Current Status of Bariatric Surgery in Asia

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1 Emerald hall A, 1:2-1:5, November 7, 213 Current Status of Bariatric Surgery in Asia Go Wakabayashi, MD, PhD, FACS Professor and Chairman Department of Surgery Iwate Medical University

2 Numbers of bariatric operations performed as a percentage of the national population High frequent (%) Low frequent (%) Nations Percentage Nations Percentage Kuwait Sweden Belguim Israel Australia Japan Ukraine India Turkey Ecuador Mean.11% (n=34,768) Buckwald H et al. Obes Surg 213;23:

3 Numbers of metabolic/bariatric surgeons as a percentage of the national population Nations Brazil USA France Singapore Taiwan Japan Bariatric surgeons 2,75 6, Percentage Mean.22% (n=6,815) Buckwald H et al. Obes Surg 213;23:

4 Types of metabolic/bariatric surgery Sasaki A, Wakabayashi G, et al. J Gastroenterol 213

5 Trends in percentage of procedures worldwide RYGP AGB SG BPD/DS Buckwald H et al. Obes Surg 213;23:

6 Trends in percentage of procedures Asia/Pacific RYGB AGB SG BPD/DS Buckwald H et al. Obes Surg 213;23:

7 Annual changes of the number of laparoscopic bariatric procedures in Japan (cases) (yr) Others LSG+duodenal jejunal bypass (LSG+DJB) Laparoscopic sleeve gastrectomy (LSG) Laparoscopic adjustable gastric banding (LAGB) Laparoscopic Roux-en-Y gastric bypass (LRYGB)

8 Laparoscopic bariatric procedures in Japan (n=176, 212) LSG+DJB 2% Others 2% LRYGB 14% LAGB 7% LSG 57% LSG is now a main bariatric procedure in Japan

9 Number of hospitals Total LSG LRYGB LSG/JDB LAGB Open

10 Outcomes of major bariatric procedures Source Procedure No. of patients %EWL 12-month %EWL 24-month %EWL 36-month JELTO LRYGB LSG LAGB Deitel et al. LSG Garb J et al. LRYGB LAGB 1,615 5, Abbreviations: JELTO, Japan Research Society for Endoscopic and Laparoscopic Treatment of Obesity; LRYGB, laparoscopic Roux-en-Y gastric bypass; LSG, laparoscopic sleeve gastrectomy; LAGB, laparoscopic adjustable gastric banding; %EWL, percentage of excess weight loss Sasaki A, Wakabayashi G, et al. J Gastroenterol 213

11 Morbidity rates after bariatric procedure in Japan Morbidities Total (%) Intraoperative (%) Postoperative (%) Bleeding (reoperation) Leakage Anastomotic stenosis Reoperation (%) LRYGB (n=91) LAGB (n=59) LSG (n=215) LSG/DJB (n=84) Abbreviations: LRYGB, laparoscopic Roux-en-Y gastric bypass; LAGB, laparoscopic adjustable gastric banding; LSG, laparoscopic sleeve gastrectomy; LSG/DJB, laparoscopic sleeve gastrectomy with duodenojejunal bypass Sasaki A, Wakabayashi G, et al. J Gastroenterol 213

12 Can diabetes be surgically cured? Bypass (n=162) Sleeve (n=23) Banding (n=32) BMI (kg/m 2 ) Duration of diabetes (y) No. of diabetes medication Use of insulin (%) 48.8±7.6 5 (2 1) 2 (1 2) ± (5 15) 2 (1 3) ±7.5 8 (4 16) 1.5 (1 3) 41 EWL (%) Short-term (2 years) Long-term ( 5 years) 66.8± ± ± ± ± ±23.4 Long-term ( 5 years) diabetes remission rate (%) Complete Partial Improvement Unchanged Brethauer SA, et al. Ann Surg 213

13 Remission and improvement rates of T2DM Source Procedure No. of patients Remission (%) JELTO LRYGB LSG LAGB Buchwald et al. LRYGB LAGB Hutter et al. LRYGB LSG LAGB 4, ,558 79* 55* 44* Abbreviations: T2DM, type 2 diabetes mellitus; JELTO, Japan Research Society for Endoscopic and Laparoscopic Treatment of Obesity; LRYGB, laparoscopic Roux-en-Y gastric bypass; LSG, laparoscopic sleeve gastrectomy; LAGB, laparoscopic adjustable gastric banding *Remission and improvement rates Sasaki A, Wakabayashi G, et al. J Gastroenterol 213

