1. The Surgical Treatment of Diabetes
Fahad Bamehriz, MD
Centre for Minimal Access Surgery
King Faisal Specialist Hospital and Research Centre
Riyadh

2. Introduction Obesity: - it is ≥ 20% than the ideal weight
- Body Mass Index (BMI) ≥ 30 kg/m²
. BMI = normal subject
= over-weight
= obese
= morbid obesity
= super MO

3. Introduction

4. Obesity and Diabetes BMI>= 40 kg/m2 and age< 55 years
Men
Women
Type 2 DM
18.1
12.9
BMI>= 40 kg/m2 and age< 55 years
Prevalence ratios generally were greater in younger than in older adults.
Must et al. The Disease Burden Associated With Overweight and Obesity JAMA. 1999;282:

5. How obesity will cause DM
Ballantyne GH et al (Obes Surg. 2005), (adipoinsular axis theory). The fat mass participates in the regulation of glucose and insulin metabolism through the release of adipocytokines in a mechanism called the adipoinsular axis. Putative adipocytokines include leptin, adiponectin and resistin.

6. How
Frezza EE (Obes Surg ), Intra-abdominal fat deposition is associated with increased plasma concentration of free fatty acids, which reduce insulin sensitivity at both muscular and hepatic sites. The progression of diabetes is heralded by the inability of the beta-cells to maintain their previously high rate of insulin secretion in response to glucose, in the face of insulin resistance.

7. How
Patriti A (Obes Surg ), (Enteroinsular axis theory), Both GLP-1 and GIP have an impaired secrtion effect in type 2 diabetics. GIP is a peptide secreted by the duodenal K-cells in response to ingested fat and carbohydrate. In obese type 2 diabetes patients, its receptor on beta-cells is down-regulated. GLP-1 is a peptide secreted by the gut L-cells, and, in type 2 diabetes, its secretion is impaired.

8. Not known
At this point, we are unable to correlate the different findings of the many questions that arise, such as: 1) Does the decrease in sensitivity to insulin result from rearrangement of the insulin receptor? 2) Is weight loss the trigger for decrease of insulin resistance? 3) Is rearrangement of part of the intestine a mechanism to trigger the secretion of hormones (incretins) that help in insulin response? 4) Which mechanism controls the insulin resistance?

9. The Epidemic of Obesity

10. Obesity, Metabolic Syndrome and [US]
The prevalence of obesity increases from an average of 6% in healthy children to 20% in adolescent males and to a further 32% in elderly patients.
“The prevalence of MS in In the Middle East, as pointed out by pilot observational projects, is estimated to be anywhere between 15-25%. The medical system is unprepared to deal with this epidemic.”
Source: Elabbassi WN, Haddad HA.Department of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada.

11. Medical Complications of obesity
Type 2 diabetes
Hypertension
Hyperlipidemia
CAD, CHF, CVA
PVD
DVT and pulmonary embolism
SLEEP APNEA
Pulmonary HTN
Edema, skin breakdown
Venous stasis, ulcers
Osteoarthritis
Gastroesophageal reflux
Gallbladder Disease
Fatty Liver
Menstrual irregularities
Infertility
Hypogonadism, ED, anorgasmia
Urinary stress incontinence
Pseudotumor cerebri

12. The Changing concept

13. Bariatric Surgery: Indications
1991 NIH Consensus
BMI > 40 kg/m2
BMI > 35 kg/m2 but with a serious co-morbidity: Diabetes, severe hypertension, obstructive sleep apnea, etc…
Several failed attempts at dieting: “patients seeking treatment for the first time should be considered” for a non-surgical program.
ASBS, SAGES, SSAT, EAES

14. How surgery can treat DM
The mechanism by which weight loss surgery improves glucose metabolism and insulin resistance remains controversial.
Reduce food intake,
Weight loss and
Modifications of the enteroinsular axis
Reduce certain GI hormonal level

