The Surgical Treatment of Diabetes Fahad Bamehriz, MD Centre for Minimal Access Surgery King Faisal Specialist Hospital and Research Centre Riyadh

Introduction Obesity: - it is ≥ 20% than the ideal weight - Body Mass Index (BMI) ≥ 30 kg/m² . BMI 25- 27 = normal subject 28-30 = over-weight 31- = obese 40- 50 = morbid obesity 50-60 = super MO

Introduction

Obesity and Diabetes BMI>= 40 kg/m2 and age< 55 years Men Women Type 2 DM 18.1 12.9 BMI>= 40 kg/m2 and age< 55 years Prevalence ratios generally were greater in younger than in older adults. Must et al. The Disease Burden Associated With Overweight and Obesity JAMA. 1999;282:1523-1529.

How obesity will cause DM Ballantyne GH et al (Obes Surg. 2005), (adipoinsular axis theory). The fat mass participates in the regulation of glucose and insulin metabolism through the release of adipocytokines in a mechanism called the adipoinsular axis. Putative adipocytokines include leptin, adiponectin and resistin.

How Frezza EE (Obes Surg. 2004 ), Intra-abdominal fat deposition is associated with increased plasma concentration of free fatty acids, which reduce insulin sensitivity at both muscular and hepatic sites. The progression of diabetes is heralded by the inability of the beta-cells to maintain their previously high rate of insulin secretion in response to glucose, in the face of insulin resistance.

How Patriti A (Obes Surg. 2004 ), (Enteroinsular axis theory), Both GLP-1 and GIP have an impaired secrtion effect in type 2 diabetics. GIP is a peptide secreted by the duodenal K-cells in response to ingested fat and carbohydrate. In obese type 2 diabetes patients, its receptor on beta-cells is down-regulated. GLP-1 is a peptide secreted by the gut L-cells, and, in type 2 diabetes, its secretion is impaired.

Not known At this point, we are unable to correlate the different findings of the many questions that arise, such as: 1) Does the decrease in sensitivity to insulin result from rearrangement of the insulin receptor? 2) Is weight loss the trigger for decrease of insulin resistance? 3) Is rearrangement of part of the intestine a mechanism to trigger the secretion of hormones (incretins) that help in insulin response? 4) Which mechanism controls the insulin resistance?

The Epidemic of Obesity

Obesity, Metabolic Syndrome and [US] The prevalence of obesity increases from an average of 6% in healthy children to 20% in adolescent males and to a further 32% in elderly patients. “The prevalence of MS in In the Middle East, as pointed out by pilot observational projects, is estimated to be anywhere between 15-25%. The medical system is unprepared to deal with this epidemic.” Source: Elabbassi WN, Haddad HA.Department of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada.

Medical Complications of obesity Type 2 diabetes Hypertension Hyperlipidemia CAD, CHF, CVA PVD DVT and pulmonary embolism SLEEP APNEA Pulmonary HTN Edema, skin breakdown Venous stasis, ulcers Osteoarthritis Gastroesophageal reflux Gallbladder Disease Fatty Liver Menstrual irregularities Infertility Hypogonadism, ED, anorgasmia Urinary stress incontinence Pseudotumor cerebri

The Changing concept

Bariatric Surgery: Indications 1991 NIH Consensus BMI > 40 kg/m2 BMI > 35 kg/m2 but with a serious co-morbidity: Diabetes, severe hypertension, obstructive sleep apnea, etc… Several failed attempts at dieting: “patients seeking treatment for the first time should be considered” for a non-surgical program. ASBS, SAGES, SSAT, EAES

How surgery can treat DM The mechanism by which weight loss surgery improves glucose metabolism and insulin resistance remains controversial. Reduce food intake, Weight loss and Modifications of the enteroinsular axis Reduce certain GI hormonal level

Types of surgery

Adjustable gastric banding Sep/1993= first laparoscopic AGB (Belachew M) Types of Adjustable Bands: 1-Bioenterics = Lap-Band=Silicone 2-Swedish adjustable gastric band

Lap. Band VS SAGB

Indications for AGB Compliance ….compliance to follow dietary and sport instructions Strong and motivated patient history of significant weight loss by dieting program Better: - lower BMI - Non-sweet eater - close to follow-up

General OR information OR time is almost 1 hr Excess weight loss is 30-40% in 6 months Can be day- surgery case Need 1-2cc filling every 4-6 weeks

LAGB complications Mortality rate is 1 in 2000 (0.05%) Overall morbidity rate is 11.3% Major complications requiring reoperation are 1% to 4%

Complication of LAGB Reflux esophagitis Gastric prolapse (2.2% to 24%) Dysphagia Stoma obstruction Esophageal and pouch dilatation (10%) Erosion (1%) Gastric necrosis (0.25%) Symptomatic gallstone disease (5%) Psychological intolerance

Outcome of LAGB and DM Ponce J et al (Obes Surg. 2004), 53/413 patients were taking medications for type 2 diabetes preoperatively Had LAGB Resolution of diabetes was observed in 66% at 1-year and 80% at 2-year follow-up. HbA1c dropped from 7.25% (5.6-11.0, n=53) preoperatively to 5.58% (5.0-6.2, n=15) at 2 years after surgery.

Outcome of LAGB and DM Fielding G et al ( Obes Surg. 2003 ) 88 patients had DM and underwent LAGB 37 of patients had all medication stopped at a median of 6.5 months following LAGB Two-thirds of the diabetic patients have had remission of diabetes following LAGB. LAGB is an effective treatment for diabetes in obese patients.

Gastric bypass First Laparoscopic gastric bypass was in 1993 by Wittgrove, Clark, and Tremblay.

