2. Metabolic Surgery Abul Fazal Ali Khan Professor of Surgery Allama Iqbal Medical College Lahore

3. Dr. Abul Fazal Ali Khan Professor of Surgery Allama Iqbal Medical College Lahore Who would have thought it? An operation proves to be the most effective therapy for T2DM

4. Background Obesity and Metabolic Syndrome are serious chronic diseases associated with complex metabolic dysfunctions that increase the risk for morbidity and mortality The dramatic rise in the prevalence of obesity and diabetes has become a major public health issue It demands urgent attention from the government, healthcare systems and the medical community

5. Objectives What is Metabolic Syndrome? Current and future clinical applications of metabolic and diabetes surgery How I do it. Recommendations for Family Physicians

6. Metabolic Syndrome Abdominal obesity – waist circumference > 41” men, > 35” women Fasting blood glucose > 110 mg/dl Hypertriglyceridemia > 150 mg/dl Low HDL­cholesterol <40 mg/dl men, < 50 mg/dl women Hypertension (> 130/ >85)

7. Metabolic Surgery Treatment of metabolic derangements with alterations of the gut anatomy.

8. Questions & Skepticism Re: MS Is there a good medical therapy which can prevent medical complications How does MS work. Is it effective? Is it durable ? Is MS useful even if DM Relapses In which subset of patients MS is most effective Does it work in non obese patients Does MS prevent T2DM

9. Is There A Good Medical Therapy Which Can Prevent Medical Complications There is now good evidence that while good Med Treatment does benefit : There are associated problems like: 1. Compliance 2.Not effective in preventing certain complications 3.Cost of TM & unmitigated complications 4.Complications of MT

10. Is MS Really effective Improves insulin sensitivity and reduces insulin secretion. Blood glucose levels in diabetic patients improve within a week of MS, in advance of any weight loss. Caloric restriction, independent of adipose tissue mass, is one mechanism. A high proportion of obese patients with diabetes derive substantial metabolic benefit from bariatric surgery.

11. What is the Evidence to Support the Concept of Diabetes Surgery?

12. Who would have thought it? An operation proves to be the most effective therapy for T2DM Surgery is more effective than MT in treating T2DM 83% of type 2 diabetic subjects euglycaemic Pories WJ, Swanson MS, MacDonald KG, et al Annals of Surgery

13. Adams et al. 40% reduction in all­cause mortality 56% reduction in cardiovascular mortality 56% reduction in cancer mortality 90% reduction in diabetes­related mortality

14. MS: Effects on CVS Risk Factors Gleysteen and colleagues first reported the beneficial effects of GBP on diabetes, hypertension and lipid profiles, SOS study confirmed these findings with both GBP and LGB Regression of LVhypertrophy & reduction of carotid artery intima-media thickness.

15. Many -although not all - patients with type 2 diabetes are able to reduce or stop their diabetes medication after surgery

16. Subset of patients MS is most effective Subjects with shortest duration diabetes diet-controlled with greatest weight loss achieved Schauer et al.

17. Effects of Bariatric Surgery on Type 2 DM Are These Durable? Greenville series : 82.9% of 165 patients with T2DM remained in remission after an average of 14 years following RYGB Schauer et al : 83% of subjects undergoing LGBP achieved normal fasting plasma glucose. Even if DM eventually relapses benefits of MS persist

18. Does it work in non obese patients Consider surgery (RYGBS, LAGB, BPD) as a non-primary alternative for inadequately controlled T2DM with BMI 30-35 kg/m 2 Rubino et al. Annals of Surgery, 2009

19. Lap RYGBS for BMI 35: A tailored approach Ricardo Cohen, M.D.*, Jose S. Pinheiro, M.D., Jose L. Correa, M.D.,Carl os A. Schiavon, M.D. Surgery for Obesity and Related Diseases 2 (2006) 401–404 37 Diabetic patients on two oral meds 81% EWL at two years All patients had normalization of FBG off meds

20. Does MS Prevent T2DM MS can effectively prevent progression from impaired glucose tolerance to diabetes in severely obese individuals Sjostrom L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. NEngl JMed. 2004;351:2683-93.

21. 851 bariatric surgery patients 852 matched controls 10 year follow­up Significant reduction in incidence of diabetes in surgery group (7% v. 24%, p< 0.001) at 10 years

22. Some More Questions Which procedure is more effective? Is RYGBS safe?

23. Which procedure is more effective? Rates of Remission of Diabetes Adjustable Gastric Banding Roux­en­Y Gastric Bypass Biliopancreatic Diversion 48% (Slow) 84% (Immediate)>95% (Immediate)

24. ASMBS Bariatric Surgery Center of Excellence Program A total of 235 patients met inclusion criteria Outcomes of MS to Treat Diabetes Gastric bypass provided superior weight loss and diabetes. More effective for than adjustable gastric banding within 6 to 12 months 90-day complications: 18% vs. 3%, P < 0.05.Most complications were minor: No mortalities Early effectiveness of MS even in patients who did not have morbid obesity. A prolonged period of normalisation of glycaemic control has benefit for diabetes even if there is eventual relapse

25. Obesity Surgery-Mortality Risk Score Risk Factors 1.BMI≥50kg/m2 2.Male gender 3.Hypertension 4.Risk of PE 5.Age≥45y CategoryNo. of factors Reported Mortality A 46-49% 0-10.2-0.3% B 48% 2-31.2-1.9% C 3-5% 4-52.4-7.6% DeMaria et al. SOARD 2007 DeMaria et al. Ann Surg 2007

26. Recommendations Bariatric surgery in obese patients with T2D has a range of health benefits, including a reduction in all-cause mortality Surgery should be considered as complimentary to medical therapies to reduce micro-vascular and cardiovascular risk. When performed within accepted guidelines the morbidity and mortality is generally low, and similar to elective cholecystectomy. Long-term nutritional supplements and support must be provided to patients after surgery

27. Conclusions Gastrointestinal bypass procedures can improve diabetes by mechanisms beyond changes in food intake and body weight. Anatomic modification of the GI tract contribute to the amelio ration of T2DM through physiological mechanisms. It is a durable therapy for all the components of the metabolic syndr ome. Surgical therapy for Type 2 diabetes is highly effective in patients with both severe and mild obesity.

28. Thank You

29. Duodenal­Jejunal Bypass Sleeve 12 patients 60 cm DJBS placed endoscopically 23% excess weight loss at 12 weeks All 4 diabetic patients had normal fasting glucose levels off medication during DJBS therapy