Basic Concepts and Rationale of Metabolic Surgery

Alper Çelik, M.D.Associate Professor of Surgery

Turkish Metabolic Surgery Foundationwww.metabolicsurgeryistanbul.com

1st Question?

• Did initial vertebrates have an appendix epiploica?

HerbivoreVoluminous and hypocaloric dietDistant hindgutLarge and Long GI Tract

CarnivoreHypercaloric dietClose hindgutSmall and Short GI Tract

Who consumes the diet with higher caloric index?

The goat has a bigger stomach that than the dog’s stomach.

And longer intestines also.

the dog is not restricted.

The dog is adapted!

Is Sleeve gastrectomy a restrictive or adaptive procedure? Reflections o the concept of Restriction and Adaptation.

It is the same with Fish !!

Tadpole intestine – transparency vision

It is the same with Amphibians !!

The tadpole gut shortens dramatically during metamorphosis

Schreiber A. M. et.al. PNAS 2005;102:3720-3725

Copyright © 2005, The National Academy of Sciences

Shortening of gut during metamorphosis

Poorer plant food Richer animal food (insects)

Bats with large digestive tract

Bats

Bats with small digestive tract

Herbivore

“vampires"

Folivores & Frugivores

From: Aiello & Wheeler. Current Anthropology 36(2), 1995.

The human abdominal cavity became smaller, when compared to primitive

Australopithecus afarensis (a herbivore)

richer diet

(less fiber)

HumanAustralopitecus

Change in Food Industry

• Refined food• Saccharification• Coca-colanisation!!!• And their metabolic outcomes.

50cm

100cm

Duodenal Switch

150-200cm

“Metabolic” Gastric bypass

The distance dilemma

50cm

100cm

Duodenal Switch

150-200cm

“Metabolic” Gastric bypass

Better metabolic results

50cm

100cm

Duodenal Switch

150-200cm

“Metabolic” Gastric bypass

Worse nutritional results

With richer dietsit seems wise

to diminish the proximal gut and

to bring the ileum closer

But exclusions

might not be the best

solution

because they bring

malabsorption

Hunger Food going fast to the gut

Ghrelin Glp-1PyyOxm

Ghrelin Glp-1PyyOxm

Gastric emptying is blocked Gluttony

Intestinal Satiety

Gastric Satiety

=Full Satiety

Mechanical RestrictionBands, rings, narrow anastomoses

Static and permanentAn obstacle to food passageActive at the first biteLimits ingestion

Functional Restriction

CircumstancialAppears at the end of the mealAt the last biteLimits stocking

Gluttony is not a sin.

It is an instinct present in animals

Gluttony and large stomachs are

adaptations to type of food

and to scarcity

“Functional Restriction”

Why Functional Restriction?

• Because, we the surgeons do not have the right to end one form of addiction and replace it with another (iron, calcium, vitamins, etc.).

There are two options that can provide;

• Ileal Proximalisation without significant malabsorption:

• Ileal Transposition and Transit Bipartition

DSIT By Alper Celik, M.D.

Transit Bipartition

Neuroendocrine component

Easy and safe anastomosis

No bypass or excluded intestinal segmenti!No absorptive or nutritional problem!

Santoro et al. Rev bras videocir 2004; 2(3):130-138.

Obes Surg 2006; 16:1371-79Obes Surg 2008; 18:1343–1345 Ann Surg. 2012;256(1):104-10.

Therefore;

• Our aim in Metabolic Surgery should be to provide:• Ileal Proximalisation

Without Significant Malabsorption

Thank you very much