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The IDF Position Statement: Implications for Surgeons

The IDF Position Statement: Implications for Surgeons. Francesco Rubino, MD Associate Professor of Surgery Chief, GI Metabolic Surgery Diabetes Surgery Center Weill Cornell Medical College- New York, NY. Disclosures. Covidien : Research grant, Educational Grant Roche: Research Grant

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The IDF Position Statement: Implications for Surgeons

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  1. The IDF Position Statement: Implications for Surgeons Francesco Rubino, MD Associate Professor of Surgery Chief, GI Metabolic Surgery Diabetes Surgery Center Weill Cornell Medical College- New York, NY

  2. Disclosures • Covidien : • Research grant, Educational Grant • Roche: • Research Grant • NGM Biotech: • Scientific Advisory Board/Consultant

  3. “My daddy is a doctor and he treats diabetes.” “My daddy is a surgeon and he cures it.” “The surgeon’s perspective”

  4. W.J. Pories The physician’s perspective “Francesco, why don’t you just give him Metformin?

  5. THE HERETICAL SUGGESTION The Heretical Suggestion: A Surgical Treatment for Diabetes Nicolaus Copernicus (1473-1543)

  6. “The Showdown: Surgeons vs Endocrinologists”

  7. “…Rubino's idea boils down to one impolite word used to refer to the excrement of steers.” …A surgeon’s perspective

  8. The IDF Position Statement on Bariatric Surgery in obese type 2 diabetes

  9. Surgeons and Endocrinologists

  10. Specific goals of the IDF Position Statement • Develop practical recommendations for clinicians on patient selection and management • Identify barriers to surgical access • Suggest health policies that ensure equitable access to surgery • Identify priorities for research Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

  11. IDF Taskforce Consensus Panel • Professor Linong Ji • Dr. Muffazal Lakdawala • Professor Wei-Jei Lee • Professor Pierre Lefebvre • Dr. Carel le Roux • Professor Jean-Claude Mbanya • Professor Gertrude Mingrone • Dr. Philip R. Schauer • Professor Luc Van Gaal • Dr. David Whiting • Professor Bruce M. Wolfe Conveners: Professor George Alberti Professor John B. Dixon Professor Francesco Rubino Professor Paul Zimmet Attendees: Professor Stephanie Amiel Professor Louise A. Baur Professor Nam H. Cho Dr. Bruno Geloneze Professor Jan Willem Greve Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

  12. Recommendations on surgical management Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

  13. IDF Position Statement • INDICATIONS TO SURGICAL TREATMENT

  14. IDF Position Statement • Bariatric surgery is an appropriate treatment for people with type 2 diabetes and obesity not achieving recommended treatment targets with medical therapies, especially when there are other major co-morbidities. • Surgery should be considered early in the treatment of diabetes patients, not as a last resort

  15. IDF Position Statement: Which patient with type 2 diabetes should be considered? • Surgery should be an accepted option in people who have type 2 diabetes and BMI of 35 or more • Surgery should also be considered as an alternative treatment option in persons with BMI 30 to 35 when diabetes cannot be adequately controlled by optimal medical regimen, especially in the presence of other major cardiovascular disease risk factors • In Asians, and some other ethnicities of increased risk, BMI action points may be lower e.g. BMI 27.5 to 32.5 Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

  16. Diabetes Surgery Summit Rome 2007

  17. IDF Position Statement • CHOICE OF PROCEDURE

  18. Recommendations on surgical management • The position group considers RYGB, LAGB, BPD/BPD-DS, SG as currently accepted bariatric surgical procedures • Only two are considered acceptable in adolescents: RYGB and LAGB • The position group acknowledges that there are limited medium- or long-term data regarding SG, and there are safety, nutritional and metabolic concerns with BPD/BPD-DS Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

  19. Recommendations on surgical management • Apart from conventional procedures now in use new techniques and devices should be explored in research settings only • New bariatric procedures require robust assessment for their efficacy, safety, and durability using similar principles to those for assessing new drug therapies and having regards to the benefits and risks of established therapy Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

  20. Factors to consider when choosing a bariatric procedure in patients with Type 2 diabetes risks and benefits, the importance of compliance, the effects on eating choices and behaviours The duration of Type 2 diabetes and the degree of apparent residual B-cell function

