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Luigi Angrisani Director - General and Endoscopic Surgery Unit

Efficacia della terapia chirurgica sulle complicanze cardiovascolari nel diabete mellito tipo 2. Luigi Angrisani Director - General and Endoscopic Surgery Unit S.Giovanni Bosco Hospital, Naples , Italy. Microangiopatia Retinopatia Nefropatia Neuropatia Macroangiopatia

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Luigi Angrisani Director - General and Endoscopic Surgery Unit

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  1. Efficacia della terapia chirurgica sulle complicanze cardiovascolari nel diabete mellito tipo 2 Luigi Angrisani Director - General and EndoscopicSurgery Unit S.Giovanni Bosco Hospital, Naples, Italy

  2. Microangiopatia Retinopatia Nefropatia Neuropatia Macroangiopatia Coronarica Cerebrale Periferica DIABETE MELLITO: COMPLICANZE CRONICHE

  3. 2-4 volte rischio di CAD 2-4 volte rischio di PAD 20 volte rischio di amputazioni 3 volte rischio di ictus Diabete mellito e complicanze croniche Diabete 2 volte mortalità per IMA a 5a. Prima causa di cecità Restenosi dopo rivascol. Prima causa di IRC

  4. “Il diabete è una malattia cardiovascolare che si diagnostica misurando la glicemia” Y. Yarvinen

  5. Macro-vascular Complications • Ischemic heart disease • Cerebrovascular disease • Peripheral vascular disease Diabetic patients have a 2 to 6 times higher risk for development of these complications than the general population

  6. Macro vascular Complications

  7. J Am Coll Surg. 2013 Apr;216(4):545-56

  8. BACKGROUND • Bariatric surgery (BAR) has been established as an effective treatment for type 2 diabetes mellitus (T2DM) in obese patients. • Few studies have examined the mid- to long-term outcomes of bariatric surgery in diabetic populations. • No comparative studies have broadly examined major macrovascular and microvascular complications in bariatric surgicalpatients vs similar, nonbariatricsurgerycontrols. Johnson et al. J Am Coll Surg. 2013 Apr;216(4):545-56

  9. STUDY DESIGN • Large, population-based, retrospective cohort study of adult obese patients with T2DM, from 1996 to 2009. • Eligible patients undergoing bariatric surgery (BAR [n=2,580]) were compared with nonbariatric surgery controls (CON [n=13,371]) for the outcomes of any first • major macrovascular event (myocardial infarction, stroke, or all-cause death) or • microvascular event (new diagnosis of blindness, laser eye or retinal surgery, nontraumatic amputation, or creation of permanent arteriovenous access for hemodialysis), assessed in combination and separately • other vascular events (carotid, coronary or lower extremity revascularization or new diagnosis of congestive heart failure or angina pectoris). Johnson et al. J Am Coll Surg. 2013 Apr;216(4):545-56

  10. RESULTS • Bariatric surgery is associated with a 60% to 70% reduction in the hazard of any major macro- or microvascular complication of T2DM in moderately to severely obese patients free of advanced cardiovascular and microvascular disease at baseline. • Macrovascular, microvascular, and other vascular events were all shown to be substantially reduced in the Bariatric Surgery patients vs Controls. • The magnitude of the estimated risk reductions ranged between 60% and 80% for all study outcomes and suggests that bariatric surgery may significantly reduce the burden of end-stage diabetes related complications for at least the first 5 to 10 years after surgery. • Although the preponderance of available data is limited by a lack of level 1 evidence, bariatric surgery appears to be emerging as one of the most effective treatments for ameliorating the excess cardiovascular disease burden imparted by T2DM and obesity. Johnson et al. J Am Coll Surg. 2013 Apr;216(4):545-56

  11. PATHOPHYSIOLOGY Weight loss likelyplaysan important role in the long-term durability of diabetes remission among bariatric patients, who exhibit improved remission rates for at least 10 years after surgery compared with control patients receiving optimal medical therapy or usual care. Johnson et al. J Am Coll Surg. 2013 Apr;216(4):545-56

