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Transcript of BARIATRIC SURGERY AND TREATMENT OF TYPE 2 DIABETES Bradley Schwack, MD Assistant Professor, Surgery...
BARIATRIC SURGERY AND TREATMENT OF TYPE 2
DIABETES
BARIATRIC SURGERY AND TREATMENT OF TYPE 2
DIABETES
Bradley Schwack, MD
Assistant Professor, Surgery
NYU School of Medicine
NYU Weight Management Program
Bradley Schwack, MD
Assistant Professor, Surgery
NYU School of Medicine
NYU Weight Management Program
BARIATRIC SURGERYBARIATRIC SURGERY
Definition of obesityDefinition of obesity
determined by height and weight
Body Mass Index (BMI)= kg/m2
100 lbs overweight
determined by height and weight
Body Mass Index (BMI)= kg/m2
100 lbs overweight
Degrees of Obesity Degrees of Obesity
NORMAL BMI 18.5 – 24.9
OVERWEIGHTBMI 25 – 29.9
OBESEBMI 30 – 34.9
SEVERE OBESEBMI 35 – 39.9
MORBIDLY OBESE
BMI 40
What does it mean to be obese?What does it mean to be obese?
hypertension hyperlipidemia diabetes mellitus respiratory
insufficiency obesity-
hypoventilation sleep apnea asthma
cardiomyopathy/MI GERD PE/DVT
hypertension hyperlipidemia diabetes mellitus respiratory
insufficiency obesity-
hypoventilation sleep apnea asthma
cardiomyopathy/MI GERD PE/DVT
CVA stress incontinence DJD wt-bearing joints low back pain venous stasis/ulcers cholelithiasis amenhorrhea infertility problems skin
infections/inflammation accident proneness
cancer (uterus, breast, colon, prostate)
CVA stress incontinence DJD wt-bearing joints low back pain venous stasis/ulcers cholelithiasis amenhorrhea infertility problems skin
infections/inflammation accident proneness
cancer (uterus, breast, colon, prostate)
Medical Implications:
Obesity is a U.S. public health epidemic: 64% Americans overweight 30% Americans obese 10% morbidly obese
400,000 deaths /year from obesity related causes
[90,000 deaths/yr from colon + breast ca]
#2 cause of preventable deaths #1 is smoking
Obesity is a U.S. public health epidemic: 64% Americans overweight 30% Americans obese 10% morbidly obese
400,000 deaths /year from obesity related causes
[90,000 deaths/yr from colon + breast ca]
#2 cause of preventable deaths #1 is smoking
Bariatric SurgeryBariatric Surgery
Bariatrics: The study of Obesity and its Treatments
Surgery: The science of operations
Bariatric surgery: A therapeutic intervention to understand and treat the cause and sequelae of morbid obesity.
Bariatrics: The study of Obesity and its Treatments
Surgery: The science of operations
Bariatric surgery: A therapeutic intervention to understand and treat the cause and sequelae of morbid obesity.
Rising Use of Weight Loss SurgeryRising Use of Weight Loss Surgery
Steinbrook, N Engl J Med, 2004Steinbrook, N Engl J Med, 2004
Bariatric Surgery and DiabetesBariatric Surgery and Diabetes
Meta-analysis (Buchwald et al – 2009) Overall remission rate of 78%
< 2 years since surgery 80% >2 years since surgery 75% Results seen with all operations, yet most dramatic
with the gastric bypass Not much data beyond 5 years
**If treated within 5 years of DM diagnosis—higher long term remission rates (Brethauer et al, 2013) – possible progressive loss of beta cell function
Meta-analysis (Buchwald et al – 2009) Overall remission rate of 78%
< 2 years since surgery 80% >2 years since surgery 75% Results seen with all operations, yet most dramatic
with the gastric bypass Not much data beyond 5 years
**If treated within 5 years of DM diagnosis—higher long term remission rates (Brethauer et al, 2013) – possible progressive loss of beta cell function
Bariatric Surgery and DiabetesBariatric Surgery and Diabetes
International Diabetes Federation (2011) Journal of Diabetes (3(2011): 261-264) “Bariatric surgery is an appropriate treatment
of people with T2D and obesity who are not achieving recommended treatment targets with existing medical therapies, especially in the presence of other major comorbidities”
<1% of those eligible actually have WLS for diabetes
International Diabetes Federation (2011) Journal of Diabetes (3(2011): 261-264) “Bariatric surgery is an appropriate treatment
of people with T2D and obesity who are not achieving recommended treatment targets with existing medical therapies, especially in the presence of other major comorbidities”
<1% of those eligible actually have WLS for diabetes
What do you do when you have 100 lbs to lose?