14 Diabetes Surgery Score Variable Points on ABCD Index BMI (kg/m2) C-peptide (mmol/l) Duration of DM (years) Age (years) Remission (%) Overall 65.3% Lee WJ et al. J Surg Obes Relat Dis 213

15 Laparoscopic Sleeve Gastrectomy

16 Laparoscopic sleeve gastrectomy for T2DM (Iwate Medical University) LSG (n=12) Sex (Male / Female) 5/7 Age(years) 4.1 ± 13.9 (23 64) Initial BMI(kg/m 2 ) 42.5 ± 4.3 (37 52) Duration of diabetes(years) Use of insulin (n) Hypoglycemic medication (n) 3.2± 3.2 (.5 5) 5 6 Initial C-peptide(ng/ml) 4.± 2.1 ( ) Diabetes Surgery Score * 6.7± 1.6 (4 1) * Lee WJ, et al. Surg Obes Relat Dis 213 Mean ± SD (range)

17 Glucose metabolism after LSG Fasting glucose (mg/dl) HbA1c(%) HOMA-IR Initial Pre 2W 1M 6M 1Y BMI (kg/m 2 ) Patient (n) (Mean)

18 Serum insulin values after 75g OGTT pmol/l Pre 1 month (BMI 43) Pre 3 days(bmi 41) Post 1 month (BMI 36) Post 6 months (BMI 31) pre min Mean

19 GLP-1 values after 75g OGTT pmol/l 8 Pre 1 month (BMI 43) Pre 3 days(bmi 41) Post 1month (BMI 36) Post 6 months (BMI 31) pre min Mean

20 GIP values after 75g OGTT pg/ml Pre 1 month (BMI 43) Pre 3 days(bmi 41) Post 1month (BMI 36) Post 6 months (BMI 31) pre min Mean

21 Mechanism of diabetes remission after LSG Body weight Inflammation LSG Ghrelin GLP-1 *2 HCl GRP Restrictive procedure *1 Glucose Insulin Liver Glucose production Dumping GLP-1 *1 Sun Y, et al. Cell Metab 26;3: *2 Basso N, et al. Surg Endosc 211; 25:

22 Laparoscopic single-anastomosis duodenal-jejunal bypass with sleevegastrectomy Laparoscopic SADJB-SG appears to be an ideal metabolic/bariatric surgery, whereas the efficacy is non-inferior to gastric bypass. Lee WJ et al. Obes Surg 213

23 Changes of NAFLD liver volume by CT ml Total Right lobe Left lobe 3 * p , ,944 1,673 * 1,61 * Pre Ope 1M 6M Mean

24 IFSO-APC Consensus statements 211 Bariatric surgery should be considered for the treatment of obesity for acceptable Asian candidates with BMI 35 with or without comorbidities Bariatric/GI metabolic surgery should be considered for the treatment of T2DM or metabolic syndrome for patients who are inadequately controlled by lifestyle alternations and medical treatment for acceptable Asian candidates with BMI 3 The surgical approach may be considered as a nonprimary alternative to treat inadequately controlled T2DM, or metabolic syndrome, for suitable Asian candidates with BMI Kasama K, et al. Obes Surg 212;22:

25 Two-stage surgery in a morbid obese patient: Laparoscopic pylorus-preserving pancreaticoduodenectomy after laparoscopic sleeve gastrectomy Hasegawa H, Sasaki A, Nitta H, Wakabayashi G. Surg Obes Relat Dis year-old-woman (BMI 4 kg/m 2 ) NET+T2DM (insulin treatment) Laparoscopic sleeve gastrectomy 6 months Laparoscopic-assisted PPPD (BMI 29) 1 months Complete remission of T2DM (BMI 25)

26 Changes of glucose, insulin, GLP-1, and GIP levels mg/dl µu/dl pmol/dl 6 Glucose pre GLP pre min pg/dl] min IRI pre GIP pre pre LSG 1POM 6POM post PPPD min min

27 The biology of incretin hormones Drucker DJ. Cell Metabolism 26; 3: GLP-1 actions in peripheral tissues GLP-1 acts directly on the endocrine pancreas, heart, stomach, and brain, whereas actions on liver and muscle are indirect.

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