NEUE CHIRURGISCH- ENDOSKOPISCHE THERAPIEN
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1 NEUE CHIRURGISCH- ENDOSKOPISCHE THERAPIEN FÜR ADIPOSITAS UND DIABETES Ricardo Zorron, MD, PhD Adipositaszentrum Charité Center for Innovative Surgery- ZIC Department of Surgery Campus Charité Mitte, Campus Virchow Klinik Charité Universitätsmedizin Berlin Head: Univ.-Prof. Dr. med. J. Pratschke
2 Neue Therapien für Adipositas und Diabetes 1. The Route for Innovation... Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
3 Neue Therapien für Adipositas und Diabetes 1. The Route for Innovation... Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
4 In 2005 GV Rao, DN Reddy, India
5 Rio de Janeiro, 13 March 2007 Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
6 Human transvaginal access... Sleeve gastrectomy
7 Down-to-Up TME Zorron et al. Surg Innovation 2010 Term coined by Zorron et al in 2009 Retrograde TME-flexible or rigid Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
8 Neue Therapien für Adipositas und Diabetes 1. Improving Access and Cosmesis 2. Innovative Solutions 3. Inverting the thoughts Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
9 Relative Weight Loss Minimally Invasive Bariatric Procedures RYGB Sleeve Gastrectomy BPD/DS? HIGH RISK Endoscopic Suturing Intragastric Balloons Diet/Medications Procedure Invasiveness Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
10 Apollo Endosurgery Group 2007 Apollo Overstich The Group designed first prototype for NOTES CJ Gostout Mayo Clinic J Pasricha Stanford S Kantsevoy J Hopkins A Kalloo J Hopkins R Zorron UFRJ, Rio Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
11 Endoscopic Sleeve Gastroplasty- Apollo Overstich Mean number of sutures= 26 ( min) Abu Dayyeh, CJ Gostout 2013
12 Endoscopic Sleeve Gastroplasty (ESG) First Series in Germany- Charité Zorron R. Endoscopic Sleeve Gastroplasty for Superobese. MIBE Madrid 2017
13 Endoscopic Sleeve Gastroplasty ESG for Superobese Indication: Impenetrable Abdomen Patient 8 Multiple Operations Giant Incisional Hernias Patient 1 Patient 3 Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
14 Endoscopic Sleeve Gastroplasty ESG Indication: High OP Risk Male, 37 y-old, 310kg BMI: 72 ASA 3 Respiratory Insufficiency As a 2-Step Concept Patient 4 Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
15 Endoscopic Sleeve Gastroplasty ESG Indication: High OP Risk Male, 45 y-old, 176kg BMI: 65 Liver Cirrhosis Esophageal Varices G 1 Aborted surgical Sleeve Patient 5 Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
16 Endoscopic Sleeve Gastroplasty ESG Indication: High OP Risk Male, 43 y-old, 268kg BMI: Patient 7 Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
17 First large Clinical Series- 1year
18 Endoscopic Sleeve Gastroplasty- Apollo Overstich Current BMI Indications for ESG Abu Dayyeh Gast End2013 BMI 33.2 to 38.3 Lopez-Nava 2015 BMI 30 to 47 Lopez-Nava 2015 BMI 30 to 49 Lopez-Nava 2016 BMI 30 to 47 Abu Dayyeh BK BMI 30 to 40 Sharaiha R. Endoscopy 2015 BMI 37 to 68 Zorron. Der Chirurg 2016 BMI 46 to 72 Zorron R. Endoscopic Sleeve Gastroplasty for Superobese. DGAV Hamburg 2016
19 Indications for ESG Charité Series Patient ASA Kg BMI Indication 1.Male IV Step 2.Male III HighRisk 3. Male III HighRisk 4.Male III HighRisk 5. Male IV Step 6.Male III Impenetrable 7.Male III Impenetrable 8.Female III HighRisk High Risk 2 Stage Concept Impenetrable NTX LTX Candidates 9.Male III HighRisk 10.Female IV HighRisk 11.Female III HighRisk 12.Male II Step 13.Male III NTX 14.Male III NTX Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
