metabolic surgery
DESCRIPTION
محاضرات عين شمسTRANSCRIPT
Metabolic SurgeryMohey Elbanna, MD FACS
Prof. of SurgeryAin Shams University
What is Metabolic Surgery ?
It is Surgery that aims to cure or improve Metabolic Sydrome
Metabolic SyndromeMetabolic syndrome is defined by the presence of
any three of the following conditions:
1- Elevated Fasting Blood Glucose > 126 mg/dL2- Elevated BP > 130/85 mm Hg3- Elevated Triglycerides > 150 mg/dL4- Reduced HDL Cholesterol <40 mg/dL (M) – 50 mg/dL (F)
Higher Risk of Cardiovascular Disease
What are the surgical operations ?
1- Duodenal Switch
2- Gastric Bypass
3- Sleeve Gastrectomy
Can this redefine Metabolic Surgery ?
Metabolic Surgery is Surgery that Cures or improves Metabolic Syndrome
It is GIT Surgery
And It is Bariatric Surgery
What is Bariatric Surgery ? Bariatric ?
Baros in Greek = Weight
Weight Loss Surgery
Bariatric Surgery1- Restrictive Procedures: Sleeve GastrectomyAdjustable Gastric BandVertical Banded GastroplastyGreater Curve Plication2- Malabsorptive Procedures:Biliopancreatic DiversionDuodenal Switch 3- Combined Procedures: Gastric Bypasses
Are All Bariatric Procedures Metabolic?No
Metabolic Surgeries are those that alter the GIT function to improve or cure Diabetes and Metabolic Syndrome
The Best Metabolic Procedure
Duodenal Switch
Gastric Bypass
Mini Gastric Bypass
Sleeve Gastrectomy
What are the results ? Mean ratios of patients with resolution ofT2DM after 2 years: Gastric Banding 48 % Vertical Banded Gastroplasty 68 %Sleeve Gastrectomy 80 % RYGB 84 % BPD or Duodenal Switch 98%
Efficacy A prospective study by Lee et al. (2008) evaluated
the effects of gastric bypass surgery in 44 patients with T2DM and BMI <35 kg/m2 as compared with 157 patients with BMI >35 kg/m2.3
After 4 years of postoperative follow-up, 90% of patients with BMI <35 kg/m2 and 98% of patients with BMI >35 kg/m2 experienced normalization of glycemia
The investigators concluded that 77% of those with a BMI <35 kg/m2 achieved the targets determined by the American Diabetes Association
What is the Goal Of Surgery?American Diabetes Association sets the targets:
HbA1C level <7.0% LDL-cholesterol level <2.59 mmol/l Serum triglyceride level <1.695 mmol/l
What is the SAFETY Profile ?
In this study including 201 patients
2.2% of patients experienced major complications (one fatality)
6.2% minor complications
Meta-analysisA meta-analysis of 361 studies that included a
total of 85,048 patients showed an overall mortality of 0.28% within 30 days after surgery, and a mortality of 0.35% between 30 days and 2 years after surgery.31 Several other studies reported surgical mortality of 0.25%–0.50%.
Non-glycemic Effects
70% of patients esperienced improvement in hyperlipidemia
79% of patients experienced improvement orresolution of hypertension
Is the Effect of Bariatric/Metabolic Surgery related to Weight Loss
Several studies proved that the improvement in the Metabolic Profile of the patient is independent of the weight loss effect of surgery
Adipocytokines (Adipokines)1. Leptin2. Tumor Necrosis Factor-alpha3. Interleukin-6 (IL-6)4. Angiotensinogen / PAI-15. Adiponectin6. Adipsin7. Resistin8. Visfatin9. Omentin
The IncretinsTwo:
1- Glucagon-Like Peptide 1 (GLP 1)
2- Gastric Inhibitory Peptide (Glucose-dependent insulinotropic polypeptide - GIP)
Both are rapidly inactivated by the enzyme dipeptidyl peptidase-4 (DPP-4)
Anti-incretin HypothesisIncretins include gut hormones, such as GLP-
1 and GIP, whose secretion is triggered by the passage of nutrients through the small bowel
These hormones increase glucose-stimulated insulin secretion by pancreatic β cells and also affect gastric emptying, nitrite influx and β-cell prolifereation (via anti-apoptotic effects)
Alterations of GIT hormonesA number of gastrointestinal hormonal changes
have been reported to occur following gastric surgery, consistent with the hypotheses that alterations in GIT anatomy affect endocrine functioning of the gut
For example, RYGB induces substantial hormonal changes, even before weight loss takes places
Increased levels of peptide YY and GLP have been consistently reported in several animal and human studies
RYGB seems to alter secretion of ghrelin and GIP
GIT and HormonesThese hormones are all involved in the
regulation of energy homeostasis via their effects on peripheral organs, as well as the brain
Although the exact molecular mechanisms that underlie the improvements in metabolism following gastric bypass surgery are not known, these findings establish that changes in GIT anatomy have profound effects on metabolism
ConclusionsTake Home MessagesWhen behavioral and pharmacological
interventions fail to manage T2DM, metabolic surgery offers an effective alternative, with the potential of complete remission of the disease
Traditional bariatric or metabolic surgeries are highly safe and effective in patients with obesity and T2DM
Gastrointestinal bypass techniques improve glucose homeostasis through mechanisms beyond reduced caloric intake and weight loss
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