  21. IDF Position Statement • PERIOPERATIVE MANAGEMENT

  22. Recommendations on diabetes management • Surgery should be considered as complementary to medical therapiesto reduce micro-vascular and cardiovascular risk • Patients should be assessed and managed by experienced multi-disciplinary teams • Glycaemic control should be optimised peri-operatively and should be closely monitored after surgery • It should be recognised that a prolonged period of normalisation of glycaemic control has benefit for diabetes even if there is eventual relapse Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

  23. Recommendations on diabetes management • There should be a minimal accepted data set for pre-surgery and follow-up • Weight, blood glucose control, assessment for diabetes complications, laboratory measures and medications etc. Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

  24. Pre-operative and Follow-Up Data Set

  25. “Diabetes Surgery” > characteristics of pts population > Pts needs and expectations > Outcomes and definition of success “Diabetes Surgery” vs “Bariatric Surgery” • Indications • Preoperative diagnostic evaluation • Choice of Procedure • Definition of success of treatment • Assessment of postoperative outcomes • Type of follow-up • Complementary therapies • Definition of “care team”

  26. IDF Position Statement • DEFINITION AND MONITORING OF SUCCESS OF TREATMENT

  27. Specific goals of the IDF Position Statement • Develop practical recommendations for clinicians on patient selection and management • Identify barriers to surgical access • Suggest health policies that ensure equitable access to surgery • Identify priorities for research Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

  28. Actual procedures in England 2009/10 compared to estimates if all PCTs were to follow NICE

  29. BARRIERS • Stigma of Obesity • Misperception about risk factors vs disease state • Misconception of “Obesity” • Identification of “Bariatric Surgery” with “Weight Loss Surgery

  30. Cultural Barriers • In the medical community: “…obesity is a cultural and behavioural problem…” “…attempt to combat excess of food by cutting out parts of stomachs and intestines Not a rational solution”

  31. BARRIERS • Stigma of Obesity • Misperception about risk factors vs disease state • Misconception of “Obesity” • Identification of “Bariatric Surgery” with “Weight Loss Surgery

  32. Cultural Barriers/ Misperceptions Treatments Considered Rationale Risk Factor Disease Surgery, Radiotherapy, Chemotherapy > Lifestyle Modification complementary Smoking Cancer

  33. Cultural Barriers/ Misperceptions Risk Factor Disease Treatments Considered Acceptable Lifestyle Modification > Not-rationale solutions: (Surgery, Drug Therapy) Overeating- Sedentary Lifestyle Obesity

  34. BARRIERS • Stigma of Obesity • Misperception about risk factors vs disease state • Misconception of “Obesity” • Identification of “Bariatric Surgery” with “Weight Loss Surgery

  35. Obesity is an ill-defined condition Excess weight is symptom of disease, not disease per se

  36. CVD/Death OBESITY Increased BP

  37. Obesity = Excess Weight • Obesity without Insulin Resistance (IR) • Obesity without Diabetes • Normal Weight Individuals with IR • Normal Weight Individuals with Diabetes and MS • Metabolically healthy obese individuals • Metabolic syndrome in non-obese individuals ARCH INTERN MED/VOL 168 (NO. 15), AUG 11/25, 2008

  38. CVD/Death OBESITY Increased BP

  39. BARRIERS • Stigma of Obesity • Misperception about risk factors vs disease state • Misconception of “Obesity” • Identification of “Bariatric Surgery” with “Weight Loss” Surgery

  40. BARIATRIC SURGERY CVD/Death OBESITY Increased BP

  41. JAMA Jan 2012

  42. JAMA Jan 2012 Baseline Insulin, Not BMI or weight loss Predict CV benefits of surgery

  43. CVD/Death OBESITY BARIATRIC SURGERY Increased BP

  44. HOW DO WE ADDRESS BARRIERS? • Advocacy for obese patients • Define risk factors vs disease state • Re-definition of “Obesity” • From Bariatric to “METABOLIC” and DIABETES SURGERY

  45. HOW DO WE ADDRESS BARRIERS? • Advocacy for obese patients • Define risk factors vs disease state • Re-definition of “Obesity” • From Bariatric to “METABOLIC” and DIABETES SURGERY

  46. HOW DO WE ADDRESS BARRIERS? • Advocacy for obese patients • Define risk factors vs disease state • Re-definition of “Obesity” • From Bariatric to “METABOLIC” and DIABETES SURGERY

  47. HOW DO WE ADDRESS BARRIERS? • Advocacy for obese patients • Define risk factors vs disease state • Re-definition of “Obesity” • From Bariatric to “METABOLIC” and “DIABETES” SURGERY

  48. CVD/Death OBESITY METABOLIC SURGERY Increased BP

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