Wat kan bariatrische heelkunde bijbrengen in de therapie bij diabetes mellitus type 2. M. Lannoo

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1 Wat kan bariatrische heelkunde bijbrengen in de therapie bij diabetes mellitus type 2 M. Lannoo

2 Surgical procedures: LAP GASTRIC BANDING

3 Surgical procedures: GASTRIC BYPASS

4 Surgical procedures: SLEEVE GASTRECTOMIE

5 Surgical procedures: Biliopancreatische diversie scopinaro Duodenal switch

6 Surgical procedures: Biliopancreatische diversie - elongation common limb ( cm ) - conversion to gastric bypass AL BPL CL

7 RESULTATEN: BARIATRIE Sjöström et al. The Swedisch Obesity Study (SOS trial) Prospective, controlled Swedish Obese Subjects study underwent bariatric surgery (surgery group) 2037 received conventional treatment (matched control group). But not randomized, treatment of the control group not well defined, more pre-baseline cardiovascular events in controls N Engl J Med Aug 23;357(8): )

8 RESULTATEN: BARIATRIE SOS study, N Engl J Med 2004

9 RESULTATEN: BARIATRIE Buchwald et al. conducted a large metaanalysis 163 studies 22,094 patients Surgical procedures Gastric Banding Gastric Bypass (Roux en Y) Gastroplasty Bilio-pancreatic Diversion Assesment of comorbities Diabetes Hypertension Hypercholesterolemia Obstructive Sleep Apnea N Engl J Med Aug 23;357(8): )

10 RESULTATEN: BARIATRIE Resolution or improvement (% of patients) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Diabetes AHT Hyperchol OSAS

11 OBSERVATIONS: mortality Adams et al. N Engl J Med 357;8 august 2007

12 RESULTATEN: BARIATRIE author N %EWL 1y IDDM 2 AHT Sleep apnoea Moon Han % 93% 100% Cottam % 75% 80% Sillechia 41 77% 63% 56,2% Vidal % Kasalicky % 65% Tagaya 30 67% 56% Akkary Obes Surg :

13 Surgical procedures: LAP GASTRIC BANDING focus is niet gewichtsverlies maar gezondheid verhouding is recht evenredig na lap gastric banding vaak dissociatie RESEARCH ARTICLE Differential Changes in Dietary Habits after Gastric Bypass Versus Gastric Banding Operations Barbara Ernst, Bernd Schultes et al. OBES SURG (2009) 19: Conclusion Collectively, data clearly point to distinct changes in dietary habits after bariatric operations which markedly differ between gastric bypass and gastric banding patients. Overall, it is tempting to conclude that gastric bypass operations lead to a healthier and a more balanced diet than gastric band implantations.

14 Compliantie lap band resultaten (= RYGBP) lange termijn qua G-verlies 6 weken interval regelmatige band aanpassing multidisciplinair consultatie O'Brien PE, Dixon JB, Brown W, Schachter LM, Chapman L, Burn AJ, Dixon ME, Scheinkestel C, Halket C, Sutherland LJ, Korin A, Baquie P. The laparoscopic adjustable gastric band (Lap-Band): a prospective study of medium-term effects on weight, health and quality of life. Obes Surg 2002;12(5):

15 Faling gewichtstoename of onvoldoende gewichts reductie gaat tot 30% Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5-year results of a prospective randomized trial. Angrisani L, Lorenzo M, Borrelli V Surg Obes Relat Dis Mar-Apr;3(2):127-32; discussion oplossing is vaak RYGBP & is gecompromitteerd door voorgaande lap gastric banding! meer lekken? langere OP-tijd meer complicaties?

16 Physiology of weight loss after RYGB Mechanical view Hormonal view 1. Isolation of the gastric cardia 2. Exclusion of the distal stomach from food 3. Enhanced exposure of undigested food to distal jejunum to Fast delivery of food GLP-1, PYY Early satiety&satiation

17 Endoscopic BANDING stoma size reduction shouldn t have potential Physiology of weight loss after RYGB Mechanical view Gut talks to the brain view RYGBP

