1. Basic Concepts and Rationale of Metabolic Surgery Alper Çelik, M.D. Associate Professor of Surgery Turkish Metabolic Surgery Foundation www.metabolicsurgeryistanbul.com

2. 1st Question? Did initial vertebrates have an appendix epiploica?

4. Herbivore Voluminous and hypocaloric diet Distant hindgut Large and Long GI Tract Carnivore Hypercaloric diet Close hindgut Small and Short GI Tract

5. Who consumes the diet with higher caloric index?

6. 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.

7. It is the same with Fish !!

8. Tadpole intestine – transparency vision It is the same with Amphibians !!

9. The tadpole gut shortens dramatically during metamorphosis Schreiber A. M. et.al. PNAS 2005;102:3720-3725 Copyright © 2005, The National Academy of Sciences

10. Shortening of gut during metamorphosis Poorer plant foodRicher animal food (insects)

11. Bats with large digestive tract Bats Bats with small digestive tract Herbivore “vampires"

12. Folivores & Frugivores

14. 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) Human Australopitecus

15. Change in Food Industry Refined food Saccharification Coca-colanisation!!! And their metabolic outcomes.

16. 50cm 100cm Duodenal Switch 150-200cm “Metabolic” Gastric bypass The distance dilemma

17. 50cm 100cm Duodenal Switch 150-200cm “Metabolic” Gastric bypass Better metabolic results

18. 50cm 100cm Duodenal Switch 150-200cm “Metabolic” Gastric bypass Worse nutritional results

19. With richer diets it 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

21. HungerFood going fast to the gut Ghrelin Glp-1 Pyy Oxm Ghrelin Glp-1 Pyy Oxm Gastric emptying is blocked Gluttony Intestinal SatietyGastric Satiety = Full Satiety

22. Mechanical Restriction Bands, rings, narrow anastomoses  Static and permanent  An obstacle to food passage  Active at the first bite  Limits ingestion Functional Restriction  Circumstancial  Appears at the end of the meal  At the last bite  Limits stocking

23. 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

24. “Functional Restriction”

25. 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.).

26. There are two options that can provide; Ileal Proximalisation without significant malabsorption: Ileal Transposition and Transit Bipartition

27. DSIT By Alper Celik, M.D.

28. 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; 16:1371-79 Obes Surg 2008; 18:1343–1345 Ann Surg. 2012;256(1):104-10.

29. Therefore; Our aim in Metabolic Surgery should be to provide: Ileal Proximalisation

30. Without Significant Malabsorption

31. Thank you very much