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Screening and Follow-up in Obese subjects Bariatric Sugery: When?

Bari 27 novembre 2009. Et lucem sed aliam reddit …. Screening and Follow-up in Obese subjects Bariatric Sugery: When?. Gabriella Garruti Department of Emergency and Organ Transplantation Section of Internal Medicine, Endocrinology , Andrology and Metabolic Diseases

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Screening and Follow-up in Obese subjects Bariatric Sugery: When?

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  1. Bari 27 novembre 2009 Et lucem sed aliam reddit… Screening and Follow-up in Obese subjects Bariatric Sugery: When? Gabriella Garruti Department of Emergency and Organ Transplantation Section of Internal Medicine, Endocrinology , Andrology and Metabolic Diseases (Chairman: prof. F. Giorgino)

  2. Bari 27 novembre 2009 Et lucem sed aliam reddit…

  3. What is Overweight?

  4. Overweight and Obesity: When? BMI FAT distribution Centralobesity Man: >94(102) cm Woman: >80(88) cm WAIST IDF/(ATPIII)

  5. Surgery Pharmacotherapy Lifestyle Modification Diet Physical Activity Bari 27 novembre 2009 Et lucem sed aliam reddit… Obesity Treatment Pyramid

  6. Guidelines for Selecting Obesity Treatment Treatment 25-26.9 27-29.9 30-34.9 35-39.9 >40 Diet, Exercise, Behavior Tx + + + + + Pharmaco-therapy With co-morbidities + + + Surgery With co-morbidities + Bari 27 novembre 2009 BMI Category (kg/m2) + The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. October 2000, NIH Pub. No.00-4084 modified by Garruti 2008

  7. Bari 27 novembre 2009 Et lucem sed aliam reddit… OnlywhenLifestyleisunhealthy Bariatric surgery Gastric Bypass (Roux-en-Y) Gastric banding 13.02.05

  8. Bari 27 novembre 2009 Et lucem sed aliam reddit… Bariatric surgery: what is? • The operations employed for morbid obesity are not to be confused with plastic surgery • Real risk comes with each surgical procedure • Prospective patients should also be thoroughly convinced that they have exhausted all other reasonable avenues of weight loss before selecting surgery

  9. Indications BMI >40 kg/m2 or BMI 35–39.9 kg/m2 and life-threatening cardiopulmonary disease, severe DIABETES, or lifestyle impairment Failure to achieve WL with Medical Treatment Controintraindications History of noncompliance with medical care Psychiatric illnesses: personality disorder, uncontrolled depression, suicidal ideation, substance abuse elevated ASA risk Bari 27 novembre 2009 Et lucem sed aliam reddit… Bariatric Surgery: When ? • EAES /ASBS 2005 • BMI 30-35 kg/m2 • & life-threatening comorbidities • Sauerland et al. Surg Endosc 19:200 • Buchwald et al. J Am Coll Surg 200:593 NIH Consensus Development Panel. Ann Intern Med 1991;115:956.

  10. Bari 27 novembre 2009 Et lucem sed aliam reddit… Indicazioni NIH 1998- LIGIO 1999 EAES /ASBS 2005 • Obesità di durata superiore a 5 anni • BMI > 40Kg/m2 o BMI >35Kg/m2 con comorbidità* • Età: da 18-65 anni • Fallimento Tx medica (dietetica, farmacologica, comportamentale) per almeno 1 anno • Assenza di cause endocrine di obesità • Rischio anestesiologico max < ASA 2 • Assenza di malattie psichiatriche e/o disturbi del comportamento alimentare (DCA). • Compliance del paziente (follow-up)

  11. Bari 27 novembre 2009 Et lucem sed aliam reddit… Indicazioni • Insuff. venosa cronica arti inferiori • Impotenza/Irregolarità mestruali /Infertilità • Iperuricemia • Irsutismo • Nefrolitiasi BMI >35 con comorbilità* • OSAS/Pickwick • Ipertensione arteriosa • Scompenso cardiaco • Diabete mellito tipo 2 • Osteoartrosi • Colelitiasi • Dislipidemie

