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

I come to praise surgical treatment of T2DM

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

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

The Metabolic Syndrome: Current Perspective Adapted from Reaven G. Drugs. 1999;58 (suppl):19-20 Body Size  BMI  Central Adiposity Body Size  BMI  Central Adiposity Glucose Metabolism Uric Acid Metabolism DyslipidemiaDyslipidemia Hemodynamic Novel Risk Factors CORONARY HEART DISEASE Insulin Resistance HyperinsulinemiaHyperinsulinemia +  TG  TG  PP lipemia  PP lipemia  HDL-C  HDL-C  PHLA  PHLA Small, dense LDL Small, dense LDL ± Glucose intolerance ± Glucose intolerance  Uric acid  Uric acid  Urinary uric acid clearance  Urinary uric acid clearance  SNS activity  SNS activity  Na retention  Na retention Hypertension Hypertension  CRP  CRP  PAI-1  PAI-1  Fibrinogen  Fibrinogen

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

Conventional Bariatric- Metabolic Procedures

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

Obesity Surgery Through the Years…

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

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

15

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

Duodenal Switch - Results 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

Henry Buchwald JAMA 2004 Meta-analysis Buckwald JAMA 2004 GBGBPBPD Improved diabetes % FBS (mmol/l) Insulin (pmol/l) Cholest tot (mmol/l) LDL (mmol/l) Tri decreased77%91%100% HTA resolved43.2%67.5%83.4% See also Prachand et al J GI Surg Feb 2010

Risk/benefit ratio comparison between procedures GBGBPBPD Operative mortality % Operative complication %915 Success rate % Reoperation rate %2010%+2

Bacterial overgrowth Current Surg 2003; 60: Manageable side effects %Treatment Mild (bloating discomfort) 20dietary cancelling probiotic Moderate (proctitis nocturnal diarrhea, abdominal distension) 2 metronidazole Severe (bypass enteritis) 0.4reversal

NormalInadequacyDeficiency n range% % Vitamin A mmol/l 325 > < Vitamin D nmol/l 307 > <306.5 Calcium mmol/l 367 > <2.003 Iron mmol/l 363 > <43.8 Ferritine Ug/l 348 > <42.6 Hgb g/l 365 > <1106 PTH pmol/l 338 < >1504 Deficiencies are infrequent and correctable 25 years gives no sign of latent damage. 10 years post duodenal switch

Gastric Band SleeveRYGBDJBBPD/DS Ileal Inter- position Endo- luminal Sleeve Gastric Restriction ± Gastrectomy Altered gastric function ? Gastric exclusion Duodenal exclusion Enhanced distal nutrient delivery Malabsorption Courtesy of Lee Kaplan

Mechanisms of diabetes control after BPD/DS Nutrients reach the distal ileum within minutes of the ingestion of food within minutes of the ingestion of food and this stimulates the secretion of GLP-1 by L-cells located in this area « Distal mechanism »

Mechanisms of Surgical Treatment of T2D The exclusion of the duodenal nutrient passage may offset an abnormality of gastrointestinal physiology responsible for insulin resistance and type 2 diabetes « Proximal mechanism »

Choosing the operation 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

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

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

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

diet Overeating Food preservatives Infectious

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

Diabetes Surgery: Cultural Barriers Professional biases /interests Professional biases /interests Limited awareness of benefits/risk of metabolic surgery/bariatric surgery Limited awareness of benefits/risk of metabolic surgery/bariatric surgery Radical departure from conventional treatment and Radical departure from conventional treatment and thinking (Healthy Skepticism)

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

Surgical Treatment of Obesity and Metabolic Disorders