What do you do when you have 100 lbs to lose?
1991 NIH Consensus StatementBariatric Surgery
At BMI 40: risk of surgery < risk of morbid obesity
1991 NIH Consensus StatementBariatric Surgery
At BMI 40: risk of surgery < risk of morbid obesity
CONSENSUS STATEMENT* Bariatric Surgery for Morbid Obesity: Health Implications for
Patients, Health Professionals, and Third-Party Payers
H. Buchwald, J Am Coll Surg 2005; 200:593
Criteria for surgeryCriteria for surgery
BMI > 40 kg/m2
-OR- BMI > 35 kg/m2 and major medical
complications of obesity
-AND- Failure of other approaches to long-term
weight loss no substance abuse, psychoses or
uncontrolled depression
BMI > 40 kg/m2
-OR- BMI > 35 kg/m2 and major medical
complications of obesity
-AND- Failure of other approaches to long-term
weight loss no substance abuse, psychoses or
uncontrolled depression
How does surgery work?How does surgery work?
Restrictive - restrict amount of food ingested Decreases appetite/hunger Early satiety Behavior modification
Gastric Banding (Lap Band) Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy
Malabsorptive- limits digestion and absorption Decreases length of intestine exposed to digested food 25% of fat is absorbed Behavior modification
Biliopancreatic Diversion, Duodenal Switch (BPD/DS)
All operations can be performed open or laparoscopically
Restrictive - restrict amount of food ingested Decreases appetite/hunger Early satiety Behavior modification
Gastric Banding (Lap Band) Roux-en Y Gastric bypass (RYGB) Sleeve Gastrectomy
Malabsorptive- limits digestion and absorption Decreases length of intestine exposed to digested food 25% of fat is absorbed Behavior modification
Biliopancreatic Diversion, Duodenal Switch (BPD/DS)
All operations can be performed open or laparoscopically
Laparoscopic Roux en Y Gastric Bypass
Laparoscopic Roux en Y Gastric Bypass
Laparoscopic Roux en Y Gastric Bypass
Laparoscopic Roux en Y Gastric Bypass
1960s invented by Drs. Mason and Ito Restrictive: small gastric pouch (15-20cc) Intestinal anatomy:
Redirect the alimentary tract so that the gastric contents are directed 75-150cm distal to the ligament of Treitz .
Redirection of intestines has 2 fold impact: Avoid the reflux of bile and pancreatic juices into the gastric
pouch Variable malabsorbtive effect.
1960s invented by Drs. Mason and Ito Restrictive: small gastric pouch (15-20cc) Intestinal anatomy:
Redirect the alimentary tract so that the gastric contents are directed 75-150cm distal to the ligament of Treitz .
Redirection of intestines has 2 fold impact: Avoid the reflux of bile and pancreatic juices into the gastric
pouch Variable malabsorbtive effect.
-Gastric pouch: 15-20 ml•Food bypasses 95% stomach and duodenum•2 anastomoses•12 mm stoma•Inaccessible gastric remnant•Require life-long vitamin supplements•Side effects:
•dumping, •stomal stricture•Deficiencies- iron, calcium
•Theoretically reversible, but very difficult.
Gastric BypassGastric Bypass
The gastric bypass has been a recognized treatment of morbid obesity for over 40 years.
Laparoscopic: 1994 Wittgrove and Clark 5-6 small abdominal incisions (0.5-2.0cm) Inflate the peritoneal cavity with gas to create space to work Reduces trauma, operative exposure, surgical insult, and post-
operative pain. Proven an equally safe and effective means of weight loss. Level of comfort with procedure is a matter of surgeon opinion,
training, and experience.Wittgrove et al. 1994
Higa et al., 2001. Lugan et al, 2004.
The gastric bypass has been a recognized treatment of morbid obesity for over 40 years.
