1. Physiologic effects of metabolic surgery
Y. Van Nieuwenhove , Piet Pattyn
Department of Gastrointestinal Surgery
UZ Gent
Vanavond leren we dat GLP-1 postprandiaal door intestinale L-cellen wordt afgescheiden en een potent incretine is terwijl Ghreline tijdens vasten vrijkomt in de oxyntische maagmucosa, en het eerst gekende perifere orexigene hormoon is.
Indien dit u niet kan boeien, vertel ik u ook erbij wat de rol is van het Gila monster in de behandeling van diabetes mellitus type2.

2. Weight loss surgery
Kremen 1955
Malabsorption
Mason 1965
Restriction

3. Metabolic effect?
Gastric banding
Gastric bypass
Sleeve gastrectomy

4. Meer vrouwen?

5. Only weight loss?
Buchwald (JAMA, 2004)
Pories (Ann Surg, 1995)

6. Diabetes epidemic
Zimmet, Nature 2001

7. Gut hormones GI tract is the biggest endocrinologic organ
Secretion
Motility
Growth
Satiety/hunger
Energy balance
Glucose and fat metabolism

8. Anorexigenous Orexigenous Systemic Central Central Systemic CCK
PYY (Y2)(fysiol.)
PP (Y4)
GLP-1
OXM
Amylin
Leptin
Central
PYY (ARC!!) PP
Orexigenous
Central
PYY (Y1 en Y5)
Ghrelin
AgRP
Systemic

9. Leptin Adiposity hormone Found in “mutant” mice
Leptin is “lipostatic” (long term)
Proportional with body fat
High concentrations in obesity resulting in insensitivity
No immediate therapeutic use

10. Ghrelin 80% secreted by P/D1 cells in stomach Hunger hormone
(Rindi, Histochem Cell Biol 2002)
80% secreted by P/D1 cells in stomach
Hunger hormone
Fat storage increases
Therapeutic role
In hyponutrition
Obesitas => Vaccinatie tegen Ghrelin
Gastrectomie

11. GLP-1 Secreted by L-cells in distal bowel Potent incretin
Increases insuline secretion
Decreases glucagon secretion
Increases beta cell mass
Slows gastric emptying and induces satiety
Half-life only 2 minutes
Degraded by DDP-4

12. Therapeutic use of GLP-1
Exenatide
GLP-1 agonist
Poison of Gila Monster (Heloderma suspectum)
Byetta®
Pancreatitis!
Liraglutide (Victoza®)
Sitagliptine
DPP-4 inhibitor
Potentializes GLP-1 en GIP
Januvia®

13. Sleeve gastrectomy Reduction of 80% of Ghrelin production
Decreases hunger sensation

14. Hindgut en foregut hypothese (F. Rubino, Ann Surg 2006)
Hindgut hypothes
R-Y gastric bypass, Scopinaro
Food reaches distal bowel earlier
early secretion of incretins
GLP-1
GIP
OXM
Foregut hypothes
Gastro-duodeno-jejunal exclusion
Less anti-incretines?

15. Thank you for your attention

16. Adult nesidioblastose (noninsulinoma pancreatogenous hypoglycemic syndrome)
Persistant hyperinsulinemic hypoglycemia
Clear link with R-Y gastric bypass
GLP-1 effect?

17. Long term outcome after laparoscopic adjustable gastric banding
Y. Van Nieuwenhove, A. Stockman, E. Snoeck, H. Van Ommeslaeghe, K. Van Renterghem, D. Van de Putte, W.Ceelen, P. Pattyn
Dept. Of Gastrointestinal Surgery
University Hospital Ghent

18. Background First LAGB in Belgium in 1994 >50% were LAGB
Peak of > interventions in 2004
Since 2006 => LAGB=LRYGB

19. Long term results?
SOS-study

20. Patients and methods A retrospective study of a prospective database*
Telephone interview - preliminary results
consecutive patients who underwent SAGB at least 4 years earlier.
Primary outcome was
presence of the banding device at the time of analysis
final excess weight loss
maximal weight loss
conversions to other procedures
(*Ceelen et al. Ann Surg 2003)

21. Results 1085 patients had been called on march 26th 2009
4 (0,36%) patients had died
10 (1%) refused to cooperate
46 (4%) lost from follow-up
664 (61%) unreachable
361 (33%) responders
Mean age was 36 years
77% were women
mean initial BMI was 41,18 ± 6,20kg/m2
The median follow-up was 90 months (range )

22. Presence of the banding
Removal of the band was carried out in 83 (24%) patients
after a median interval of 61 months (range 6-125).

23. Weight loss Weight kg BMI kg/m2
BMI dropped to 30,10 ± 5,44kg/m2 after a mean of 43 ± 33 months
Weight regain to 33,64 ± 6,74 kg/m2 at the time of analysis
Overall 40 ± 31% excess weight loss and 28% of BMI
Weight kg
BMI kg/m2

24. Late complications Food impaction 11 3% Pouch dilatation 36 10%
Band leakage 7 2%
Port problem 10
2,3%
Erosion 16
4,5%
Oesophagitis 8
Oesophageal dilat. 5
1,3%
Total 93
25%

25. Reinterventions
280 interventions in 123 patients (34%)

26. Conclusion
These preliminary data show that after a follow-up between 4 and 12 years
High intervention rate
High system related problems
Minor complications
more than 3 out of 4 devices are still functioning,
1 out of 3 successfull
40% excess weight loss

27. Conclusion Not only weight loss as objective
Comorbidities can cure after surgery
Obese diabetici
Clear metabolic effect
GLP-1
Ghrelin
Other types of surgery?
For non-obese diabetics?

28. Duodenal-jejunal Bypass Sleeve
EndoBarrier TM Gastrointestinal Liner
Endo- and fluoroscopy
Gersin et al,
Surgical Innovation
December 2007