Choice Critria in Bariatric Surgery. Giovanni Camerini

Transcription

1 Choice Critria in Bariatric Surgery Giovanni Camerini

2 Surgical vs Medical treatment

3 Indications for Bariatric Surgery (WHO 1992) BMI of at least 40; BMI of 35 in case of serious diseases related to obesity; People who have not responded to non-surgical treatments.

4 Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient 2013 Update: Cosponsored by American Association of Clinical Endocrinologists, The obesity Society, and American Society for Metabolic & Bariatric Surgery BMI of at least 40; Patients with a BMI 35 and 1 or more severe obesity-related comorbidities (T2D, hypertension, hyperlipidemia,osa, OHS, Pickwickian syndrome, NAFLD, NAS), GERD, asthma, venous stasis disease, debilitating arthritis); BMI of kg/m2 with diabetes or meta-bolic syndrome; Insufficient evidence for for glycemic control alone, lipid lowering alone, or cardiovascular disease risk reduction alone, independent of BMI criteria. Jeffrey I. Mechanick, Obesity, Vol 21, NUMBER S1, MARCH 2013

5 AMERICAN DIABETES ASSOCIATION STANDARDS OF MEDICAL CARE IN DIABETES 2017

6 Prevalence of Class II or III obesity 15.5% of the US adult population has a BMI of 35 or more; 6.3% are severely obese (BMI 40); 1.7% of men and 3.1% of women had a BMI of 40 in UK in 2012; 1.3% of men had a BMI of 35 or more in Sweden in 2005; 8.1% of adults had a BMI of 35 or more in Australia in 2006.

7 Prevalence of Class I obesity Worldwide: 11% (300 million women and 200 million men); US: 29.7% women and 23.5% men; Europe: 23.1% women and 20.4% men; Africa: 11.1% women and 5.3% men; Italy: 21% women and 17% men.

8 Bariatric procedures 1. Roux-en-Y gastric bypass 46.6%; 2. Sleeve gastrectomy 27.8%; 3. Adjustable gastric banding 17.8%; 4. BPD with duodenal switch 2.2%.

9 Angrisani L, Bariatric Surgery Worldwide Obes Surg Apr 4.

10 Restriction of intake

11 VBG ASGB SG

12 VERTICAL BANDED GASTROPLASTY (MASON 1980)

13 VBG (MASON 1980) IEW%L yrs

14 Ten and more years after vertical banded gastroplasty as primary operation for morbid obesity Only 26% of patients after VBG have maintained a weight loss of at least 50% of their excess body weight. Thus VBG is not an effective, durable bariatric operation. Balsiger BM, Sarr MG. J Gastrointest Surg 2000 Nov-Dec;4(6):

15 A.S.G.B.

16 A.S.G.B. (KUZMAK 1986)

17 Thirteen Years of Follow-up in Patients with Adjustable Silicone Gastric Banding for Obesity: Weight Loss and Constant Rate of Late Specific Complications Camerini G, Obesity Surgery ,

18 Thirteen Years of Follow-up in Patients with Adjustable Silicone Gastric Banding for Obesity: Weight Loss and Constant Rate of Late Specific Complications Camerini G, Obesity Surgery ,

19 Long-term Outcomes of Laparoscopic Adjustable Gastric Banding Jacques Himpens ARCH SURG/VOL 146 (NO. 7), JULY 2011

20 Comparative Effectiveness of Laparoscopic Adjustable Gastric Banding vs Laparoscopic Gastric Bypass David Arterburn, MD, MPH JAMA Surgery Published online October 29, 2014

21 Specific Late Complications of A.S.G.B. Anemia 14% Esophagitis 31% Esophageal dilation 8.6% Gastritis 14% Peptic Ulcer 2.8% Reservoir infection 17% Outlet stenosis 34% Pouch dilatation 23% Band displacement 2.8% Intragastric migration 17% Camerini G, Obesity Surgery ,

22 Thirteen Years of Follow-up in Patients with Adjustable Silicone Gastric Banding for Obesity: Weight Loss and Constant Rate of Late Specific Complications Camerini G, Obesity Surgery ,

23 Thirteen Years of Follow-up in Patients with Adjustable Silicone Gastric Banding for Obesity: Weight Loss and Constant Rate of Late Specific Complications Camerini G, Obesity Surgery ,

24 Reoperation and Medicare Expenditures After Laparoscopic Gastric Band Surgery Ibrahim AM, JAMA Surg. doi: /jamasurg.2017.published May 17, 2017.