Laparoscopic: 1994 Wittgrove and Clark 5-6 small abdominal incisions (0.5-2.0cm) Inflate the peritoneal cavity with gas to create space to work Reduces trauma, operative exposure, surgical insult, and post-
operative pain. Proven an equally safe and effective means of weight loss. Level of comfort with procedure is a matter of surgeon opinion,
training, and experience.Wittgrove et al. 1994
Higa et al., 2001. Lugan et al, 2004.
Gastric BypassGastric Bypass
Gastric BypassGastric Bypass
1.5-2 years 60-68% excess weight loss Majority of weight loss in first 9 months Plateau at 1.5 years
5 years may regain 15%-20% excess wt
1.5-2 years 60-68% excess weight loss Majority of weight loss in first 9 months Plateau at 1.5 years
5 years may regain 15%-20% excess wt
Gastric Bypass ComplicationsGastric Bypass Complications
PneumoniaBlood clots in legsBleedingInfection
Perotinitis intestinal leakage (2-3%)Popped staples
Death: 1 in 200
Nutritional RisksNutritional Risks
Lifelong vitamins (Calcium, Fe, B-12) Daily multivitamin Bi-annual labs Watch for anemia Wait >18months before pregnancy Dehydration
Lifelong vitamins (Calcium, Fe, B-12) Daily multivitamin Bi-annual labs Watch for anemia Wait >18months before pregnancy Dehydration
Bypass and DiabetesBypass and Diabetes
Pories et al (1995)-Greenville, NC (ECU) >600 patients 83% w/ T2DM—normal glc, HbA1c, insulin 99% w/ glc intolerance—normal “No other therapy has produced such durable
and complete control of diabetes mellitus.” Ann Surg (1995; 222: 339-52)
Pories et al (1995)-Greenville, NC (ECU) >600 patients 83% w/ T2DM—normal glc, HbA1c, insulin 99% w/ glc intolerance—normal “No other therapy has produced such durable
and complete control of diabetes mellitus.” Ann Surg (1995; 222: 339-52)
Bypass and DiabetesBypass and Diabetes
Bypass shows more promising resolution of diabetes than the sleeve or band.
Parikh et al (2013)—Meta-analysis (1389pts) Remission rates (1 year):
33% Lap band 54% Sleeve 64% Gastric Bypass
Buchwald et al (2009) Resolution of T2DM
57% Lap band patients 80% Gastric bypass patients
Bypass shows more promising resolution of diabetes than the sleeve or band.
Parikh et al (2013)—Meta-analysis (1389pts) Remission rates (1 year):
33% Lap band 54% Sleeve 64% Gastric Bypass
Buchwald et al (2009) Resolution of T2DM
57% Lap band patients 80% Gastric bypass patients
Bypass and DiabetesBypass and Diabetes
Unique to bypass—DM resolution can come before weight loss
Rubino et al (2006) – animal studies Bypassing a short segment of proximal intestine
directly ameliorates T2DM, independent of food intake, body weight, etc.
Potentially undiscovered factors from proximal small bowel contributing to pathophysiology of DM
Unique to bypass—DM resolution can come before weight loss
Rubino et al (2006) – animal studies Bypassing a short segment of proximal intestine
directly ameliorates T2DM, independent of food intake, body weight, etc.
