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Sleeve Gastrectomy The Metabolic Choice

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Why Sleeve Gastrectomy? We need a bariatric procedure that does not cause as much morbidity and does not need as much follow up as the current ones E.E. Mason Presidential Address 2007 ASMBS

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Mechanism of action 1. Restriction 2. Natural Band Formation 3. Hormonal

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1. Restriction LSG reduces the size of the gastric reservoir to 60-100 ml permitting intake of only small amounts of food and imparting a feeling of satiety earlier during a meal

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2. Natural Band The pylorus functions as a natural band in this procedure facilitating further restriction

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3. Ghrelin hormone produced mainly by P/D1 cells lining the fundus of the human stomach and epsilon cells of the pancreas that stimulates hunger Ghrelin levels increase before meals and decrease after meals. the counterpart of the hormone leptin, produced by adipose tissue, which induces satiation when present at higher levels

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3. Ghrelin By resecting the fundus in a LSG, the majority of ghrelin producing cells are removed reducing plasma ghrelin levels and subsequently hunger.

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Current Weight loss Evidence 35 Studies between 1/03 and 1/09 2,570 patients Pre-op BMI 35 69 kg/m 2 (mean 50) Post-op BMI 26 53 kg/m 2 ( mean 37) Follow-up 3 months to 5 years 33 83% EWL (mean 55%) Complication rate 0 24% 0 15% in 11 studies with n> 100 5 postoperative mortalities (0.19%)

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Sleeve Gastrectomy Good Excess Weight loss Technically feasible Safe

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Sleeve Gastrectomy and Diabetic Control

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Resolution, Remission or Cure It is generally accepted that effective medical or surgical diabetes therapy results in remission of the disease and not cure This generally means that the patient is off all hypoglycemic medications and/or insulin and that they have normal fasting plasma glucose, normal post prandial glucose excursions and normal HbA 1c

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| Bariatric Surgery Efficacy Buchwald H. JAMA, 2004 Procedure% EWLT2DM (Remission) Gastric Banding47% (n=1848)48% Gastric Bypass62% (n=4204) 84% BPD70% (n=2480)98%

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| Bariatric Surgery is Effective, But Not Equal-Where does sleeve fit in? 30 Day Mortality Adapted from Buckwald H, et al, Bariatric surgery, a systematic review and meta- analysis, JAMA. 2004;292:1724-1737 and Maggard M, et al, Meta-Analysis: Surgical Treatment of Obesity, Ann Intern Med. 2005;142:547-559. Risk Benefit 0.0010.010.1110 Banding Roux-en-Y Switch 10% 50% 100% Diabetes Resolution Rate Excess Weight Loss

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14 | Diabetes Surgical Interventions (DSI) Technical Complexity Low MediumHigh Low Medium High Efficacy

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How does a Sleeve Gastrectomy impart its Diabetic Remission?

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1. Hormonal Changes 2. Hindgut theory

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1. Hormonal Changes-Ghrelin Effect Marked Reduction of fasting ghrelin levels post- operatively Karamkos et al. 2008 Ghrelin is a hormone produced primarily by the gastric fundus Ghrelin : suppress the insulin sensitizing hormone adiponectin Blocks hepatic insulin signaling Inhibits insulin secretion By gastric fundus removal, the reduced circulating ghrelin level and its insulinostatic effect will increase the maximal captacity of glucose induced insulin release and enable the islet to secrete more insulin Abbatini et al. 2009

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| 2. The Hindgut Theory The more rapid delivery of undigested nutrients to the distal bowel upregulates the production of L-cell derivatives like GLP-1, Peptide YY Rubino et.al, Ann Surg, 2006 Mason E. Obes Surg 2005 15, 459-461

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The But we are not making any new anastamosis like a BPD or a RNYGB so how does this happen with a SG??? Melissas et al. Obes Surg 2007 gastric emptying half-time (T1/2) accelerated (47.6 +/- 23.2 vs 94.3 +/- 15.4, P