20 Weight (kg) Weight Loss pre and postoperative Days Postoperative PATIENT 1 PATIENT 2 PATIENT 3 PATIENT 4 PATIENT 5 PATIENT 6 PATIENT 7 PATIENT 8 PATIENT 9 PATIENT 10 PATIENT 11 Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
21 Who would have thought it? An Endoscopic Restrictive Procedure Effectively Reduces Ghrelin Levels Clin Gastroenterol Hepatol Jan;15(1):37-43.? Zorron R. Endoscopic Sleeve Gastroplasty for Superobese. MIBE Madrid 2017
22 Physiology of ESG Changes in gastric emptying by scintigraphy Gastric Retention at 240 min 3M after ESG Gómez, Woodman, Gostout, Abu Dayyeh IFSO 2015
23 Endoscopic Sleeve Gastroplasty ESG LIVE ESG OP- Congress DGE-BV ENDOLIVE Berlin Patient 9 Zorron R. Endoscopic Sleeve Gastroplasty for Superobese. DGCH München 2017
24 Endoscopic Sleeve Gastroplasty for Super-Obese Indication for BMI over 50...over Why do that? 1. Sole therapy for High-Risk 2. Superobese as a 2-Stage Procedure 3. Impenetrable abdomen 4. Transplant Recipients (Kidney, Liver) Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
25 Neue Therapien für Adipositas und Diabetes 1. Improving Access and Cosmesis 2. Innovative Solutions 3. Inverting the thoughts Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
26 New Devices Sleeve Gastrectomy LIVAC System, Australia Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
27 Results Chronic Hyperinsulinemic Hypoglycemia with Neutroglycopenia after RYGB Distal Pancreatectomy Back to Original Pouch Restriction 67% 76% 82% Mala T. Postprandial hyperinsulinemic hypoglycemia after gastric bypass surgical treatment. Surg Obes Rel Dis 2014; 10: Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
28 One Anastomosis Jejunal Interposition with Gastric Remnant Resection Branco-Zorron Switch Gastric Remnant Resection 2. Leave 20cm alimentary limb 3. Resect 130cm Jejunal until Roux-en-Y
29 Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
30 Branco-Zorron Switch Physiology 1. Food goes again through Duodenum 2. GLP-1? 3. Is still restrictive and malabsortive Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
31 Results with Apollo Outlet Repair for Dumping Christine Stier, Offenbach 2016 Stier C, et al 2016
32 IGS Intragastric Single Port Zorron R, et al. IGS for GIST Tumors. EAES Paris 2014 Zorron et al.2016 Zorron et al.2016 JAMA Surg Aug 1;152(8): Assessment of Intragastric Single-Port Surgery for Gastric Tumors. Krenzien F 1,2, Pratschke J 1, Zorron R 1. Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
33 Surgical Technique IGS Intragastric Single Port GIST Resection Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
34 IGS Intragastric Single Port ERCP Zorron et al.2016 JAMA Surg Aug 1;152(8): Assessment of Intragastric Single-Port Surgery for Gastric Tumors. Krenzien F 1,2, Pratschke J 1, Zorron R 1. Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
35 Intragastric Single Port Sleeve Gastrectomy Animal Study Mini-Pig survival (14 days) Intragastric Sleeve Gastrectomy Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
36 IGS INTRAGASTRIC SLEEVE GASTRECTOMY What is different? No vascular ligation Easy access and closure Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
37 Neue Therapien für Adipositas und Diabetes 1. Improving Access and Cosmesis 2. Innovative Solutions 3. Inverting the thoughts Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
38 Obese versus Non-Obese T2 Diabetes Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
39 Bariatric surgery and resolution of T2DM: Yarborough, USA, BMI 89.7Kg/m2 Type II DM for 8 years Insulin Therapy Takase, Japan BMI 25.3 Kg/m2 Type II DM for 2 years Oral Hypoglicemiants Possibly a whole different profile of patients for bariatric surgery. Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
40 For Diabetes? Duodenal-Jejunal bypass Delivery Procedure (typically minutes) Endobarrier