15. Types of surgery

16. Adjustable gastric banding
Sep/1993= first laparoscopic AGB (Belachew M)
Types of Adjustable Bands:
1-Bioenterics = Lap-Band=Silicone
2-Swedish adjustable gastric band

17. Lap. Band VS SAGB

18. Indications for AGB
Compliance ….compliance to follow dietary and sport instructions
Strong and motivated patient
history of significant weight loss by dieting program
Better: - lower BMI
- Non-sweet eater
- close to follow-up

19. General OR information
OR time is almost 1 hr
Excess weight loss is 30-40% in 6 months
Can be day- surgery case
Need 1-2cc filling every 4-6 weeks

20. LAGB complications Mortality rate is 1 in 2000 (0.05%)
Overall morbidity rate is 11.3%
Major complications requiring reoperation are 1% to 4%

21. Complication of LAGB Reflux esophagitis Gastric prolapse (2.2% to 24%)
Dysphagia
Stoma obstruction
Esophageal and pouch dilatation (10%)
Erosion (1%)
Gastric necrosis (0.25%)
Symptomatic gallstone disease (5%)
Psychological intolerance

22. Outcome of LAGB and DM Ponce J et al (Obes Surg. 2004),
53/413 patients were taking medications for type 2 diabetes preoperatively
Had LAGB
Resolution of diabetes was observed in 66% at 1-year and 80% at 2-year follow-up.
HbA1c dropped from 7.25% ( , n=53) preoperatively to 5.58% ( , n=15) at 2 years after surgery.

23. Outcome of LAGB and DM Fielding G et al ( Obes Surg. 2003 )
88 patients had DM and underwent LAGB
37 of patients had all medication stopped at a median of 6.5 months following LAGB
Two-thirds of the diabetic patients have had remission of diabetes following LAGB. LAGB is an effective treatment for diabetes in obese patients.

24. Gastric bypass
First Laparoscopic gastric bypass was in 1993 by Wittgrove, Clark, and Tremblay.

25. Surgical indications Sweet eater
Older patients, less activity and motivation
Better: - bigger BMI ( BMI ≥ 50)
- DM

26. General OR information
OR time is almost 3-4 hours
Excess weight loss is 60-70% in 6 months
Important points :
- leakage rate is 5%
- close follow-up for vitamins, Ca level

27. Complications of LRYGBP
Anastomotic leakage (2%-5%)
Wound infection (2%-9%)
Incisional hernia (0.5%-2%)
Mortality (0.3%-3%)
Bowel obstruction (3.5%-20%)
GI bleeding (2%-4%)
Stomal stenosis (4%-27%)
Conversion to open (2.2%)
Pulmonary embolism (0.5%)
Gastric perforation ( 1%)
Marginal ulcer (1%-10%)
Symptomatic cholelithiasis (2%-4%)
Internal hernia (0.7%-3.3%)
Pulmonary complication (6%)

28. Malabsorpative complications
Dumping syendrom
Diarreah
Hair loss
Anemia
Vitamines deficiency

29. Outcome of LROYGB and DM
Stubbs RS et al (Obes Surg. 2005)
62/342 patients had type 2 diabetes
Follow-up was 10 years
85% of those with type 2 diabetes were cured and 10% had improved. No patients with impaired glucose tolerance had progressed to diabetes.

30. Outcome of LROYGB and DM
Goodman GN et al (Obes Surg )
46/133 (35%) patients were on insulin preoperatively, only 11/133 (8%) have remained on insulin and 9/11 at lower doses
64/133 (48%) were on oral hypoglycemics, but only 8/133 (6%) continue their use
23/133 (17%) were on diet alone or no treatment before surgery
91/133 (68%) claimed diet alone or no treatment after surgery

31. Outcome of LROYGB and DM
Wittgrove AC et al (Obes Surg (
24/100 had DM who underwent LROYGB
Follow-up was for 30 months
Diabetes mellitus was normalized in 22 of 24 patients

32. RYGB and DM: Results
68 patients with type II DM underwent RYGBP (66 laparoscopic, 2 open). One conversion to open
There were 24 women and 44 men with an average age of 50 years. Average weight was 150 kg and average BMI was 49.2 kg/m2.
Mortality:zero
Major morbidity within 30 days 5%.
%EWL 3, 6, and 12 months was 30, 50, and 70%.
DM resolved in 82.3% and improved in 16.7% at a mean follow up of 6 months.