18 Walter Pories claimed in 1992 TYPE 2 DIABETES IS A SURGICAL DISEASE

19 RESULTATEN: DIABETES

20 RESULTATEN: DIABETES THE FIRST OBSERVATIONS W. Pories 500 patients Long term sufficient weight los Adequate follow up

21 RESULTATEN: DIABETES Buchwald et al. conducted a large meta-analysis (Buchwald H, Avidor Y,Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta analysis. Jama Oct 13;292(14): ) For all surgical procedures combined type 2 diabetes Resolved in 76.8% Resolved or improved in 86% of patients Complete remission by type of surgery 48% after gastric banding (operative mortality 0.1%) 84% after Roux en Y (operative mortality 0.5%) >95% after bilio-pancreatic diversion (operative mortality 1.1%) Remission of diabetes after gastric banding occurs over several weeks or month, whereas after gastric bypass it can occur within days

22 RESULTATEN: DIABETES Sjöström et al. The Swedisch Obesity Study (SOS trial) Prospective, controlled Swedish Obese Subjects study underwent bariatric surgery (surgery group) CVD of DM 2037 received conventional treatment (matched control group). But not randomized, Effect= mainly pat treatment of the control group not well defined, more pre-baseline cardiovascular events in controls N Engl J Med Aug 23;357(8): )

23 RESULTATEN: DIABETES The Swedisch Obesity Study (SOS trial) Sjostrom L et al. n engl j med; 351;26, 2004

24 RESULTATEN: DIABETES author N %EWL 1y IDDM 2 AHT Sleep apnoea Moon Han % 93% 100% Cottam % 75% 80% Sillechia 41 77% 63% 56,2% Vidal % Kasalicky % 65% Tagaya 30 67% 56% Akkary Obes Surg :

25 RESULTATEN: DIABETES R DURATION OF DIABETES IS IMPORTANT Rosenthal et al Surg Obes Relat Dis 2009 Epub corrected proof REMARKABLE ANALOGY WITH RYGBP

26 gewichtsverlies Surgical procedures: LAP GASTRIC BANDING vergelijkbaar in beste geval door meer falingen in realiteit 20% lager minder effect op co-morbiditeit Diabetes Tice JA, Feldman MD. et al. Am J Med 2008;121(10):

27 MECHANISMEN: DIABETES Insulin deficiency Islet Pancreas Alpha cell produces excess glucagon Beta cell produces less insulin Excess glucagon Diminished insulin Liver Diminished insulin Hyperglycemia Muscle and fat Excess glucose output Adapted from Buse JB et al. In Williams Textbook of Endocrinology. 10th ed. Philadelphia, Saunders, 2003: ; Buchanan TA Clin Ther 2003;25(suppl B):B32 B46; Powers AC. In: Harrison s Principles of Internal Medicine. 16th ed. New York: McGraw-Hill, 2005: ; Rhodes CJ Science 2005;307: Insulin resistance (decreased glucose uptake)

28 MECHANISMEN: DIABETES Ingestion of food GI tract Release of incretin gut hormones Active GLP-1 and GIP Pancreas Beta cells Alpha cells Glucose dependent Insulin from beta cells (GLP-1 and GIP) Insulin increases peripheral glucose uptake Blood glucose control Glucagon from alpha cells (GLP-1) Glucose dependent Increased insulin and decreased glucagon reduce hepatic glucose output Adapted from Brubaker PL, Drucker DJ Endocrinology 2004;145: ; Zander M et al Lancet 2002;359: ; Ahrén B Curr Diab Rep 2003;3: ; Buse JB et al. In Williams Textbook of Endocrinology. 10th ed. Philadelphia, Saunders, 2003:

29 MECHANISMEN: DIABETES Hypothesis of the distal bowel: Expedited of nutrients to the distal bowel enhances a physiologic signal that improves glucose metabolism (GLP-1) Hypothesis of the proximal bowel: Exclusion of duodenum and proximal jejunum may prevent secretion of a putative signal that promotes insuline resistance (involvement of the proximal small intestine in the physiology of IR.

