• BMI≥ 30• 4 RCT and 16 observational studies showing
benefit– Not usually covered by insurance or MEDICARE
• Same benefit as higher BMI for T2DM• Lap Band
![Page 45: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/45.jpg)
Class 1 Obesity
• Dr Abbatini/SOARD: T2DM BMI 30-34: 18 patients– 9 LSG: 88.8% resolution@1year– 9 Medical: no change
• D Lakdawala/SOARD: 52 Patients: LRYGB– EWL 72%@1yr, 68%@5yr– DM2: CR 73%@1yr/58%@ 5yr
![Page 46: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/46.jpg)
Class 1 Obesity
• RCT: 61 pt, BMI 30-35: Surgery vs. Lifestyle intervention. Endpoints: DM remission full/ partial, medication reduction
• 3 yr: 40% RYGB full or partial remission– 65% off insulin or oral DM meds– None in medical control grp
![Page 47: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/47.jpg)
T2DM: Paradigm Shift?
• Tremendous rapid/durable response with bypass and sleeve (100% improvement, majority CR)
• WLS should be prioritized for all T2DM with morbid obesity who are Surgical Candidates
• The earlier the intervention the better the CR rates (drop at 5 yr with large drop at 7)
![Page 48: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/48.jpg)
What about Morbidly ObeseType 1 DM?
• WLS: Sleeve or bypass improves insulin sensitivity/control, Improves other comorbid conditions like HTN/DL/OSA the same as Pt’s withT2DM
• Consider WLS referral for selected T1DM with morbid obesity
![Page 49: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/49.jpg)
Type 1 Diabetes Case Report
• 41F T1 DM x10 years, insulin pump 6 yr, BMI 38– 4.8 units insulin/hr, A1c Pre: 9.8%– Severe hypertriglyceridemia: 950-3000– GERD/SUI
• 10 months post LSG : 80lb wt loss, BMI 25• Insulin .3u/hr night, .6u/hr day, A1C 6.8%• Trig: 106, SUI/GERD resolved
![Page 50: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/50.jpg)
What About Surgical Risk?
• Intl Journal of Cardiology Mar 2014– 29000 pt’s, 14 studies– After surgery 50% less risk of CVA or MI– 40% lower death rate
Amer J Cardiol 2011: 52 studies/ 16,867 pt• 40% reduction in 10-yr Coronary dz risk
![Page 51: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/51.jpg)
What About Surgical Risk?
• SOS study surgery vs medical group– CV dz decreased by 72% at 5 years– Mortality from cardiac dz 59% lower – Mortality all causes 29% lower, 10.9 yr f/u(used mostly VBG/band, 2010 surgery pt vs 2037 med)
National Health and Nutrition Survey 99-2006Coronary heart risk increases with BMI >30
![Page 52: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/52.jpg)
What About Surgical Risk?
• Univ Utah 7,925 RYGB , 1984-02 compared to random controls with BMI>35
• 7 yr f/u: 40% lower death rate in surgical group– 92%less for T2DM– 59% less cardiac– 60% less for CA
![Page 53: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/53.jpg)
What About Surgical Risk?
• 1035 bariatric pt (1986-02)• 5746 matched medical controls• 5 yr F/U• EWL 67%• Mortality 0.68% vs 6.17% • Relative RR: 89%
Dr Christou, Ann of Surg Sept 2004
![Page 54: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/54.jpg)
FIVE-YEAR MORTALITY REDUCTION•89 Percent Reduction in Risk of Death Over Five Years
* Includes perioperative (30-day) mortality of 0.4%.
p-value 0.001Christou NV, Sampalis JS, Liberman M, et al. Surgery Decreases Long-Term Mortality, Morbidity, and
Health Care Use in Morbidly Obese Patients. Annals of Surgery 2004;240(3):416-424.
![Page 55: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/55.jpg)
What About Surgical Risk?
• People with BMI >30 have 50%-100% increased risk of premature death compared to healthy weight
• Risk of WLS today is 0.1%, less than gallbladder (0.7%) or hip replacement (0.93%)– Caveats: COE, Laparoscopic
• Overall risk of major complications 4.3%
![Page 56: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/56.jpg)
Why Surgery?
• WLS alleviates associated comorbid disease and prolongs length of life
• Risk of WLS today is far less than the natural history of severe obesity and associated health risks
![Page 57: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/57.jpg)
Medical Co-Morbidities Resolved
Wittgrove AC,Clark GW. Laparoscopic Gastric bypass roux-en-y-500 patients. Obes Surg 2000. And others.
![Page 58: Bariatric/Metabolic Surgery and Type 2 Diabetes September 2015 Deron Ludwig MD/Erik Simchuk MD North Valley Surgical Associates Chico, CA](https://reader035.vdocuments.site/reader035/viewer/2022062802/56649e8f5503460f94b92c91/html5/thumbnails/58.jpg)