1. Effect of Metabolic Surgery on diabetes and hypertension

2. Objectives brief overview of Bariatric surgery
management of bariatric surgery patients and complications
effects of bariatric surgery on diabetes

3. Metabolic Syndrome
Central obesity. (defined as waist circumference ≥ 40 inches for men and ≥ 35cm for women)
raised TG level: ≥ 150 mg/dL
reduced HDL cholesterol: < 40 mg/dL
raised blood pressure: systolic BP ≥ 130 or diastolic BP ≥ 85 mm Hg, or treatment of previously diagnosed hypertension
raised fasting plasma glucose (FPG) ≥ 100 mg/dL or previously diagnosed type 2 diabetes

4. Metabolic Syndrome 54 Million Americans!
A quarter of the world’s adults have metabolic syndrome
twice as likely to die from, and three times as likely to have a MI or CVA
a five-fold greater risk of developing type 2 diabetes

5. The Metabolic Syndrome: A Network of Atherogenic Factors
9/14/2018
The Metabolic Syndrome: A Network of Atherogenic Factors
Type 2 diabetes and glycemic disorders
Dyslipidemia
- Low HDL
- Small, dense LDL particles
Hypertriglyceridemia
Hypertension
Impaired thrombolysis
-  PAI-1
Endothelial dysfunction/
inflammation
-  CRP, MMP-9
Microalbuminuria
Insulin
Resistance
 Free Fatty
Acids
Visceral Obesity
Atherosclerosis

6. Medical Sequelae of Obesity
Hypertension
Lipid disorders
Diabetes
Ischaemic heart disease
Cardiomyopathy
Pulmonary hypertension
Asthma
Obstructive sleep apnea
Gallstones
NASH (Non-alcoholic steatohepatitis)
Urinary incontinence
GERD
Arthritis/back pain
Infertility/menstrual problems
Obstetric complications
DVT and thromboembolism
Depression
Immobility
Breast/bowel/prostate/endometrial cancer
Venous stasis ulcers
Intertrigo
Accident prone

8. Body Mass Index BMI > 25: Over weight, 2/3rd US
BMI > 30: Obese, 1/3rd US
BMI > 40: Morbid Obese, 6% US (18 million Americans)

9. Criteria BMI > 40 BMI > 35 plus 1 or 2 co-morbidities
T2D , Hypertension
OSA, NASH
Hyperlipidemia, Pseudo tumor cerebri
Considerably impaired quality of life

10. Bariatric surgery or weight-loss surgery refers to surgery usually performed in patients with a body mass index (BMI) of 40 kg/m2 or greater and those with a BMI between 35 and 40 kg/m2 and a major medical comorbidity in order to:
Support weight loss
Treat or prevent obesity-related comorbidities (e.g., diabetes, hypertension, cardiovascular disease, obstructive sleep apnea)
The most common types of bariatric surgery include:
Laparoscopic adjustable gastric banding (LAGB)
Roux-en-Y gastric bypass (RYGB)
Sleeve gastrectomy
Biliopancreatic diversion with duodenal switch (BPD/DS)

12. Studies show that bariatric surgery causes significant weight loss and is more effective at improving diabetes in the short term (up to 2 years) than nonsurgical interventions (diet, exercise, other behavioral interventions, and medications).
Diabetes improvement starts rapidly after surgery, before significant weight loss has occurred.
The mechanism for postoperative metabolic improvements has not been fully elucidated and may be, in part, independent of weight loss.
This suggests that bariatric surgery may improve metabolic comorbidities even in patients who are not morbidly obese.

15. The Adipo-insular Axis
Free fatty acids and insulin resistance – Theories
Impaired insulin signaling (muscle) / glucose transport
Increased oxidative stress (reactive oxygen species)
Inhibition of insulin suppression of glycogenolysis in liver
Direct endothelial damage
Impairment of beta cell function
Alterations in blood pressure

16. Outcomes Non-Surgical management: only 5-10% success
T2D remission: up to 72% at 2 years
RYGB sustained remission of 62% at 6 years
All-cause mortality reduced by 40% 7 years after RYGB
Cause specific mortality reduction:
T2D 92%, Cancer 60%, CAD 56%

17. Pre-op work up Cardiology, Pulmonary, Psychiatry Home sleep study
Blood test
Clinical nutrition evaluation
smoking cessation
Pregnancy counseling

18. Thank you