25 SLEEVE GASTRECTOMY

26 SLEEVE GASTRECTOMY

27 SLEEVE GASTRECTOMY Gagner M, Obes Surg Dec;23(12):2013-7

28 Long-term Metabolic Effects of Laparoscopic Sleeve Gastrectomy The mean(sd) preoperative excess weight was 51.2 (18.4) kg, and the mean (SD) preoperative BMI was 43.9 (6.6). At 1 year of follow up, the mean (SD) body weight was 81.4 (16.7) kg, the mean (SD) BMI was 29.9 (5.1),and the %EWL was 76.8%. At 3 years of follow up, the mean(sd) body weight was 84.1 (17.2) kg, the mean BMI was 30.8 (5.3), and the %EWL was 69.7%. At 5 years of follow-up, the mean (SD) weight was 88.6 (15.7) kg, the mean (SD) BMI was 32.3 (5.1), and the %EWL was 56.1%. Inbal Golomb, JAMA Surgery August 5, 2015

29 Five-year results after laparoscopic sleeve gastrectomy: a prospective study Daniel P. Lemanu, S.O.R.D. 11 (2015)

30 Specific Complications of S.G. Bleeding % Leak 0-7% Stenosis 0.2-4% Gastritis 14% G.E.R.D. 7.9% Minimally Invasive Bariatric and Metabolic Surgery

31 Survey on laparoscopic sleeve gastrectomy (LSG) at the Fourth International Summit on Sleeve Gastrectomy Gagner M, Obes Surg Dec;23(12):2013-7

32 R.Y.G.B.P.

33 R.Y.G.B.P. (Miller 1979)

34 Weight Loss after R.Y.G.B.P. Approximately 80% of gastric bypass patients experience a 60% 80% excess weight loss in the first year, with longer term stabilization at 50% 60% loss of excess body weight.

35 R.Y.G.B.P. (Pories 1995)

36 R.Y.G.B.P. (Christou 2006)

37 Late Morbidity of R.Y.G.B.P. Internal Hernia 16.1 Marginal Ulcer 4.5% Gastro-gastric Fistula 0.4% 0.2-4% Gallstones 7% Hernia trocar site 1.2% Minimally Invasive Bariatric and Metabolic Surgery

38 Malabsorption of ingested food

39 BILIOPANCREATIC DIVERSION (SCOPINARO 1976)

40 BILIOPANCREATIC DIVERSION (HESS 1994)

41 Changes in body weight after BPD % IEW reduction Years

42 SIDE EFFECTS foul-smelling stools; increase of bowel movements; flatulence; need of follow-up and supplementation.

43 SPECIFIC LATE COMPLICATIONS stomal ulcer (3-4 %); bone demineralization (7%); sporadic protein malnutrition (2%); recurrent protein malnutrition (1%).

44 WHICH OPERATION?

45 Gagner M, OBES SURG (2016) 26: Is Sleeve Gastrectomy Always an Absolute Contraindication in Patients with Barrett s?

46 MALABSORPTION 1. super-obesity 2. revisional surgery 3. type 2 DM

47 Super-obesity

48 Randomized clinical trial of laparoscopic gastric bypass vs laparoscopic duodenal switch for superobesity. Søvik TT, Br J Surg Feb;97(2):160-6.

49 Randomized clinical trial of laparoscopic gastric bypass vs laparoscopic duodenal switch for superobesity. Søvik TT, Br J Surg Feb;97(2):160-6.

50 Duodenal switch provides superior weight loss in the super-obese (BMI > or =50 kg/m2) compared with gastric bypass. Prachand VN1, Ann Surg Oct;244(4):611-9.