  12. Bari 27 novembre 2009 Et lucem sed aliam reddit… Bariatric Sugery: how important is the multidisciplinary approach?

  13. Bari 27 novembre 2009 Et lucem sed aliam reddit… Bariatric Sugery: how important is the multidisciplinary approach? Anesthesiologist, Cardiologist, Dietitian or Nutritionist, Endocrinologist , Pneumologist, Psychiatrist, Surgeon

  14. Valutazione clinica e strumentale prima della chirurgia Bari 27 novembre 2009 Et lucem sed aliam reddit… • Esami ematochimici • Inquadramento endocrino-metabolico* e genetico • Rx torace • Ecografia addome superiore e inferiore • Doppler venoso arti inferiori • Emogasanalisi, spirometria, polisonnografia • Inquadramento psicologico-nutrizionale (psichiatra e dietisti) • Rx baritato (+Trendelenburg per ernia iatale) • EGDS + biopsia per infezione H. pylori • Consulenza cardio-anestesiologica

  15. Bari 27 novembre 2009 Et lucem sed aliam reddit… Inquadramento endocrino-metabolico e nutrizionale • Indagine alimentare, variabili antropometriche • Indici nutrizionali • HOMA/ OGTT per glicemia e insulinemia • Pattern ormonali: • asse ipofisi-surrene/gonadi • asse ipofisi-tiroide • asse GH /IGF1 • Ecografia tiroidea • Mineralometria ossea computerizzata “Total body”

  16. Bari 27 novembre 2009 Et lucem sed aliam reddit… IsDietdependent on …? Energy needs Environment Genes (metabolism) • Palatableness (taste receptors) • Geography • Nutrients availability • Economic situation • Culture • Religion Your Gut Has Taste Receptors ScienceDaily (Aug. 21, 2007)

  17. Lazar Science 2005 modified by Garruti In the Pima, survival mechanisms evolved to store fat extremely efficiently (“thrifty genotype”) This GENETIC MAKE-UP would have served the tribe well in the harsh desert climes of the southwest Today this so-called "thrifty gene" means 70% of the Arizona Pima are obese and diabetics Bari 27 novembre 2009 Et lucem sed aliam reddit… The Desert’s perfect foods Overweight Normalweight Obese

  18. Bari 27 novembre 2009 Et lucem sed aliam reddit…

  19. Bari 27 novembre 2009 Indagine alimentare Et lucem sed aliam reddit… 41.8 62 99.2 154 2200 12% 60% 28% 20 3 X X X pane, pasta, condimenti, rustici verdura Dieta a b.i.g 1200 Kcal/Die Attività fisica (v. piramide attività fisica) Giovanna Mallardi

  20. Bari 27 novembre 2009 Diet & Energy needs Et lucem sed aliam reddit… Neuronalcircuits in the hypothalamusaffect Satiation(leveloffullnessduring a mealwhichregulates the amountoffoodconsumed) Satiety (levelofhungerafter a mealisconsumedwhichregulates the frequencyofeating) Schwartz et al. 2000 Nature

  21. Bari 27 novembre 2009 Et lucem sed aliam reddit… Energy density: Volume versus calories All foods have a certain number of calories within a given amount (volume) Foods with high energy density have a large number of calories in a small volume Alternatively foods with low energy density provide a larger portion size with a fewer number of calories.

  22. Energy Density of Selected Foods Bari 27 novembre 2009 Et lucem sed aliam reddit… Lettuce Vegetable soup Skim milk Apple Black beans White fish Yogurt Vegetable lasagna Roast chicken White bread Pretzels Cheddar cheese Salad dressing Potato chips Bacon Butter Energy Density (kcal/g) Klein S, et al. Gastroenterology. 2002

  23. Bari 27 novembre 2009 HEALTHY PYRAMID FOOD (Harvard Medical School)

  24. Classification Gastric restriction Primarily restrictive and partially malabsorptive Primarily malabsorptive and partially restrictive Procedure Adjustable Gastric Banding Roux-en-Y Gastric Bypass Sleeve Gastrectomy Bari 27 novembre 2009 Et lucem sed aliam reddit… Current Bariatric Surgical Procedures • Biliopancreatic diversion with duodenal switch • Biliopancreatic diversion • Distal gastric bypass

  25. Bari 27 novembre 2009 Et lucem sed aliam reddit… Restrictive Gastric Surgery Vertical gastroplasty Adjustable gastric banding Intragastric balloon(BIB)

