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

Thank You

Thank You