41 % Total Body Weight Loss Duodenal-Jejunal bypass 0% -5% -10% US Sham Chile Diet Europe Diet US Device Chile Device Europe Device Chile Device -15% Brazil Device Endobarrier -20% -25% Chile Device Elapsed Time (weeks) Courtesy Galvao Neto MP 2016
42 Endoscopic treatment of Diabetes ENDOSCOPIC DUODENAL MUCOSAL RESURFACING (Fractyl ) Galvao Neto MP, Rodriguez L, Rodriguez P, et al. Duodenal Mucosal Resurfacing. A New Procedural Therapy for Type 2 Diabetes Safety and Proof-of-Principle. First In Human Clinical Study. IFSO 2014 Courtesy Galvao Neto MP 2016
43 Courtesy Galvao Neto MP 2016 DUODENAL MUCOSAL RESURFACING
44 Duodenal Mucosal Resurfacing (DMR): Pathophysiologic Principle Bypass of the upper GI tract (surgery, sleeve) elicits potent corrective effects on metabolism Nutrient re-exposure to the Roux elicits return to hyperglycemia Abnormal hypertrophy and hyperplasia of mucosa noted in upper GI tract of diabetes patients Abnormal entero-endocrine cellular sub-population in upper GI mucosa of diabetes Pories et al. Ann Surg. 222 (3): ; 1995 Rohde et al. BMJ Sep 13;3(9): 2013 Dirksen et al. Diabetes Care. 33(2): Verdam et al. JCEM. 96(2):E379 83; 2011 Theodorakis et al. AJP. 290(3):E Gniuli et al. Diabetologia. 53(10):
45 DMR Improves Fasting and Post-Prandial Glucose: Mixed-Meal Tolerance Test Fractyl Confidential Long segment cohort 120- min MMTT (n=28) Plasma glucose (mg/dl) Meal ingestion Baseline 1 month Minutes Fasting glucose * Delta PPG Baseline 1 month * Baseline 1 month AUC-PPG * Baseline 1 month p< p< p<
46 Endoscopic treatment of Diabetes ENDOSCOPIC JEJUNO ILEAL BYPASS
47 Compression Anastomosis Tissue Remodeling Human Magnetic Gastrojejunostomy Tissue Necrosis Tissue Remodeling Jamshidi R, et al. J Ped Surg 2009 Cope, et al. Endoscopy 2009
48 Endoscopic Dual-path Enteral Anastomosis Using Self-Assembling Magnets: First-in-Human Clinical Feasibility Evzen Machytka 1, Marek Buzga 1, Marvin Ryou 2, David B. Lautz 3, Christopher C. Thompson 2 (1) University Hospital Ostrava, Czech Republic (2) Consultants, West Bridgewater, Massachusetts, USA (3) Emerson Hospital, Concord, USA University Hospital Ostrava, Czech Republic
49 Bypass vs Diversion Jejunal-ileal Bypass Dual Path Enteral Diversion Single Path Complete Bypass Native Path Remains Open 10-15cm Common Channel Blind Limb (No Fluids Passing) cm Common Channel Treatment Path Partial Diversion
50 Fasting Glucose Change - Diabetics (n=4) Diabetes
51 Weight Change from Baseline (n=10) No diet restrictions for patients full procedure effect Average 6-month weight loss: 28.3 lbs (13 kgs)
52
53 Thinking OUTSIDE the Box Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
54 Cheap Solutions for Bariatric Surgery I From the Dentist. Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
55 Cheap Solutions for Bariatric Surgery II From the Plastic Surgeon. TONGUE PATCH, Beverly Hills, California Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
56 ASPIRE System New Trends for Bariatric Surgery Zorron R. Neue Chirurgisch-Endoskopische Therapien für Adipositas und Diabetes.Bern 2017
57 INITIAL RESULTS Courtesy Shelby Sullivan 2017, Poster Presentation The Obesity Society
58 Zorron R. Thinking Outside the Box for Bariatric Surgery and Endoscopy IFSO 2016
59 Peroral Endoscopic Thyroidectomy POET Zorron et al -FIRST CASES IN GERMANY
60
61 Neue Therapien für Adipositas und Diabetes Conclusion Innovative endoscopy and new technology offers an array of possibilities for bariatric and metabolic therapy Zorron R. New Trends for Upper GI Surgery. DGAV. 2017
62 Vielen Dank! Zorron R. New Trends for Upper GI Surgery. DGAV. 2017
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