1 / 33

Alfons Pomp, MD, FACS Weill Medical College of Cornell University

Biliopancreatic Diversion/Duodenal Switch. Alfons Pomp, MD, FACS Weill Medical College of Cornell University. Disclosure. Consultant/speaker bureau Covidien Ethicon Endo Surgery W.L.Gore Associates. CHUM Hotel-Dieu. I come to bury Cesar not to praise him.

locke
Download Presentation

Alfons Pomp, MD, FACS Weill Medical College of Cornell University

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Biliopancreatic Diversion/Duodenal Switch Alfons Pomp, MD, FACS Weill Medical College of Cornell University

  2. Disclosure • Consultant/speaker bureau Covidien Ethicon Endo Surgery W.L.Gore Associates

  3. CHUM Hotel-Dieu

  4. I come to bury Cesar not to praise him

  5. I come to praise surgical treatment of T2DM

  6. Thanks Dr Sharma 50% of type 2 diabetics CDA guidelines target glucose Hypoglycemics lower Hb1Ac; at the price of weight gain Dr Genest; weight gain is associated with HTN and other problems “metabolic syndrome” –cardiovascular risk

  7. 93% of diabetic patients ARE NOT well controlled for glucose, cholesterol and blood pressure • Only 7% of adult diabetic patients from NHANES (1999-2000) achieved: • A1C <7% • PA <130/80 mm Hg • Total Cholesterol < 200 mg/dL • Saydah SH et al. JAMA. 2004

  8. The Metabolic Syndrome:Current Perspective Body Size  BMI  Central Adiposity Insulin Resistance + Hyperinsulinemia GlucoseMetabolism Uric AcidMetabolism Dyslipidemia Hemodynamic Novel RiskFactors •  TG •  PP lipemia •  HDL-C •  PHLA • Small, dense LDL •  Uric acid •  Urinary uricacid clearance •  SNS activity •  Na retention • Hypertension •  CRP •  PAI-1 •  Fibrinogen • ± Glucoseintolerance CORONARY HEART DISEASE Adapted from Reaven G. Drugs. 1999;58 (suppl):19-20

  9. Does Tight Glycemic Control Reduce Cardiovascular Disease or Mortality? • ACCORD • Intensive group:  non-fatal MI,  hypoglycemia & weight gain • Trial stopped b/o  mortality in intensive group (Why?) • ADVANCE • No difference between intensive & conventional treatment in macrovascular disease or mortality (either overall or CV) • VADT • No differences between intensive & conventional treatment in cardiovascular events • Severe hypoglycemia was strong predictor or CVD events & death

  10. Conventional Bariatric-Metabolic Procedures

  11. Santayana • “Those who cannot remember the past are condemned to repeat it” George Santayana, The Life of Reason, Vol. 1, 1905

  12. Obesity Surgery Through the Years…

  13. Nicola Scopinaro, Italy 1976 Large gastric pouch Alimentary limb 250 cm Biliopancreatic limb Common channel 50-75 cm Mechanism: mildly restrictive malabsorptive Bilio-pancreatic Diversion 1Scopinaro N. World J Surg 1998;22:936.

  14. Doug Hess, 19881 “Sleeve” gastric pouch Alimentary limb 40% of bowel (250-300 cm) Common channel 50-100 cm (arbitrary) Benefits over BPD: no dumping decreased marginal ulcer better tolerated BPD – with Duodenal Switch 1Hess DS Obesity Surgery 1998;8:267-282.

  15. Laparoscopic Approach Michel Gagner, 19991 “Sleeve” gastric pouch Alimentary limb: 150 cm Common channel: 100 cm Two mechanisms Primarily malabsorptive Somewhat restrictive Duodenal Switch - Today 1Ren, Gagner. Obesity Surg 2000; 10:514-523

  16. Excellent weight loss 73% EWL Long-term follow-up 70% EWL at 15 years 3-4 day stay Complicated procedure Need experienced team Lifelong follow-up Labs q6 months! Supplements 5x day! Resolution of co-morbidities Short and Long-term complications Nutritional complications Protein deficiency Vitamin deficiencies Behavioral changes Diarrhea Odor Duodenal Switch - Results

  17. Henry Buchwald JAMA 2004 Meta-analysis Buckwald JAMA 2004 See also Prachand et al J GI Surg Feb 2010

  18. Risk/benefit ratiocomparison between procedures

  19. Manageable side effects Bacterial overgrowth Current Surg 2003; 60: 274-277

  20. Deficiencies are infrequent and correctable 25 years gives no sign of latent damage. 10 years post duodenal switch

  21. Courtesy of Lee Kaplan

  22. Mechanisms of diabetes control after BPD/DS Nutrientsreach the distal ileum within minutes of the ingestion of food and thisstimulates the secretion of GLP-1 by L-cellslocated in this area « Distal  mechanism »

  23. Mechanisms of Surgical Treatment of T2D The exclusion of the duodenalnutrient passage may offset an abnormality of gastrointestinalphysiologyresponsible for insulinresistance and type 2 diabetes « Proximal mechanism » 

  24. Do you really want to take medications every day for the rest of your life? 4 operations Lap band Sleeve gastrectomy Gastric bypass Duodenal Switch Choosing the operation

  25. Summary - BPD Excellent long-term weight loss (65%) Resolution of most co-morbidities 100% DM, 80% HTN Potential malnutrition or mineral/vitamin deficiency requires intense life-long monitoring Laparoscopic approach still being investigated

  26. Words for the Wise • This operation is not for every patient (nor for every surgeon) • “TRIFECTA” motivated, intelligent patient financial resources ($1000-1500/year) compulsive (12-15 supplements/5 doses)

  27. Super Obese (>50 or >60 BMI) • Band is not be the best option • DS results are superior to GBP long term data does not support sustained weight loss BMI <35 in this group • High risk group Staged procedure may be best option “lower” risk procedure, evaluate patient

  28. diet Overeating Food preservatives Infectious

  29. Algorithm for treating metabolic syndrome? • Lifestyle changes • Diet • Drugs • Lipid lowering agents • Antihypertensive agents • ASA • Anti-diabetic agents • GI-Bariatric Surgery

  30. Traditional wisdom can be long on tradition and short on wisdom Warren Buffet

  31. Surgical Treatment of Obesity and Metabolic Disorders

More Related