33. Clinical Observations: RYGB & DM
Improvement in DM is immediate and precedes weight loss
Patients are less hungry and have different taste threshold to sugar (less craving) despite weight loss
Why: ?gastric restriction ?dumping ?Mechanical ?Hormonal
RYGB as a metabolic operation

34. Biliopancreatic diversion ± DS

35. Sleeve gastrectomy

36. Sleeve gastrectomy First introduced by Ganger Micheal in 2002
It is the first step when you do Biliopancreatic diversion with Duodenal switch procedure (BPD+DS)
It is temporary step to reduce weight before the permanent procedure which is BPD+DS (when BPD+DS is difficult to be done duo to excessive fat or huge Lt. liver lobe)

37. Indications for SG Super-super obese (BMI >65)
First step to reduce weight before attempting BPD+DS

38. General OR information
OR time is 2-3 hours
Excess weight loss is 80% but can not be maintained for longer than 3 years
It is a temporary procedure, which it need to be completed later on
Stable line leakage is 5%
It may be even difficult to do or finish (duo to a lot of fat or huge Lt. liver lobe

39. Vertical Banded Gastroplasty

40. Indications for VBG Big…big size single meal eater Non-sweet eater
Non-compliance patients
± motivated patients
Does not loss significant by dieting history

41. General information VBG
60% a mean excess weight loss
Less than 10% early morbidity rate
Less than 1% perioperative mortality
Nearly 80% failure rate (long term follow-up
Poor weight loss maintenance
15% to 20% reoperation rate duo to stomal outlet stenosis or severe reflux

42. Outcome of VBG and DM Arribas del Amo D et al (Obes Surg. 2002 Jun )
9/80 patients had diabetes
follow-up > 5 years in 52 patients
Diabetes resolved in 55.55% (5 of 9 )

43. Bariatric Surgery: Impact on Mortality
RCT: None
observational 2-cohort study:
SOS Trial: ? survival advantage at 10-years ?RYGB
McGill (Christou): 0.68% vs. 6.17% 5-years
Washington State (Flum): 16.3% vs. 11.8% at 15-years

44. Age, gender, race
No DM HTN
HTN DM
White female
5.2
20.8
29.8
6.3 16
30.5 6
13.3
27.4
5.4
12.4
24.4
≥ 40
4.7
11.8
21.1
White male
7.9
27.1
35.9
6.9
17.8 31
6.8
14.3
27.2
6.5
13.9
29.1
8.7
18.6
28.1
Black female
4.5 19 33
4.6
13.7 22
12.8
19.3
5.8
15.2
17.2 10
24.3
Black male
8.6
39.3
18.7
7.3
13.8
26.4
7.4
22.3
21.3
9.4

45. Age, gender, race
No DM HTN
HTN DM
White female
5.2
20.8
29.8
6.3 16
30.5 6
13.3
27.4
5.4
12.4
24.4
≥ 40
4.7
11.8
21.1
White male
7.9
27.1
35.9
6.9
17.8 31
6.8
14.3
27.2
6.5
13.9
29.1
8.7
18.6
28.1
Black female
4.5 19 33
4.6
13.7 22
12.8
19.3
5.8
15.2
17.2 10
24.3
Black male
8.6
39.3
18.7
7.3
13.8
26.4
7.4
22.3
21.3
9.4

46. Conclusion
Bariatric surgery is the only available effective treatment for diabetes in patients with morbid obesity.
Bariatric surgery should be viewed as metabolic surgery.
We have to better refine indications for surgery.
Bariatric surgery should be performed in high volume specialized centers.

47. Thank You
Q and A