III WORKSHOP CONGIUNTO SICOB SID SIO CONFRONTO TRA LE DIVERSE TECNICHE NEL TRATTAMENTO CHIRURGICO DEL DIABETE TIPO 2.
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1 III WORKSHOP CONGIUNTO SICOB SID SIO CONFRONTO TRA LE DIVERSE TECNICHE NEL TRATTAMENTO CHIRURGICO DEL DIABETE TIPO 2 Luigi Angrisani Direttore UOC di Chirurgia Generale ed Endoscopica Ospedale S.Giovanni Bosco ASL Napoli 1 Centro Presidente-Federazione Mondiale per la Chirurgia Bariatrica e Metabolica (IFSO)
2 Where is the increase in diabetes occurring? Where is the increase in diabetes occurring? Gregg EW, Cheng YJ, Narayan KM, et al. Prev Med. 2007;45:
3 American Diabetes Association Clinical Practice Recommendations In overweight and obese insulin-resistant individuals, modest weight loss has been shown to reduce insulin resistance. Thus, weight loss is recommended for all overweight or obese individuals who have or are at risk for diabetes. Diabetes Care 2010;33:S4.
4 ANTI-OBESITY PROCEDURES N=1956 Jan Dec 2013 LAP-BAND BYPASS DUODENAL SWITCH BIB N=475 LAP-BAND N=342 BPD SLEEVE GASTRECTO OBALON BIB OBALON N=8 BYPASS N=510 SLEEVE N=596 BPD N=9 DUODENAL SWITCH N=16 ANGRISANI 2014
5 N= 111 BARIATRIC PROCEDURES IN N=95 OBESE TYPE II DIABETIC PATIENTS Jan Dec 2013 All Obese patients Obese &T2DM patients BIB LAP-BAND SLEEVE BYPASS BPD-DS 1 25 Obese with BMI <35 &T2DM patients ANGRISANI 2014
6 S. GIOVANNI BOSCO EXPERIENCE N=1399 Pts Gastric Banding Gastric Bypass Sleeve Gastrectomy ANGRISANI 2014
7 CHIRURGIA BARIATRICA E DIABETE MELLITO Tutte le tecniche chirurgiche e parachirurgiche in grado di procurare calo ponderale comportano la remissione parziale o completa del Diabete Mellito di tipo 2. ANGRISANI 2014
8 CHIRURGIA BARIATRICA E DIABETE MELLITO La percentuale di successo (remissione/cura) del Diabete Tipo II nei pazienti obesi è direttamente proporzionale al BMI di partenza: ottimale negli Obesi Patologici e Super Obesi ANGRISANI 2014
9 CHIRURGIA BARIATRICA E DIABETE MELLITO Il recupero del peso perso nei Diabetici Obesi sottoposti con successo a Chirurgia Bariatrica comporta la ripresa della malattia ANGRISANI 2014
10 GERARCHIA DELLA CHIRURGIA DELL OBESITA PRE- CHIRURGICHE (I LIVELLO) PALLONE AD ARIA PRE- CHIRURGICHE (II LIVELLO) PALLONE AD ACQUA CHIRURGICHE (I LIVELLO) BENDAGGIO GASTRICO
11 GERARCHIA DELLA CHIRURGIA DELL OBESITA CHIRURGICHE (II LIVELLO) GASTRECTOMIA VERTICALE CHIRURGICHE (III LIVELLO) BYPASS GASTRICO CHIRURGICHE (IV LIVELLO) DIVERSIONE BILIOPANCREATICA / DUODENAL SWITCH
12
13 The Lancet Diabetes & Endocrinology in press
14 The Lancet Diabetes & Endocrinology in press
15 The Lancet Diabetes & Endocrinology in press
16 OBES SURG 2012
17 SOARD 2012
18 33 morbidly obese T2DM patients underwent LSG Of the super obese patients, 7 underwent biliopancreatic diversion 1 year after LSG and 2 others did after 36 months because of insufficient weight loss irrespective of T2DM remission 11 patients did not achieve 5 years follow-up. SOARD 2012
