1. Francesco Rubino, MD Associate Professor of Surgery Chief, GI Metabolic Surgery Diabetes Surgery Center Weill Cornell Medical College- New York, NY

2.  Covidien : ◦ Research grant, Educational Grant  Roche: ◦ Research Grant  NGM Biotech: ◦ Scientific Advisory Board/Consultant

3. “My daddy is a doctor and he treats diabetes.” “My daddy is a surgeon and he cures it.” “The surgeon’s perspective”

4. “Francesco, why don’t you just give him Metformin? W.J. Pories The physician’s perspective

5. THE HERETICAL SUGGESTION Nicolaus Copernicus (1473-1543) The Heretical Suggestion: A Surgical Treatment for Diabetes

6. “ The Showdown: Surgeons vs Endocrinologists ”

7. “…Rubino's idea boils down to one impolite word used to refer to the excrement of steers.” …A surgeon’s perspective

10.  Develop practical recommendations for clinicians on patient selection and management  Identify barriers to surgical access  Suggest health policies that ensure equitable access to surgery  Identify priorities for research Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

11. Conveners: Professor George Alberti Professor John B. Dixon Professor Francesco Rubino Professor Paul Zimmet Attendees: Professor Stephanie Amiel Professor Louise A. Baur Professor Nam H. Cho Dr. Bruno Geloneze Professor Jan Willem Greve Professor Linong Ji Dr. Muffazal Lakdawala Professor Wei-Jei Lee Professor Pierre Lefebvre Dr. Carel le Roux Professor Jean-Claude Mbanya Professor Gertrude Mingrone Dr. Philip R. Schauer Professor Luc Van Gaal Dr. David Whiting Professor Bruce M. Wolfe Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

13.  INDICATIONS TO SURGICAL TREATMENT

14.  Bariatric surgery is an appropriate treatment for people with type 2 diabetes and obesity not achieving recommended treatment targets with medical therapies, especially when there are other major co-morbidities.  Surgery should be considered early in the treatment of diabetes patients, not as a last resort

15.  Surgery should be an accepted option in people who have type 2 diabetes and BMI of 35 or more  Surgery should also be considered as an alternative treatment option in persons with BMI 30 to 35 when diabetes cannot be adequately controlled by optimal medical regimen, especially in the presence of other major cardiovascular disease risk factors  In Asians, and some other ethnicities of increased risk, BMI action points may be lower e.g. BMI 27.5 to 32.5 Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

16. Diabetes Surgery Summit Rome 2007

17.  CHOICE OF PROCEDURE

18.  The position group considers RYGB, LAGB, BPD/BPD-DS, SG as currently accepted bariatric surgical procedures  Only two are considered acceptable in adolescents: RYGB and LAGB  The position group acknowledges that there are limited medium- or long-term data regarding SG, and there are safety, nutritional and metabolic concerns with BPD/BPD-DS Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

19.  Apart from conventional procedures now in use new techniques and devices should be explored in research settings only  New bariatric procedures require robust assessment for their efficacy, safety, and durability using similar principles to those for assessing new drug therapies and having regards to the benefits and risks of established therapy Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

20. risks and benefits, the importance of compliance, the effects on eating choices and behaviours Factors to consider when choosing a bariatric procedure in patients with Type 2 diabetes The duration of Type 2 diabetes and the degree of apparent residual B-cell function

21.  PERIOPERATIVE MANAGEMENT

22.  Surgery should be considered as complementary to medical therapies to reduce micro-vascular and cardiovascular risk  Patients should be assessed and managed by experienced multi- disciplinary teams  Glycaemic control should be optimised peri-operatively and should be closely monitored after surgery  It should be recognised that a prolonged period of normalisation of glycaemic control has benefit for diabetes even if there is eventual relapse Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

23.  There should be a minimal accepted data set for pre-surgery and follow-up ◦ Weight, blood glucose control, assessment for diabetes complications, laboratory measures and medications etc. Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

