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
Numbers of bariatric operations performed as a percentage of the national population High frequent (%) Low frequent (%) Nations Percentage Nations Percentage 1 2 3 4 5 Kuwait Sweden Belguim Israel Australia.1642.899.7722.644.52 1 2 3 3 5 Japan Ukraine India Turkey Ecuador.1.3.4.4.1 Mean.11% (n=34,768) Buckwald H et al. Obes Surg 213;23:427-436
Numbers of metabolic/bariatric surgeons as a percentage of the national population Nations Brazil USA France Singapore Taiwan Japan Bariatric surgeons 2,75 6,815 31 16 2 19 Percentage.14.4.47.31.9.1 Mean.22% (n=6,815) Buckwald H et al. Obes Surg 213;23:427-436
Types of metabolic/bariatric surgery Sasaki A, Wakabayashi G, et al. J Gastroenterol 213
Trends in percentage of procedures worldwide 7 6 5 4 3 2 1 65.1 49 46.6 42.3 27.8 24.4 17.8 4.8 5.3 2 2.2 23 28 211 RYGP AGB SG BPD/DS Buckwald H et al. Obes Surg 213;23:427-436
Trends in percentage of procedures Asia/Pacific 9 8 7 6 5 4 3 2 1 8.4 82.5 55.1 32.6 8.4 9.1 9.6 3 4.1.5 23 28 211 RYGB AGB SG BPD/DS Buckwald H et al. Obes Surg 213;23:427-436
Annual changes of the number of laparoscopic bariatric procedures in Japan (cases) 18 16 14 12 1 8 6 4 2 (yr) Others LSG+duodenal jejunal bypass (LSG+DJB) Laparoscopic sleeve gastrectomy (LSG) Laparoscopic adjustable gastric banding (LAGB) Laparoscopic Roux-en-Y gastric bypass (LRYGB)
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
Number of hospitals 16 14 12 1 8 6 4 2 15 15 15 15 3 3 2 2 1 1 1 1 Total LSG LRYGB LSG/JDB LAGB Open 211 212
Outcomes of major bariatric procedures Source Procedure No. of patients %EWL 12-month %EWL 24-month %EWL 36-month JELTO LRYGB LSG LAGB 147 12 55 76 66 43 77 68 58 74-55 Deitel et al. LSG 19.66 62.7 64.7 64. Garb J et al. LRYGB LAGB 1,615 5,768 61.5 42.6 69.7 5.3 71.2 55.2 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
Morbidity rates after bariatric procedure in Japan Morbidities Total (%) Intraoperative (%) Postoperative (%) Bleeding (reoperation) Leakage Anastomotic stenosis Reoperation (%) LRYGB (n=91) 25.3 1.1 1.1 15.4 9.9 LAGB (n=59) 5.1 1.7 5.1 LSG (n=215) 15.3.9 1.9 1.9 5.1 LSG/DJB (n=84) 15.5 3.6 1.2 7.1 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
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) 29 5.7±1.6 1.5 (5 15) 2 (1 3) 48 47.5±7.5 8 (4 16) 1.5 (1 3) 41 EWL (%) Short-term (2 years) Long-term ( 5 years) 66.8±2.4 6.5±24.6 49.7±32.5 49.5±24.9 37.±17.8 29.5±23.4 Long-term ( 5 years) diabetes remission rate (%) Complete Partial Improvement Unchanged 31 3 31 8 9 22 52 17 9 35 56 Brethauer SA, et al. Ann Surg 213
Remission and improvement rates of T2DM Source Procedure No. of patients Remission (%) JELTO LRYGB LSG LAGB 64 35 19 88 91 63 Buchwald et al. LRYGB LAGB 989 25 83.8 47.8 Hutter et al. LRYGB LSG LAGB 4,452 249 2,558 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
Diabetes Surgery Score Variable Points on ABCD Index 1 2 3 BMI (kg/m2) 3 3-39 4-49 5 C-peptide (mmol/l).9-1.9 2.-3.9 4.-5.9 6. Duration of DM (years) 1 5-1 2-4.9 2 Age (years) 4 4 1 8 6 4 2 Remission (%) 1 1 1 83 87 33 33 43 57 46 41 1 2 3 4 5 6 7 8 9 1 Overall 65.3% Lee WJ et al. J Surg Obes Relat Dis 213
Laparoscopic Sleeve Gastrectomy
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 (1.9 8.5) Diabetes Surgery Score * 6.7± 1.6 (4 1) * Lee WJ, et al. Surg Obes Relat Dis 213 Mean ± SD (range)
Glucose metabolism after LSG Fasting glucose (mg/dl) HbA1c(%) HOMA-IR 1 16 88 91 1 12.4 8.8 5.8 5.1 5. 2.3 1 Initial Pre 2W 1M 6M 1Y BMI (kg/m 2 ) Patient (n) 43 12 41 12 37 12 36 11 31 11 28 8 (Mean)
Serum insulin values after 75g OGTT pmol/l 2 18 16 14 12 1 8 6 4 2 Pre 1 month (BMI 43) Pre 3 days(bmi 41) Post 1 month (BMI 36) Post 6 months (BMI 31) pre 3 6 9 12 min Mean
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) 7 6 5 4 3 2 1 pre 3 6 9 12 min Mean
GIP values after 75g OGTT pg/ml 5 45 4 35 3 25 2 15 1 5 Pre 1 month (BMI 43) Pre 3 days(bmi 41) Post 1month (BMI 36) Post 6 months (BMI 31) pre 3 6 9 12 min Mean
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: 379-386 *2 Basso N, et al. Surg Endosc 211; 25: 354-355
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
Changes of NAFLD liver volume by CT ml Total Right lobe Left lobe 3 * p.1 25 2,383 2 1,944 1,673 * 1,61 * 15 1 5 Pre Ope 1M 6M Mean
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 27.5. Kasama K, et al. Obes Surg 212;22:677-684
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 213 63 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)
Changes of glucose, insulin, GLP-1, and GIP levels mg/dl µu/dl 25 2 15 1 5 pmol/dl 6 Glucose pre 3 6 9 12 GLP-1 5 4 3 2 1 pre 3 6 9 12 2 15 1 5 min pg/dl] min 8 6 4 2 IRI pre 3 6 9 12 GIP pre 3 6 9 12 pre LSG 1POM 6POM post PPPD min min
The biology of incretin hormones Drucker DJ. Cell Metabolism 26; 3:153-165 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.