51 Management of super super obese patients: comparison between one anastomosis (mini) gastric bypass and Roux-en-Y gastric bypass Chetan Parmar, Surg Endosc Surg Endosc 2016: DOI /s x

52 Mini Gastric Bypass (Rutledge R 2001)

53 Revisional Surgery

54 Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass is Effective for Gastro-Oesophageal Reflux Disease but not for Further Weight Loss Chetan D Parmar, OBES SURG DOI /s

55 Biliopancreatic diversion with duodenal switch or gastric bypass for failed gastric banding: retrospective study from two institutions with preliminary results Topart Ph, Surgery for Obesity and Related Diseases 3 (2007)

56 Laparoscopic conversion of sleeve gastrectomy to a biliopancreatic diversion with duodenal switch or a Roux-en-Y gastric bypass due to weight loss failure: our algorithm Carmeli I, Surgery for Obesity and Related Diseases 11 (2015) 79 87

57 Secondary surgery after sleeve gastrectomy: Roux-en-Y gastric bypass or biliopancreatic diversion with duodenal switch Homan G, Surgery for Obesity and Related Diseases 11 (2015)

58 Analysis of Obesity-Related Outcomes and Bariatric Failure Rates With the Duodenal Switch vs Gastric Bypass for Morbid Obesity Daniel W. Nelson, Arch Surg. 2012;147(9):

59 Re-emergence of diabetes after gastric bypass in patients with mid- to long-term follow-up M. DiGiorgi, Surgery for Obesity and Related Diseases 6 (2010)

60 Tipe II diabetes

61 Excess weight loss and resolution of diabetes Total Gastric Banding VBG RYGBP BPD EWL 61.2% 47.4% 68.2% 61.6% 70.1% Diabetes Resolution 76.8% 47.8% 68.2% 83.8% 97.9% Buchwald H, JAMA 2004; 292:

62 VBG, ASGB and SG Caloric restriction and weight loss are the dominant mechanisms of improved glucose metabolism in restrictive operations; The former appears to account for the early postsurgical recovery of insulin sensitivity and secretory dynamics; The latter is the final determinant of the outcome once weight and caloric balance have stabilized

63 ASGB and Conventional Therapy for Type 2 Diabetes DIXON JB et al. JAMA 2008;

64 unlike LAGB, GBP reroute food through the upper small bowel, which may activate mechanisms of diabetes control that are independent of weight

65 «Hindgut hypothesis» Nutrients reach the distal ileum within 5 min of the ingestion of food and this stimulates the secretion of GLP-1 by L-cells located in this area. GLP-1 stimulates insulin secretion and exerts a proliferative and antiapoptotic effects on pancreatic beta cells.

66 «Foregut hypothesis» The exclusion of the proximal small intestine reduces or suppresses the secretion of anti-incretin hormones, leading to improvement of blood glucose control as a consequence.

67 Gastric Bypass vs Sleeve Gastrectomy for Type 2 Diabetes Mellitus Lee WJ et al, Arch Surg 2011;

68 Bariatric Surgery vs Intensive Medical Therapy in Obese Patients with Diabetes Schauer P, NEJM 2012;

69 BPD and BPD/DS Malabsorption of fat translates in lower levels of circulating triglycerides and cholesterol, in consequent dramatic reduction of of intramyocellular lipid accumulation with normalisation of whole body insulin resistance.

70 Effects of Biliopancreatic Diversion on the Major Components of Metabolic Syndrome Scopinaro N et al. Diabetes Care 28: , 2005

71 ENVIRONEMENT excessive fat availability fat penetration into the muscular cell the muscular cell uses fat instead of glucose as the energy source insulin resistance hyperinsulinemia

72 Magnetic resonance spectroscopy facilitates assessment ofintramyocellular lipid changes Adami GF, Obes Surg. 2005;

73 Quantitative maps editing in PMOD 30 µmol/100g/min 20 µmol/100g/min 10 µmol/100g/min CT-based voi construction on quantitative map generated by PMOD to obtain absolute metabolic consumption (micromol/100 g/min) for back muscle, myocardium and adipose tissue. 0 µmol/100g/min

74 Tissue specificity in fasting glucose utilization in slightly obese diabetic patients submitted to bariatric surgery Briatore L, Obesity 2010;

75 Superior weight loss and lower HbA1c 3 years after duodenal switch compared with Roux-en-Y gastric bypass--a randomized controlled trial 4.7% 4% Hedberg J. SORD 2012;

76 Benefits and complications of the duodenal switch/biliopancreatic diversion compared to the Roux-en-Y gastric bypass 82% 64% Dorman RB, Surgery. 2012:758-65

77 Bariatric surgery versus conventional medical therapy for type 2 diabetes 75% 95% Mingrone G. N Engl J Med 2012;

78 WHICH OPERATION? 1. Degree of compliance and motivation; 2. Age; 3. Compliance to follow-up; 4. Side effects and complications of surgical procedures; 5. BMI; 6. Metabolic complications; 7. Revisional surgery.

79 thank you for your attention