Potentially undiscovered factors from proximal small bowel contributing to pathophysiology of DM
Bypass and DiabetesBypass and Diabetes
Theories as to “why” (and factors unique to bypass?) Weight loss Ghrelin suppression (bypassed stomach) Metabolic due to exclusion of the proximal
small intestines (unsure of reasons why)
Theories as to “why” (and factors unique to bypass?) Weight loss Ghrelin suppression (bypassed stomach) Metabolic due to exclusion of the proximal
small intestines (unsure of reasons why)
Sleeve GastrectomySleeve Gastrectomy
Sleeve GastrectomySleeve Gastrectomy
Purely restrictive Partial gastrectomy of
greater curvature Leaves tube of
stomach sized to 32 French Bougie
No long term data
Purely restrictive Partial gastrectomy of
greater curvature Leaves tube of
stomach sized to 32 French Bougie
No long term data
Sleeve GastrectomySleeve Gastrectomy
1-2% risk of leak at upper stomach from staple line Possible re-operation Death Lengthy hospitalization
Possible re-operation for completion Gastric bypass or malabsorbtive procedure Lap Band Re-sleeve gastrectomy
1-2% risk of leak at upper stomach from staple line Possible re-operation Death Lengthy hospitalization
Possible re-operation for completion Gastric bypass or malabsorbtive procedure Lap Band Re-sleeve gastrectomy
Sleeve Gastrectomy and DiabtesSleeve Gastrectomy and Diabtes
“New Kid on the Block” Mechanism most likely related to acute
weight loss ? Ghrelin suppression No part of GI tract is bypassed
“New Kid on the Block” Mechanism most likely related to acute
weight loss ? Ghrelin suppression No part of GI tract is bypassed
Sleeve Gastrectomy and DiabetesSleeve Gastrectomy and Diabetes
Sleeve has been done as a primary operation for a few years
Small studies showing improvement of diabetes with weight loss
Some show equal remission to and some show a bit less remission than with bypass Factors may be higher vs lower BMI Insulin insensitivity vs low insulin production
Sleeve has been done as a primary operation for a few years
Small studies showing improvement of diabetes with weight loss
Some show equal remission to and some show a bit less remission than with bypass Factors may be higher vs lower BMI Insulin insensitivity vs low insulin production
The Laparoscopic Adjustable Gastric Band System
The Laparoscopic Adjustable Gastric Band System
A silicone band is placed around the upper part of the stomach
A small pouch is created Slows down gastric pouch
emptying Early feeling of satiety Surgical appetite suppressant
Purely restrictive Quick recovery Adjustable restriction
through mediport Reversible (if necessary)
Depends on surgeon and patient commitment (much f/u)
A silicone band is placed around the upper part of the stomach
A small pouch is created Slows down gastric pouch
emptying Early feeling of satiety Surgical appetite suppressant
Purely restrictive Quick recovery Adjustable restriction
through mediport Reversible (if necessary)
Depends on surgeon and patient commitment (much f/u)
LAP-BAND AdjustabilityLAP-BAND Adjustability
Unfilled Band Filled Band
Adjustments are made in the officeAdjustments are made in the office
% Excess Weight Loss% Excess Weight Loss
0
10
20
30
40
50
60
70
80
90
0 1 yr 2 yrs 3 yrs 4 yrs 5 yr
LapBandGBBPD
0
10
20
30
40
50
60
70
80
90
0 1 yr 2 yrs 3 yrs 4 yrs 5 yr
LapBandGBBPD
1 Pories 1995
2 Marceau, 1998; Hess 1998; Scopinaro 1998
3 O’Brien 1999; Cadiere 2000; Fielding1999; Dargent 1999; Belachew 1998
%E
WL
AdvantagesAdvantages
No intestinal surgery
No stapling/cutting of stomach
No nutritional risks
Adjustable
Reversible
Safe
No intestinal surgery
No stapling/cutting of stomach
No nutritional risks
Adjustable
Reversible
Safe
Foreign body Frequent follow-up
visits Needs more
commitment Easy to cheat
Foreign body Frequent follow-up
visits Needs more
commitment Easy to cheat
DisadvantagesDisadvantages
Complications of the BandComplications of the Band Slippage (5%)—gastric prolapse
Need reoperation laparoscopically Erosion (0.1%)—band erodes into lumen
Need laparoscopic removal Tubing breakage (1%)
Replace in day surgery Port infection (0.5%)
Antibiotics Weight loss failure (5%)