Surgical indications Sweet eater Older patients, less activity and motivation Better: - bigger BMI ( BMI ≥ 50) - DM

General OR information OR time is almost 3-4 hours Excess weight loss is 60-70% in 6 months Important points : - leakage rate is 5% - close follow-up for vitamins, Ca level

Complications of LRYGBP Anastomotic leakage (2%-5%) Wound infection (2%-9%) Incisional hernia (0.5%-2%) Mortality (0.3%-3%) Bowel obstruction (3.5%-20%) GI bleeding (2%-4%) Stomal stenosis (4%-27%) Conversion to open (2.2%) Pulmonary embolism (0.5%) Gastric perforation ( 1%) Marginal ulcer (1%-10%) Symptomatic cholelithiasis (2%-4%) Internal hernia (0.7%-3.3%) Pulmonary complication (6%)

Malabsorpative complications Dumping syendrom Diarreah Hair loss Anemia Vitamines deficiency

Outcome of LROYGB and DM Stubbs RS et al (Obes Surg. 2005) 62/342 patients had type 2 diabetes Follow-up was 10 years 85% of those with type 2 diabetes were cured and 10% had improved. No patients with impaired glucose tolerance had progressed to diabetes.

Outcome of LROYGB and DM Goodman GN et al (Obes Surg. 1996 ) 46/133 (35%) patients were on insulin preoperatively, only 11/133 (8%) have remained on insulin and 9/11 at lower doses 64/133 (48%) were on oral hypoglycemics, but only 8/133 (6%) continue their use 23/133 (17%) were on diet alone or no treatment before surgery 91/133 (68%) claimed diet alone or no treatment after surgery

Outcome of LROYGB and DM Wittgrove AC et al (Obes Surg. 1996 ( 24/100 had DM who underwent LROYGB Follow-up was for 30 months Diabetes mellitus was normalized in 22 of 24 patients

RYGB and DM: Results 68 patients with type II DM underwent RYGBP (66 laparoscopic, 2 open). One conversion to open There were 24 women and 44 men with an average age of 50 years. Average weight was 150 kg and average BMI was 49.2 kg/m2. Mortality:zero Major morbidity within 30 days 5%. %EWL 3, 6, and 12 months was 30, 50, and 70%. DM resolved in 82.3% and improved in 16.7% at a mean follow up of 6 months.

Clinical Observations: RYGB & DM Improvement in DM is immediate and precedes weight loss Patients are less hungry and have different taste threshold to sugar (less craving) despite weight loss Why: ?gastric restriction ?dumping ?Mechanical ?Hormonal RYGB as a metabolic operation

Biliopancreatic diversion ± DS

Sleeve gastrectomy

Sleeve gastrectomy First introduced by Ganger Micheal in 2002 It is the first step when you do Biliopancreatic diversion with Duodenal switch procedure (BPD+DS) It is temporary step to reduce weight before the permanent procedure which is BPD+DS (when BPD+DS is difficult to be done duo to excessive fat or huge Lt. liver lobe)

Indications for SG Super-super obese (BMI >65) First step to reduce weight before attempting BPD+DS

General OR information OR time is 2-3 hours Excess weight loss is 80% but can not be maintained for longer than 3 years It is a temporary procedure, which it need to be completed later on Stable line leakage is 5% It may be even difficult to do or finish (duo to a lot of fat or huge Lt. liver lobe

Vertical Banded Gastroplasty

Indications for VBG Big…big size single meal eater Non-sweet eater Non-compliance patients ± motivated patients Does not loss significant by dieting history

General information VBG 60% a mean excess weight loss Less than 10% early morbidity rate Less than 1% perioperative mortality Nearly 80% failure rate (long term follow-up Poor weight loss maintenance 15% to 20% reoperation rate duo to stomal outlet stenosis or severe reflux

Outcome of VBG and DM Arribas del Amo D et al (Obes Surg. 2002 Jun ) 9/80 patients had diabetes follow-up > 5 years in 52 patients Diabetes resolved in 55.55% (5 of 9 )

Bariatric Surgery: Impact on Mortality RCT: None observational 2-cohort study: SOS Trial: ? survival advantage at 10-years ?RYGB McGill (Christou): 0.68% vs. 6.17% 5-years Washington State (Flum): 16.3% vs. 11.8% at 15-years

Age, gender, race No DM HTN HTN DM White female   18.5-24.9 5.2 20.8 29.8 25.0-29.9 6.3 16 30.5 30.0-34.9 6 13.3 27.4 35.0-39.9 5.4 12.4 24.4 ≥ 40 4.7 11.8 21.1 White male 7.9 27.1 35.9 6.9 17.8 31 6.8 14.3 27.2 6.5 13.9 29.1 8.7 18.6 28.1 Black female 4.5 19 33 4.6 13.7 22 12.8 19.3 5.8 15.2 17.2 10 24.3 Black male 8.6 39.3 18.7 7.3 13.8 26.4 7.4 22.3 21.3 9.4

Age, gender, race No DM HTN HTN DM White female   18.5-24.9 5.2 20.8 29.8 25.0-29.9 6.3 16 30.5 30.0-34.9 6 13.3 27.4 35.0-39.9 5.4 12.4 24.4 ≥ 40 4.7 11.8 21.1 White male 7.9 27.1 35.9 6.9 17.8 31 6.8 14.3 27.2 6.5 13.9 29.1 8.7 18.6 28.1 Black female 4.5 19 33 4.6 13.7 22 12.8 19.3 5.8 15.2 17.2 10 24.3 Black male 8.6 39.3 18.7 7.3 13.8 26.4 7.4 22.3 21.3 9.4

Conclusion Bariatric surgery is the only available effective treatment for diabetes in patients with morbid obesity. Bariatric surgery should be viewed as metabolic surgery. We have to better refine indications for surgery. Bariatric surgery should be performed in high volume specialized centers.

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