Bariatric surgery: has anything changed in the last few years? Mauro Toppino University of Turin Digestive and Colorectal Surgery Minimal Invasive Surgery Center (Head:Prof. Mario Morino) XIV Annual Conference ESS, Turin, November 25-27, 2010
Bariatric surgery: has anything changed in the last few years? The past The present The future?
Bariatric surgery: has anything changed in the last few years? The past
70s Jejuno-ileal By-pass
Gastric Bypass (GBP) 80s Transected Roux-en-Y gastric by-pass Torres lesser curve pouch gastric by-pass
80s VERTICAL BANDED GASTROPLASTY (VBG) (MASON) MacLean
80s Bilio-Pancreatic Diversion (BPD) (Scopinaro)
80s GASTRIC BANDING (ASGB)
Obesity Surgery at the end of the 80s Many discussions about the best technique: the simpler (with lesser results on weight loss) or the more complex (with better results)?
Change in the 90s LAPAROSCOPY * Real revolution * Widespreading obesity surgery
FEASIBILITY BY LAPAROSCOPY Simple and easy techniques
ADJUSTABLE SILICONE GASTRIC BANDING Widespread (Europe) New surgeons (without bariatric experience) Many failures and complications Wrong indications
Evolution of the laparoscopic techniques
BARIATRIC SURGERY BARIATRIC SURGERY WORLDWIDE WORLDWIDE 2003 2003 Henry Buchwald
BARIATRIC SURGERY WORLDWIDE 2003 Weighted Percentages (Open and Laparoscopic Pooled) 70% 65,11% 60% 50% 40% 30% 24,41% 20% 10% 5,43% 4,85% 0% RYGB ASGB VBG BPD/DS
Italian Registry * for bariatric surgery * Official Registry of S.I.C.OB. (Italian Society Obesity Surgery)
10250 Interventions 1996-2004 ASGB 4437 (43.3 %) VBG 3405 (33.2 %) BPD 1741 (17 %) GBP 427 (4.2 %) Others 240 (2.4 %)
Bariatric surgery: has anything changed in the last few years? The present
Improvement of techniques (more details for safety)
New technique 2 steps procedure (p. with BMI > 60) (M. Gagner) Sleeve gastrectomy Duodenal switch (after 1 year)
Sleeve gastrectomy Later proposed as a single procedure (due to good results on weight loss)
METABOLIC BARIATRIC SURGERY WORLDWIDE 2008 Buchwald H., Obes. Surg., 2009 50% 45% Weighted Percentages (Open and Laparoscopic Pooled) 49,0% 42,3% 40% 35% 30% 25% 20% 15% 10% 5% 1,1% 1,7% 5,3% 0% RYGB ASGB VBG BPD/DS Sleeve Gastrectomy
METABOLIC BARIATRIC SURGERY WORLDWIDE 2008 USA / Canada Buchwald H., Obes. Surg., 2009 Weighted Percentages (Open and Laparoscopic Pooled) 90% 80% 70% 85% 2003 2008 60% 50% 40% 51% 44% 30% 20% 10% 0% 9% 4,5% 1% 0% 4% RYGB ASGB BPD/DS Sleeve G.
METABOLIC BARIATRIC SURGERY WORLDWIDE 2008 Europe Buchwald H., Obes. Surg., 2009 Weighted Percentages (Open and Laparoscopic Pooled) 70% 60% 63,7% 2003 2008 50% 40% 39,0% 43,2% 30% 20% 10% 11,1% 6,1% 4,9% 0,0% 7,0% 0% RYGB ASGB BPD/DS Sleeve G.
Italian Obesity Surgery Registry 2004-2009 12561 interventions Gastric banding 49.4% 4% (6208) Gastric bypass 22.4% (2810) Gastroplasty 10.3% (1288) Sleeve gastrectomy 8.4% (1053) Bilio-pancr. Diversion 7.1% (890)
New!!! Metabolic Surgery
Obesity Surgery Literature Data (patients with BMI > 40 Kg/m2 or 35-40 with comorbidities) Bariatric operations lead to important weight loss and comorbidities improvement (type 2 diabetes too)
Excellent effects of biliopancreatic diversion on type 2 diabetes Scopinaro Noya Mingrone- Castagneto
Buchwald, JAMA 2004 Metanalysis 136 papers 22094 patients Type 2 Diabetes - disappeared: 76.8% of cases - disappeared or improved: 86% of cases
Buchwald, JAMA 2004 Recovery from type 2 diabetes * No need for medical therapies * Glycemia and glycosylated hemoglobin normal values 98.9% Bilio-pancreatic diversion 83.7% Gastric bypass 71.6% Vertical Banded Gastroplasty 47.9% Adjustable Gastric Banding
Experimental studies on rats Francesco Rubino Ann. Surg., 2004
Specific effect of gastro-intestinal bypass surgery Endocrine mechanism Incretins secerning cells Anti-incretins secerning cells
Type 2 Diabetes can be cured by surgery
Consensus Conference Diabetes Surgery Summit Roma, Marzo 2007 Gastrointestinal Surgery for Type 2 Diabetes, in patients with BMI < 35, has to be considered a research priority
European Workshop on Metabolic Surgery for Type 2 Diabetes Rome, Italy September 27-28, 2010 Universita Cattolica S. Cuore Rome, Italy
Need for randomized studies Dixon J.B., JAMA 2008 Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial
Studies on bariatric operations on diabetic patients Bilio-pancreatic Diversion (Scopinaro, Obes. Surg., 2007) (BMI < 35) Gastric Bypass (Alexandrides, Obes. Surg., 2007) Sleeve Gastrectomy (Lacy, Obes. Surg., 2007)
Duodenal Jejunal Bypass (DJB)
Ileal interposition (IT) Ileal interposition (De Paula, Surg. Endosc., 2007) (BMI < 35)
Bariatric surgery: has anything changed in the last few years? The future?
NOTES Swanström LL, Khajanchee Y, Abbas MA. Natural Orifice Transluminal Endoscopic Surgery: The Future of Gastrointestinal Surgery. The Permanente Journal/ Spring 2008/ Volume 12 No. 2:42-7
NOTES Surgical Access Natural Orifice Surgery Trans-vaginal, parietal, umbilical access SA-NOS Endoscopic Access Natural Orifice Surgery Trans-gastric, colic, vescical access EA-NOS
SA-NOS: TRANSUMBILICAL ACCESS (E-NOTES or SILS)
SA-NOS: TRANSUMBILICAL ACCESS (E-NOTES or SILS)
Transvaginal Sleeve Gastrectomy
Endocinch (BBraun) Endoluminal Vertical Gastroplasty
TOGa Trans Oral Gastroplasty STOMAPHYX
EndoBarrier TM Liner
ValenTx Endo-Bypass Pass System ValenTx Endo Bypass
Bariatric surgery CONCLUSIONS Something is changed in the last few years New technique: sleeve gastrectomy Improvement of safety Metabolic Surgery
Bariatric surgery Future Will NOTES demonstrate efficacy and safety?? The major part of the medical community had the same doubt at the beginning of laparoscopy