Remove laparoscopically and do a RNY Death: 1 in >3000
Slippage (5%)—gastric prolapse Need reoperation laparoscopically
Erosion (0.1%)—band erodes into lumen Need laparoscopic removal
Tubing breakage (1%) Replace in day surgery
Port infection (0.5%) Antibiotics
Weight loss failure (5%) Remove laparoscopically and do a RNY
Death: 1 in >3000
LAGB and DiabetesLAGB and Diabetes
Dolan and Fielding. Obes Surg, 2004 88 patients, BMI 45, Type II DM 2 years after surgery
51% EWL 65% patients off all medications (insulin, oral)
30% EWL by 6 months after surgery--> more likely to be off all DM medications
Dolan and Fielding. Obes Surg, 2004 88 patients, BMI 45, Type II DM 2 years after surgery
51% EWL 65% patients off all medications (insulin, oral)
30% EWL by 6 months after surgery--> more likely to be off all DM medications
Lap Band and DiabetesLap Band and Diabetes
Sultan et al (2010: SOARD 6:373-376.) 102 patients LAGB (5 year mean EWL 48.3%) 88% preop on meds for DM, 46.5% on @5yrs 14.9% preop on insulin for DM, 8.5% @ 5yrs HbA1c: 7.53 avg preop; 6.58 avg 5 yrs later DM resolved—no meds, glc, HbA1c—in 40% of
LAGB 5 years out Combined improvement/remission rate was 80%
at 5 years
Sultan et al (2010: SOARD 6:373-376.) 102 patients LAGB (5 year mean EWL 48.3%) 88% preop on meds for DM, 46.5% on @5yrs 14.9% preop on insulin for DM, 8.5% @ 5yrs HbA1c: 7.53 avg preop; 6.58 avg 5 yrs later DM resolved—no meds, glc, HbA1c—in 40% of
LAGB 5 years out Combined improvement/remission rate was 80%
at 5 years
Lap Band and DiabetesLap Band and Diabetes
Dixon et al (2012: Obesity Reviews 13:57-67) Remission improvement rates varied from 53-
70% within 2 years after LAGB placement Look at success of weight loss in lap band
populations as well Varied results
Dixon et al (2012: Obesity Reviews 13:57-67) Remission improvement rates varied from 53-
70% within 2 years after LAGB placement Look at success of weight loss in lap band
populations as well Varied results
Surgery Deters Progression of IllnessSurgery Deters Progression of Illness
8
1
24
7
2924
49
41
22
8
27
17
05
101520253035404550
Incidence (%)
2 YR 10 YR 2 YR 10 YR 2 YR 10 YR
DM HTN TG
ControlSurgery
8
1
24
7
2924
49
41
22
8
27
17
05
101520253035404550
Incidence (%)
2 YR 10 YR 2 YR 10 YR 2 YR 10 YR
DM HTN TG
ControlSurgery
SjSjööstrströöm et al., NEJM 2004,352:2683m et al., NEJM 2004,352:2683
StudyMortality
with SurgeryMortality
without Surgery
MacDonald, 1997 9% 28%
Christou, 2004 0.7% 6.1%
O’Brien, 2006 0.3% 10.6%
Surgery Decreases Long-term Mortality
Surgery Decreases Long-term Mortality
Restrictive Bariatric SurgeryRestrictive Bariatric Surgery
A tool against obesity Not a magic bullet Patient follow up and compliance is
necessary
A tool against obesity Not a magic bullet Patient follow up and compliance is
necessary
Restrictive Bariatric Procedures and Diabetes
Restrictive Bariatric Procedures and Diabetes
BARIATRIC PROCEDURES HAVE BEEN SHOWN TO BE SUPERIOR TO CONSERVATIVE THERAPY IN THE MANAGEMENT OF TYPE 2 DIABETES
Schauer et al (2012: N Engl J Med 366: 1567-1576)
Dixon et al (2011: SOARD 7: 433-447) “Internation Diabetes Federation taskforce”
BARIATRIC PROCEDURES HAVE BEEN SHOWN TO BE SUPERIOR TO CONSERVATIVE THERAPY IN THE MANAGEMENT OF TYPE 2 DIABETES
Schauer et al (2012: N Engl J Med 366: 1567-1576)
Dixon et al (2011: SOARD 7: 433-447) “Internation Diabetes Federation taskforce”
The Conclusion. . . .?The Conclusion. . . .?
Type 2 Diabetes BMI < 35 Moderate response to
conservative/medical treatment Will Bariatric Surgery be a treatment
option and will insurance companies cover such a procedure??
Type 2 Diabetes BMI < 35 Moderate response to
conservative/medical treatment Will Bariatric Surgery be a treatment
option and will insurance companies cover such a procedure??
This is not necessarily the goal of Bariatric Surgeon
This is not necessarily the goal of Bariatric Surgeon
The Goal is to be HealthyThe Goal is to be Healthy
55 – 70% of the excess weight off Feeling less tired and sick Off high blood pressure meds Control and possible remission of
Diabetes
55 – 70% of the excess weight off Feeling less tired and sick Off high blood pressure meds Control and possible remission of
Diabetes