19 Lee WJ, et al. Arch Surg 2011;146:143 8.
20 Annals of Surgery October 2013
21 Among the surgical procedures, the glycemic outcomes were significantly better after RYGB. Remission rate of T2DM after RYGB vs LSG (P = 0.006), RYGB vs LAGB (P<0.001), and LSG vs LAGB (P=0.04). Annals of Surgery October 2013
22 Annals of Surgery October 2013
23 Our study reports durable weight loss in type 2 diabetic patients with an overall T2DM remission rate (complete and partial) of 50% with a median follow-up period of 6 years after bariatric surgery. Although the term cure with respect to T2DM is still controversial, our study demonstrated that 24% of all patients and 31% of gastric bypass patients achieved longterm complete remission with an A1C less than 6.0% and that 27% of the gastric bypass patients sustained that level of glycemic control off medication continuously for more than 5 years. Annals of Surgery October 2013
24 Rates of Remission of Diabetes Adjustable Gastric Banding 48% (Slow) Roux-en-Y Gastric Bypass 84% (Immediate) Biliopancreatic Diversion >95% (Immediate) Buchwald H. JAMA, 2004
25 CONCLUSIONI
26 Annals of Surgery October 2013
27
28 Lancet Diabetes Endocrinol Feb 201
29 Randomised trials of surgical versus medical or lifestyle interventions, or both, for type 2 diabetes and obesity Lancet Diabetes Endocrinol Feb 201
30 The Diabetes Surgery Summit recommends surgery for patients with class 1 obesity (BMI kg/m²) only in cases where all medical and lifestyle interventions for type 2 diabetes have failed. The International Diabetes Federation deems surgery reasonable for patients with class 1 obesity and type 2 diabetes who have failed to respond adequately to just lifestyle changes and two oral antidiabetic drugs, placing surgery on the same algorithmic level as thiazolidinediones, dipeptidyl peptidase-4 inhibitors,acarbose, and basal insulin. Lancet Diabetes Endocrinol Feb 201
31 Several communications have reported that regardless of BMI complete or partial remission of type 2 diabetes mellitus (T2DM) is possible. These results mostly occur before weight loss, positioning metabolic surgery as a good tool for controlling the current T2DMepidemic. Medical treatment is evolving, but is expensive and not risk-free. Surgery aimed mainly at diseases such as diabetes and not weight loss are referred to as metabolic surgery. Metabolic surgery has been proven to be safe and effective and can effectively treat T2DM in individuals with any BMI, including that below 35 kg/m 2. OBES SURG 2013
32 OBES SURG 201
33 Dixon JB, O Brien PE, Playfair J, et al. JAMA 2008
34 OBES SURG 201
35 META-ANALYSIS - 13 studies selected patients evaluated. -Bariatric procedures performed Laparoscopic Roux-en-Y gastric bypass (4 studies) Duodenal-jejunal bypass (3 studies) Bilio-pancreatic diversion (3 studies) Laparoscopic mini-gastric bypass (2 studies) Laparoscopic ileal interposition with diverted sleeve gastrectomy (1 study)
36 Total weight loss kg (p< ). Mean BMI reduction 5.18 kg/m2 (p< ). 80% patients reached a HbA1c value <7% and these patients were off T2DM medications. Mean reduction in fasting plasma glucose levels was -4.4mmol/L (p < ) mean reduction of HbA1c was 2.59% (p< ) in 11 studies. These important effects on glucose metabolism were accompanied by a significant reduction in LDL-cholesterol and triglycerides levels.
37
38 BARIATRIC SURGERY IN CLASS I OBESITY. A Position Statement from the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) Luigi Angrisani Director General and Endoscopic Surgery Unit S.Giovanni Bosco Hospital, Naples, Italy Incoming President IFSO
39 BMI> or <35 & Type 2 Diabetes Laparoscopic Adjustable Gastric Band (LAGB) Roux-en-Y Gastric Bypass (RYGB) Biliopancreatic Diversion (BPD) Vertical Sleeve Gastrectomy (VSG) Mini Gastric Bypass Ileal interposition
40 Is T2DM a Surgical Disease? My daddy is a doctor and he treats diabetes. My daddy is a surgeon and he cures it. Courtesy of Walter Pories, MD
41 DM TIPO 2:PREVALENZA IN ITALIA I dati riportati nell annuario statistico ISTAT 2012 indicano che è diabetico il 5,5% degli italiani (5,5% delle donne e 5,4 % degli uomini) Circa di persone affette
3 WORKSHOP CONGIUNTO SICOb SID SIO 7 MARZO 2014 L integrazione tra terapia medica e chirurgica nel trattamento del paziente obeso diabetico
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