24. Pre-operative and Follow-Up Data Set

25. > characteristics of pts population > Pts needs and expectations > Outcomes and definition of success “Diabetes Surgery” vs “Bariatric Surgery” ◦ Indications ◦ Preoperative diagnostic evaluation ◦ Choice of Procedure ◦ Definition of success of treatment ◦ Assessment of postoperative outcomes ◦ Type of follow-up ◦ Complementary therapies ◦ Definition of “care team”

26.  DEFINITION AND MONITORING OF SUCCESS OF TREATMENT

29.  Develop practical recommendations for clinicians on patient selection and management  Identify barriers to surgical access  Suggest health policies that ensure equitable access to surgery  Identify priorities for research Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

31.  Stigma of Obesity  Misperception about risk factors vs disease state  Misconception of “Obesity”  Identification of “Bariatric Surgery” with “Weight Loss Surgery

32.  In the medical community: “…obesity is a cultural and behavioural problem…” “…attempt to combat excess of food by cutting out parts of stomachs and intestines Not a rational solution”

33.  Stigma of Obesity  Misperception about risk factors vs disease state  Misconception of “Obesity”  Identification of “Bariatric Surgery” with “Weight Loss Surgery

34. Risk FactorDisease Lifestyle Modification complementary Surgery, Radiotherapy, Chemotherapy Treatments Considered Rationale SmokingCancer >

35. Lifestyle Modification Not-rationale solutions: (Surgery, Drug Therapy ) Risk FactorDisease Treatments Considered Acceptable Overeating- Sedentary Lifestyle Obesity >

36.  Stigma of Obesity  Misperception about risk factors vs disease state  Misconception of “Obesity”  Identification of “Bariatric Surgery” with “Weight Loss Surgery

37. Obesity is an ill-defined condition Excess weight is symptom of disease, not disease per se

38. Excess WEIGHT DysglycemiaDyslipidemia OBESITY Increased BP CVD/Death

39.  Obesity without Insulin Resistance (IR)  Obesity without Diabetes  Normal Weight Individuals with IR  Normal Weight Individuals with Diabetes and MS ◦ Metabolically healthy obese individuals ◦ Metabolic syndrome in non-obese individuals ARCH INTERN MED/VOL 168 (NO. 15), AUG 11/25, 2008

40. Excess WEIGHT DysglycemiaDyslipidemia OBESITY Increased BP CVD/Death

41.  Stigma of Obesity  Misperception about risk factors vs disease state  Misconception of “Obesity”  Identification of “Bariatric Surgery” with “Weight Loss” Surgery

42. Excess WEIGHT DysglycemiaDyslipidemia OBESITY Increased BP CVD/Death BARIATRIC SURGERY

43. JAMA Jan 2012

44. Baseline Insulin, Not BMI or weight loss Predict CV benefits of surgery

45. Excess WEIGHT DysglycemiaDyslipidemia OBESITY Increased BP CVD/Death BARIATRIC SURGERY

46.  Advocacy for obese patients  Define risk factors vs disease state  Re-definition of “Obesity”  From Bariatric to “METABOLIC” and DIABETES SURGERY

47.  Advocacy for obese patients  Define risk factors vs disease state  Re-definition of “Obesity”  From Bariatric to “METABOLIC” and DIABETES SURGERY

48.  Advocacy for obese patients  Define risk factors vs disease state  Re-definition of “Obesity”  From Bariatric to “METABOLIC” and DIABETES SURGERY

49.  Advocacy for obese patients  Define risk factors vs disease state  Re-definition of “Obesity”  From Bariatric to “METABOLIC” and “DIABETES” SURGERY

50. Excess WEIGHT DysglycemiaDyslipidemia OBESITY Increased BP CVD/Death METABOLIC SURGERY

51.  Advocacy for obese patients  Define risk factors vs disease state  Re-definition of “Obesity”  From Bariatric to “METABOLIC” and “DIABETES” SURGERY  Recognize the role of GI Tract in the Physiology/Pathophysiology of Metabolic Illnesses

52. The GI Tract: An Endocrine Organ