1. Bariatric Surgery and Metabolism Goal: to review 4 important and clinically relevant papers from 2010 on Bariatric Surgery and Metabolism 10/10/20151

2. Disclosures 1.I am still pissed we’re not at Vail. 2.Ethicon: Advisory board

3. Whistler 2004

5. Objective Metabolic surgery to treat type 2 diabetes mellitus in patients who do not meet body weight criteria for morbid obesity (BMI 30-35) Comparing LRYGB and LAGB in this patient population

6. Methods Bariatric Outcomes Longitudinal Database (BOLD) 66264 bariatric procedures 794 with BMI 30-35 kg/m 2 235 with diabetes requiring medication 109 LAGB ; 109 LRYGB 92% Laparoscopic

7. Results More severe DM in bypass group More complications in bypass group

8. Results Both procedures resulted in significant decrease in BMI, DM severity and # of DM medications Gastric bypass showed better results than gastric band

9. Results # DM Meds.BMI

10. Results

11. Conclusion Both LAGB and LRYGB achieve significant, favorable impact on type 2 diabetes in the moderately obese (BMI 30-35) Both procedures demonstrate a significant reduction in diabetes co-morbidity score and # of diabetes medication Gastric bypass provides more effective treatment at the price of higher complication rates (mostly minor)

13. Objective Evaluation of bariatric surgery as secondary prevention in obese patients with ischemic heart disease (IHD)

14. Methods 4047 subjects in the Swedish Obese Subjects (SOS) group 35 with IHD 21 treated with bariatric surgery ; 14 treated conventionally Mean follow-up 10.8 years

15. Methods SOS study:

16. Results Mean weight change At 2 and 10 years bariatric surgery resulted in significantly greater weight loss compared to the control group

17. Results

20. Conclusion Bariatric surgery appears to be a safe and feasible treatment to achieve long-term weight loss and improvement in cardio- vascular risk factors, symptoms and quality of life in obese subjects with IHD

22. Objective To present the longest follow-up report of any lipid-atherosclerosis interventional trial

23. Methods 25 years of follow-up in the POSCH study: Overall mortality Specific cause of death Prediction for increase in life expectancy

24. Results

28. Conclusion A 25 year mortality follow-up in POSCH shows statistically significant gains in overall survival, cardio-vascular disease free survival and life expectancy in the surgery group compared to the controlled group

30. Objective To investigate the rate of type 2 diabetes remission after gastric bypass and banding and establish the mechanism leading to remission of type 2 diabetes after bariatric surgery

31. Study 1: 34 obese type 2 diabetics Gastric bypass or banding 3 year follow-up Study 2 41 obese type 2 diabetics Gastric bypass, banding or very low calorie diet 42 day follow-up

32. Results Study 1

33. Results Study 2

36. Conclusion

38. Methods Trials comparing bariatric surgery vs. no surgery in patients with morbid obesity with the following end-points: Non-CV mortality CV mortality Global mortality – CV + non-CV

39. Results Small (<3000 pts.) vs. Large (>3000 pts.)

40. Results LAGB Vs. RYGB

41. Conclusion Bariatric surgery reduces the risk of global mortality, CV mortality and all-cause mortality compared to participants not undergoing surgery Risk reduction is lower in large studies than in small studies Both gastric bypass and gastric band seem to reduce mortality risk

42. Bariatric surgery and metabolism Other papers of interest

43. 10/10/201543

46. SUMMARY: Diabetes  Both restrictive (AGB) and malabsorptive (RGBP) procedures improve diabetic control  Improvement and remission of DM is significantly greater with malabsorptive (largely GBP), even with equivalent weight loss in some studies  Postprandial increase in GLP-1, insulin secretion and improvement in insulin resistance occurs only with GBP, even before weight loss; mechanisms (duodenal exclusion, incretin effects, neural, etc.) still incompletely explained  Restrictive and malabsorptive procedures both improve DM in patients with BMI 35 10/10/201546

47. SUMMARY: Mortality  Partial ileal bypass for hyperlipidemia improves 25 year survival, > in patients with baseline EF ≥ 50% (survival  by 1.7 years; 100,000 less deaths per million patients at 25 years)  Reduced mortality after both AGB and GBP compared to controls (global and all-cause)  ? Greater reduction in CV mortality with GBP reported in diabetics  Bariatric surgery can be performed safely in patients with IHD, but no reduction in CV events or deaths compared to controls (limitations of study: low BMI, small sample size, primarily restrictive procedures (VBG)) 10/10/201547