  26. Laparoscopic Adjustable Gastric Banding Bari 27 novembre 2009 Et lucem sed aliam reddit… Access port (reservoir) LapBandTM Connection tubing Gastric Band Silicone band placed around upper stomach to create a small pouch. Outlet diameter can be changed by infusing or withdrawing saline from port. Puglisi 2008 American Society for Metabolic and Bariatric Surgery, www.asbs.org

  27. Roux-en-Y gastric bypass Bari 27 novembre 2009 Et lucem sed aliam reddit…

  28. Bari 27 novembre 2009 Et lucem sed aliam reddit… Biliopancreatic Diversion with Duodenal Switch • Sleeve gastrectomy with rerouting of small intestine through “nutrient limb” and “biliopancreatic limb” • Digestion and absorption are limited to 100 cm “common channel” of terminal ileum • Causes marked weight loss, but can lead to significant nutritional deficiencies Marceau P. et al. World J Surg 1998;22:947-54

  29. Follow-up (post- LAGB and post-GBP) Bari 27 novembre 2009 Et lucem sed aliam reddit… months 0 1 3 6 9 12 15 18 21 24 surgeon EGDS Calibration Rx ? ……? Cardiologist, Dietitian or Nutritionist, Endocrinologist , Pneumologist, Psychiatrist

  30. Energy Metabolism in mammals Basal Metabolic Rate [Obbligatory Thermogenesis (Th)] Exercise-induced Th Diet-induced Th Bari 27 novembre 2009 Et lucem sed aliam reddit… Major effects of Bariatric Surgery Weight

  31. Bari 27 novembre 2009 Et lucem sed aliam reddit…

  32. Bari 27 novembre 2009 Indagine alimentare Et lucem sed aliam reddit… 41.8 99.2 154 1000 15% 57% 28% 30 3 X X X X X ? Dieta a b.i.g 1000-1200 Kcal/Die Attività fisica (v. piramide attività fisica) Maria A. Lucafo’ & Giovanna Mallardi

  33. Bari 27 novembre 2009 Et lucem sed aliam reddit…

  34. Suggested Energy Deficit based on Initial BMI Bari 27 novembre 2009 Et lucem sed aliam reddit… National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults – The Evidence Report. Obes Res. 1998;6(suppl 2):51S-209S

  35. Bari 27 novembre 2009 Et lucem sed aliam reddit… Weight Loss after Bariatric Surgery or Medical Therapy* BMI between 30 and 35 Kg/m2 Weight Loss, % Surgical (LapBand) Nonsurgical 6 mo 12 mo 18 mo 24 mo Baseline *VLCD, behavioral modification, and pharmacotherapy Obrien et al. Ann Intern Med. 2006

  36. Bari 27 novembre 2009 Et lucem sed aliam reddit… Parametri antropometrici dopo BIB

  37. Bari 27 novembre 2009 Parametri antropometrici dopo LapGB Et lucem sed aliam reddit…

  38. Bari 27 novembre 2009 Et lucem sed aliam reddit… Excess Weight Loss (EWL) and Compliance to Comprehensive Medical Therapy* after Gastric Banding % of subjects with low or high compliance %EWL in subjects with low or high compliance low high *[life-style modifications (diet, exercise) + pharmacotherapy] low high Lucafo’ MA, Rotelli MT, De Tullio A. 2008 unpublished

  39. Effect of Different Bariatric Surgical Procedures on Weight Loss Bari 27 novembre 2009 Et lucem sed aliam reddit… Procedure Approximate Loss of Excess Weight (%) Laparoscopic gastric banding 45–65 Gastric bypass procedure 55–65 Biliopancreatic diversion (DS) 60–75 Klein et al. Gastroenterology. 2002;123:882-932

  40. Comorbidity outcomes after Bariatric surgery Bari 27 novembre 2009 Et lucem sed aliam reddit… ComorbidityImproved/Resolved Diabetes 100% Coronaryarterydisease 100% Hypercolesterolemia 96% Gastroesophagealreflux d. 96% Sleep apnea 93% Hypertension 88% Osteoarthritis 88% Hypertriglyceridemia 86% Depression 55% AdaptedfromSchaueret al. AnnSurg 2000 Busettoet al. ObesSurg 2000 10: 569 Pontiroliet al JCEM 2002 87:3555 Scopinaroet al. Diabetes Care 2005; 28:2406 Busettoet al. NMCD 2008; 18:112

