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METABOLIC SURGERY

METABOLIC SURGERY. Dr.Parvin Shapoori Fellowship of MIS & Metabolic Surgery. TOPICS. C oncept of “metabolic” versus bariatric surgery E ffects of metabolic surgery on the various organ systems T he role of the gut in hyperinsulinemia of the metabolic syndrome. “metabolic” surgery.

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METABOLIC SURGERY

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  1. METABOLIC SURGERY Dr.ParvinShapoori Fellowship of MIS &Metabolic Surgery

  2. TOPICS • Concept of “metabolic” versus bariatric surgery • Effects of metabolic surgery on the various organ systems • The role of the gut in hyperinsulinemia of the metabolic syndrome

  3. “metabolic” surgery • The idea of operating on a normal organ to improve health • Gastric surgery for PUD • Removal of a normal spleen for congenital hematologic diseases • Excision of normal ovaries and testicles for cancers of the breast and prostate. • Tubal ligation, vasectomy • Transplantation of organs in which normal organs are removed to overcome diseases in recipients. • The most common metabolic operations, foregut procedures known as bariatric surgery

  4. What Is in the Name? • Barros the Greek word for weight. More than 60 years ago, a variety of operations—adevised by pioneers such as Payne,Varco, and Mason

  5. “Metabolic surgery” • Metabolic intestinal surgery was originally referred to in an article by Starkloff et al. [ 1975 ] • And metabolic surgery was defined by Buchwald and Varco [ 1978 ] • The operative manipulation of a normal organ or organ system to achieve a biological result for a potential health gain

  6. The Four Major Metabolic Operations • The basic design • Reduce contact between food and the gut • Reduction of intake • Removal of part of the stomach • Exclusion of segments of the foregut • or all of these

  7. Metabolic Surgery: Not Just a “LittleIntestinal Operation” RYGB 1. Reduction in food volume by the small gastric pouch(30 CC) 2. Delayed gastric emptying due to the small gastroenterostomy(10 m) 3. Early “dumping” of undigested food into the upper jejunum 4. Partial injury to the vagus nerve supply to the stomach 5. Exclusion of food from the fundus, antrum, duodenum,px jejunum

  8. 6. Rapid transit of food through the small bowel 7. Alterations in the microbiome (i.e., the microorganisms of the gut 8. Changes in dietary intake 9. Secondary effects such as weight loss with a reduction and change in adipokines 10. Changes in signaling between the gut, liver, muscle,adipocytes, and each organ system

  9. The Broad Effects of Metabolic Surgeryon Just One Disease: Type 2 Diabetes Mellitus • In 1982, surgeons first reported that Gastric Bypass” was not only more effective in producing weight loss than any other previous therapy, but it also induced remission of T2DM • In later publications, the group reported that the remissions were full, durable, and safe with a reduction in mortality by 78 % • Further, the remission occurred in a number of days before there was significant weight loss—an observation that demonstrated the important role of the foregut in the regulation of energy metabolism.

  10. “metabolic syndrome” • Obesity, hypertension, sleep apnea, nonalcoholic steatohepatosis • (NASH), and PCO • characterized by hyperinsulinemia • Insulin levels might be a better gauge of disease severity and response to bariatric surgery

  11. Other Effects of Bariatric Metabolic Surgery • Resolution of hypertension (63.3 %) • Obstructive sleep apnea (68.9 %) • Gastroesophageal reflux disease (GERD) (87.6 %) • Venous insufficiency (71.0 %) • Asthma (66 %) • Stress incontinence (84 %) • Depression (31.4 %) • Degenerative joint disease (67.1 %) • Hyperlipidemia (61.4 %)

  12. “metabolic bariatric surgery affects every organ system and every tissue in the body.”

  13. Adipose Tissues and Circulating Lipids • Cholesterol and low-density lipoprotein showed significantly greater improvement with DS compared with SG and GB • Baseline C-reactive protein (CRP) levels among DS patients were double that of SG and RYGB, rapidly declined to equivalent levels by 3 months and normalized in 79 %. • DS procedure resulted in a superior reduction in cardiovascular and proinflammatory risk markers compared with GB and SG.

  14. Bone • Metabolic surgery is followed by significant bone loss • Significant loss of weight • malnutrition • endocrine signaling to and from the bone • the data do not support increased incidence of osteoporosis or increased fracture risk in post-bariatric patients.”

  15. Cardiovascular System • SOS 20 y • “Bariatric surgery was associated with a reduced MIincidence” • The effect was stronger in individuals with higher serum cholesterol and triglycerides

  16. Endocrine System “The overall prevalence of endocrine diseases, not including T2D, was 47.4 %. The primary hypothyroidism pituitary disease Cushing syndrome polycystic ovary syndrome rare cases of secondary hypoparathyroidism

  17. Female Reproductive System • Reversal of the (PCOS), a component of the metabolic syndrome associated with obesity, as well as an insulin resistance and hyperinsulinemia. • Bariatric surgery decreases bodyweight and fat excess and reverses hyperandrogenismand sterility. • Contraception during the first postoperative year is essential

  18. Gastrointestinal Tract • A large number of the signals, including cholecystokinin • (CCK), peptide YY 3–36 (PYY), glucagon-like peptide-1 • (GLP-1), gastric inhibitory polypeptide (GIP), pancreatic • glucagons, ghrelin, and gastrin