30 MECHANISMEN: DIABETES Hypoglycemia Nesidioblastosis Insulin resistance

31 MECHANISM: sleeve gastrectomy RYGBP SLEEV E Karamanakos et al Ann of Surg 2008;247(3):401-7

32 Mechanisms Sleeve gastrectomy Early Postoperative Insulin-Resistance Changes After Sleeve Gastrectomy Nicola Basso OBES SURG (2010) 20:

33 INDICATIONS : Lower BMI in type 2 DM Quote of Professor Scopinaro Why should you treat a disease When you can cure it!!!! September 15-16th ste World Congress on Interventional therapies for type 2 Diabetes; September 15-16th 2008

34 INDICATIONS : <35 BMI type 2 DM Rubino et al.: Effect of Duodenal Jejunal Exclusion in a Non-obese Animal Model of Type 2 Diabetes LEAN TYPE 2 DIABETIC RATS Rubino F. Ann Surg Jan;239(1):1-11.

35 INDICATIONS : <35 BMI type 2 DM LAGB vs RYGBP BMI 30<>35 DM TYPE Early Postoperative Outcomes of Metabolic Surgery to Treat Diabetes 2 % resolution 3-6 months 6-12 months BMI 3-6 months 6-12 months RYGBP 50 55,2 27,2 27,1 Lap Banding 31,8 27, ,9 P 0,0579 0,0199 <0,0001 0,0002 From Sites Participating in the ASMBS BSCOE Program as Reported in the BOLD Eric J. DeMaria, MD, Walter J. Pories, MD Annals of Surgery Volume 252, Number 3, Sept. 2010

36 MECHANISM: Diabetes Insulin resistance Unhealthy lifestyle and environmental factors + Metabolic syndrome Increased risk of cardiovascular disease Healthy beta-cells

37 MECHANISM: diabetes Unhealthy lifestyle and environmental factors Genes Environment Inflammation + Free fatty acid Glucose Hyperglycaemia Failing beta-cells Type 2 diabetes

38 WEIGHT LOSS is IMPORTANT Rubino

39 WEIGHT LOSS is IMPORTANT COULD NOT REPRODUCE THE RESULT ON DM W. PORIES Walter J. Pories, G. Lynis Dohm, Obes Surg Nov 18. Epub ahead o

40 WEIGHT LOSS is IMPORTANT Insulin resistance did not change either Walter J. Pories, G. Lynis Dohm, Obes Surg Nov 18. Epub ahead o

41 WEIGHT LOSS is IMPORTANT WEIGHT REGAIN IS STRONGLY ASSOCIATED WITH RELAPSE Lower preoperative BMI is also contributing factor Possible mechanisms: -Increased calory intake -Increased fat mass -Adaptation of the gut Further research is needed Surg Obes Relat Dis DiGiorgi M, Bessler

42 WEIGHT LOSS is IMPORTANT

43 CALORIC RESCTRICTION is IMPORTANT BYPASS VERSUS NO OPERATION DIET ONE WEEK IDENTICAL FOR BOTH RYGBP CHANGES HORMONES INSULINE RESISTANCE IS CHANGED BY CALORY RESTRICTION JAMES M. ISBELL, NAJI N. ABUMRAD,DIABETES CARE, VOLUME 33, NUMBER 7, JULY 2010

44 NEW DEVICES

45 NEW DEVICES

46 NEW OPERATIONS

47 NEW OPERATIONS An ileal interposition with a diverted sleeve gastrectomy is an effective operation for the treatment of type 2 diabetes mellitus patients with BMI Depaula AL, Surg Endosc 2008 Oct 2.

48 Indicaties BMI 35 + DM2 of hypertension with 3 R/ of OSAS Dyslipidemia/hypertension/GERD/ orthopedic/psy BMI 40 One year diet Multidiscplinary intake: psy, DIT,surgeon, physician * NIH statement RIZIV

49 CAVEAT IDF statement: Bariatric surgery: an IDF statement for obese Type 2 diabetes J.B. Dixon a, P. Zimmet a,, and International Diabetes Federation Taskforce on Epidemiology and Prevention Surgery should be an accepted option in people who have Type 2 diabetes and a BMI of 35 kg m2 or more. Surgery should be considered as an alternative treatment option in patients with a BMI between 30 and 35 kg m2 when diabetes cannot be adequately controlled by optimal medical regimen, especially in the presence of other major cardiovascular disease risk factors.

50 CAVEAT Operatie noopt tot een volledige verandering van levenstijl en voedingsgewoonte. Patiënt moet dit weten en willen! Patiënt verliest een chronische ziekte maar niet de behandeling! DUS NIET FORCEREN MAAR INFORMEREN

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