  41. Bari 27 novembre 2009 Et lucem sed aliam reddit… THE EFFECTS OF GASTRIC BANDING ON RED BLOOD CELL AGGREGATION & DEFORMABILITY IN MORBIDLY OBESE SUBJECTS Puglisi Francesco, Capuano Palma, Giorgio Catalano, Garruti Gabriella, Trerotoli Paolo, Tedeschi Michele, De Fazio Michele, Cicco Giuseppe, Giorgino Francesco, Memeo Vincenzo Box plot comparing EI 3 PA at baseline and 3 and 6 months after surgery. AI: aggregation index; EI: elongation index

  42. Bari 27 novembre 2009 Et lucem sed aliam reddit… THE EFFECTS OF GASTRIC BANDING ON RED BLOOD CELL AGGREGATION & DEFORMABILITY IN MORBID OBESE PATIENTS Puglisi Francesco et al. Bs 3M 6M Box plot comparing AI% 3 at baseline and 3 and 6 months after surgery AI: aggregation index; EI: elongation index

  43. BMI DISTRIBUTION IN A COHORT OF TYPE 2 DIABETIC SUBJECTS Bari 27 novembre 2009 Et lucem sed aliam reddit… GARRUTI G., VITA MG, GIAMPETRUZZI F et al. 2008 unpublished

  44. LapGB LIMITI Anestesia (vs Tx medica integrata) Limitato calo ponderale (vs Tx chirurgica malassorbitiva) Obbligatorio “counseling” Alimentazione semiliquida per ~ 1 settimana (600 - 800Kcal/die) (vs Terapia medica ed chirurgica malassorbitiva) Durata del pasto:> 40 min Intervallo tra cena e bed-time: 2 h VANTAGGI Dieta ipocalorica bilanciata (proteine 19,4%; glucidi 56,2% ; lipidi 24,4%) + integratori Graduali modificazioni dell’immagine corporea Bari 27 novembre 2009 Et lucem sed aliam reddit…

  45. Complications after Gastric Bypass The bypassed portion of intestine is where the majority of calcium and iron absorption takes place LONG-TERM COMPLICATIONS anemia osteoporosis Other clinically important deficiencies Vitamin B 1 (thiamine) Vitamin B 12 lack of gastric intrinsic factor (GIF) Lifelong follow-up with a daily multi-vitamins and mineral supplementation are strongly recommended to prevent nutritional complications Bari 27 novembre 2009 Et lucem sed aliam reddit…

  46. GBP & Dumping syndrome Bari 27 novembre 2009 Et lucem sed aliam reddit… • Gastric bypass operations may also cause "dumping syndrome" food or liquids travel too rapidly through the small intestine (sweets are often the culprit) • Dumping symptoms include nausea weakness sweating faintness diarrhea • Symptoms dissipate after the patient rests???

  47. External factors Emotions Food characteristics Lifestyle behaviors Environmental cues  +  + Bari 27 novembre 2009 RegulationofFoodIntake Et lucem sed aliam reddit… Brain Central Signals Stimulate Inibit NPY AGRP galanin Orexin-A dynorphin α-MSH CRH/UCN GLP-I CART NE 5-HT Peripheral signals Peripheral organs Glucose CCK, GLP-1Apo-A-IVVagal afferents Insulin GhrelinLeptinCortisol Gastrointestinaltract FoodIntake Adiposetissue Adrenal glands Schwartz et al. 2000 Nature

  48. Bari 27 novembre 2009 Et lucem sed aliam reddit…

  49. Bari 27 novembre 2009 Et lucem sed aliam reddit… Adipose Tissue depots are a marvelous source of adipocyte precursors stem cells ANP

  50. Bari 27 novembre 2009 Et lucem sed aliam reddit… Bariatricsurgery and Glycaemia • Any surgical procedure • normalizes hyperglycemia • restores insulin sensitivity • prevents progression from IGT to DM • reduces mortality from DM • Gastric bypass and Biliopancreatic diversion • restores euglycemia and normal insulin long before any significant weight loss • Changes in hormones secretion from the GI tract

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