  12. STUDY’S LIMITATIONS • Retrospective nature • Lack of information on body weight and markers of glycemic control preclude analysis of the proposed mechanisms for the observed risk reductions. • Lack of information on duration and severity of diabetes at the time of study inclusion Johnson et al. J Am Coll Surg. 2013 Apr;216(4):545-56

  13. Cardiovascularriskreduction and bariatricsurgery *47 % in diabeticsubgroup

  14. CONCLUSIONS Bariatric surgery is associated with a 65% reduction in major macrovascular and microvascular events in moderately and severely obese patients with T2DM. Johnson et al. J Am Coll Surg. 2013 Apr;216(4):545-56

  15. Micro vascular Complications

  16. Diabetic Retinopathy (DR) • DR is the leading cause of blindness in the working population of the Western world • The prevalence increase with the duration of the disease (few within 5 years, 80 – 100% will have some form of DR after 20 years) • Maculopathy is most common in type 2 patients and can cause severe visual loss

  17. Rapid and significant improvement in diabetes control is known to worsen diabetic retinopathy (DR). • 38/ 119 patients had surgeries T2DM preoperatively. • 9% new DR after surgery • 9% progression of pre-existent DR after surgery • - 59% no DR before and after surgery • - 14% stable DR through surgery. • - 9% regression of DR after surgery. • Changes in DR are unpredictable after bariatric surgery. • A small but significant proportion (18%) of patients with diabetes and bariatric surgery tended to develop new DR or worsen their retinopathy.

  18. Diabetic Nephropathy (DN) • Diabetes has become the most common cause of end stage renal failure in the US and Europe • About 20 – 30% of patients with diabetes develop evidence of nephropathy • The prevalence of DN is higher in Black Americans than in Whites (Figures for South Africa is not available)

  19. Conclusions • Bariatricsurgeryreducesoverallmortality in obese subjects • Bariatricsurgeryreducescardiovascularevents in non-diabeticpopulation • Bariatricsurgery can provide a significative percentageoftreatedpatientswithprolongedremissionof T2DM • Bariatricsurgeryseemstobeassociatedwith a significantreduction in major macrovascular and microvascularevents in moderately and severely obese subjectswith T2DM. Angrisani 2013

  20. SICOB National RegistryPts BMI < 35 (1998 – 2012)

  21. SICOB National RegistryPts BMI < 35 (1998 – 2012)

  22. ANGRISANI 2013 Naples, Italy

  23. 93 BariatricProcedures in 70 Obese Type 2 Diabetics General and Endoscopic Surgery Unit“S. Giovanni Bosco” Hospital - Naples - ItalyDirector: Luigi Angrisani

  24. CHIRURGIA DEL DIABETE • L’efficacia delle tecniche chirurgiche è inversamente proporzionale al BMI di partenza • Tra le tecniche chirurgiche (BPD, bypass gastrico, sleeve gastrectomy, bendaggio gastrico) quelle più complesse sono anche le più efficaci (e nello stesso tempo rischiose) • Il meccanismo fisiopatologico è sostanzialmente basato sul calo ponderale. Angrisani 2013

  25. STAMPEDE trial: conclusions

  26. Schauer PR et al NEJM 2012

  27. STAMPEDE trial

  28. STAMPEDE trial

  29. Bariatric surgery is associated with a 60% to 70% reduction in the hazard of any major macro- or microvascular complication of T2DM in moderately to severely obese patients free of advanced cardiovascular and microvascular disease at baseline. • Macrovascular, microvascular, and other vascular events were all shown to be substantially reduced in the Bariatric Surfgery patients vs Controls. • The magnitude of the estimated risk reductions ranged between 60% and 80% for all study outcomes and suggests that bariatric surgery may significantly reduce the burden of end-stage diabetes related complications for at least the first 5 to 10 years after surgery. • Although the preponderance of available data is limited by a lack of level 1 evidence, bariatric surgery appears to be emerging as one of the most effective treatments for ameliorating the excess cardiovascular disease burden imparted by T2DM and obesity. Johnson et al. J Am Coll Surg. 2013 Apr;216(4):545-56

  30. Johnson et al. J Am Coll Surg. 2013 Apr;216(4):545-56

  31. CHIRURGIA BARIATRICA E COMPLICANZE DEL DIABETE

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