  19. Genomic Effects • AMS(after metabolic surgery) children than BMS(before MS) offspring • threefold lower prevalence of severe obesity • greater insulin sensitivity • improved lipid profile (cholesterol/high-density lipoprotein cholesterol • lower C-reactive protein , and leptin • and increased ghrelin • In addition, the post-bariatric surgery children performed better in school than their siblings

  20. Inflammation and the Immune Response • Chronic low-grade inflammation,( high prevalence of cancer, asthma, and degenerative joint disease) • “Bariatric surgery produces about 66% reduction in CRP and and27 % interleukin-6 (IL-6) levels • RYGB, AGB,andGS noted that “all three treatment arms showed a significant decrease in the mean body mass index, mean arterial pressure, and urinary and serum inflammatory markers

  21. Liver • Following bariatric surgery, the cirrhosis due to nonalcoholic hepatic steatosis (NASH)clear, although some periportal scarring appears to be permanent

  22. Muscle • Reduction of fatty acid oxidation in the severely obese due to intrinsic mitochondrial defects

  23. Neoplastic Response • Reduction in the prevalence of cancer • most effective preventive intervention in the control of cancer

  24. Nutrition • The most prevalent deficiency BS is vitamin D25 (OH): obese 94 %,control 24 % magnesium, vitamin B6, and anemia- in the macroelementsincluding iron and calcium; trace elements including zinc, copper, and chromium; vitamins, especially thiamine,riboflavin, and vitamin D. • The likelihood of deficiency(i.e., biliopancreatic bypass with a duodenal switch > gastric bypass > gastric sleeve > adjustable gastric band) • malnutrition is common after bariatric surgery,andthe best treatment is prevention

  25. Pulmonary • Bariatric surgery improves pulmonary function (FEV1), forced expiratory vital capacity (FVC),Functional residual capacity (FRC), FRC/total lung capacity (FRC/TLC), and expiratory reserve volume (ERV) all improved . • C-reactive protein decreased

  26. Renal • Bariatric surgery has good and bad effects on renal function. • The hyperoxaluriafollowing the gastric bypass increases the • risk for renal stones

  27. Metabolism/Energy • low capacity for fuel oxidation, which may play a role in the • predisposition of obesity. • Whether lower mitochondrial capacity is a cause or a consequence of obesity”

  28. Operation of Choice for Metabolic Surgery • Obesity is a major contributing factor in the pathogenesis of T2DM, such that more than 80 % of diabetic patients are overweight or obese. • Although lifestyle modifications and pharmacotherapy are the cornerstone for treatment of obesity and T2DM • adequate glycemic control is not obtained in most obese patients with T2DM

  29. Advantage of MS • long-term improved glycemic control resulting from surgery may result in less end-organ damage, even if there is an eventual relapse • Bariatric surgery is not only considered an extremely effective therapeutic intervention in T2DM, but it also prevents the development of diabetes in the severely obese population

  30. Diabetes Surgery Summit Consensus Guidelines • GI surgery (i.e., RYGB, LAGB, or BPD) should be considered for the treatment of T2DM in acceptable surgical candidates with BMI ≥35 kg/m 2 who are inadequately controlled by lifestyle and medical therapy • A surgical approach may be appropriate as a non-primary alternative to treat inadequately controlled T2DM in suitable surgical candidates with mild-to-moderate obesity (BMI 30–35 kg/m 2 ) • RYGB may be an appropriate surgical option for diabetes treatment in this patient population

  31. weight loss alone explains diabetes control after LAGB • In contrast, intestinal bypass procedures such as RYGB, BPD, and DJB appear to engage additional antidiabetesmechanisms beyond those related to reduced food intake and body weight • Anatomic modifications of various regions of the GI tract ameliorate T2DM through distinct physiological mechanisms

  32. Antidiabetic efficacy gradient among standard metabolic operations • (BPD > RYGB > SG > LAGB),

  33. Metabolic Surgery in Patients withBMI <35 kg/m 2 • 87 % of the patients stopped taking antidiabeticmedications • metabolic surgery therapeutic alternative in carefully • selected type 2 diabetic patients with a BMI between • 30 and 35 kg/m 2 who do not respond to fully optimized • medical therapy (i.e., glycated hemoglobin >7.5 %), especially • in the presence of other weight-responsive comorbidities

  34. Operation of Choice

  35. Operation of Choice • Expertise and experience in bariatric surgical procedures • The patient’s preference • The patient’s general health and risk factors • The simplicity and reversibility of a procedure • The duration of T2DM and the degree of apparent residual beta cell function • The follow-up regimen for the procedure and the commitment of the patient

  36. Mechanism of action of standard metabolic operations

  37. Novel Metabolic Procedures and Devices • Duodenal - jejunal bypass (DJB) is a stomach-sparing • bypass of the proximal intestine that has comparable limb • lengths to the standard RYGB • good alternative to RYGB in high-risk groups for gastric cancer

  38. Novel Metabolic Procedures and Devices • In ileal interposition (IT), a small segment of terminal • leum, with intact mesentery and neurovascular supply, is • inserted into the proximal jejunum, enhancing its exposure • to ingested nutrients. This procedure exaggerates release of • incretin hormones without any weight loss effect

  39. Novel Metabolic Procedures and Devices • Laparoscopic gastric plication • Laparoscopic adjustable gastric banded plication • novel endoscopically placed devices, ntragastric balloons; gastric volume restriction by stapling, suturing, or anchoring (endoluminalgastroplasties); • and restrictive valves ,endosleeve

  40. Thanks for Your Attention

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