Bariatric Surgery and Metabolism

• Goal: to review 4 important and clinically relevant papers from 2010 on Bariatric Surgery and Metabolism

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Disclosures

1. I am still pissed we’re not at Vail.

2. Ethicon: Advisory board

Whistler 2004

Objective

• Metabolic surgery to treat type 2 diabetes mellitus in patients who do not meet body weight criteria for morbid obesity (BMI 30-35)

• Comparing LRYGB and LAGB in this patient population

Methods

• Bariatric Outcomes Longitudinal Database (BOLD)

• 66264 bariatric procedures• 794 with BMI 30-35 kg/m2

• 235 with diabetes requiring medication• 109 LAGB ; 109 LRYGB• 92% Laparoscopic

Results

More severe DM in bypass group

More complications in bypass group

Results

• Both procedures resulted in significant decrease in BMI, DM severity and # of DM medications

• Gastric bypass showed better results than gastric band

Results

# DM Meds.BMI

Results

Conclusion

• Both LAGB and LRYGB achieve significant, favorable impact on type 2 diabetes in the moderately obese (BMI 30-35)

• Both procedures demonstrate a significant reduction in diabetes co-morbidity score and # of diabetes medication

• Gastric bypass provides more effective treatment at the price of higher complication rates (mostly minor)

Objective

• Evaluation of bariatric surgery as secondary prevention in obese patients with ischemic heart disease (IHD)

Methods

• 4047 subjects in the Swedish Obese Subjects (SOS) group

• 35 with IHD• 21 treated with bariatric surgery ; 14 treated

conventionally• Mean follow-up 10.8 years

Methods

• SOS study:

Results

Mean weight change

At 2 and 10 years bariatric surgery resulted in significantly greater weight loss compared to the control group

Results

Results

Results

Conclusion

• Bariatric surgery appears to be a safe and feasible treatment to achieve long-term weight loss and improvement in cardio-vascular risk factors, symptoms and quality of life in obese subjects with IHD

Objective

• To present the longest follow-up report of any lipid-atherosclerosis interventional trial

Methods

• 25 years of follow-up in the POSCH study:

Overall mortalitySpecific cause of deathPrediction for increase in life expectancy

Results

Results

Results

Results

Conclusion

• A 25 year mortality follow-up in POSCH shows statistically significant gains in overall survival, cardio-vascular disease free survival and life expectancy in the surgery group compared to the controlled group

Objective

• To investigate the rate of type 2 diabetes remission after gastric bypass and banding and establish the mechanism leading to remission of type 2 diabetes after bariatric surgery

• Study 1:

34 obese type 2 diabetics

Gastric bypass or banding

3 year follow-up

• Study 2

41 obese type 2 diabetics

Gastric bypass, banding orvery low calorie diet

42 day follow-up

Results Study 1

ResultsStudy 2

ResultsStudy 2

ResultsStudy 2

Conclusion

Methods

• Trials comparing bariatric surgery vs. no surgery in patients with morbid obesity with the following end-points:

• Non-CV mortality• CV mortality• Global mortality – CV + non-CV

Results

Small (<3000 pts.) vs.

Large (>3000 pts.)

Results

LAGB

Vs.

RYGB

Conclusion

• Bariatric surgery reduces the risk of global mortality, CV mortality and all-cause mortality compared to participants not undergoing surgery

• Risk reduction is lower in large studies than in small studies

• Both gastric bypass and gastric band seem to reduce mortality risk

Bariatric surgery and metabolism

Other papers of interest

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SUMMARY: Diabetes

Both restrictive (AGB) and malabsorptive (RGBP) procedures improve diabetic control

Improvement and remission of DM is significantly greater with malabsorptive (largely GBP), even with equivalent weight loss in some studies

Postprandial increase in GLP-1, insulin secretion and improvement in insulin resistance occurs only with GBP, even before weight loss; mechanisms (duodenal exclusion, incretin effects, neural, etc.) still incompletely explained

Restrictive and malabsorptive procedures both improve DM in patients with BMI <35, although less dramatically than in patients with BMI > 35

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SUMMARY: Mortality

Partial ileal bypass for hyperlipidemia improves 25 year survival, > in patients with baseline EF ≥ 50% (survival by 1.7 years; 100,000 less deaths per million patients at 25 years)

Reduced mortality after both AGB and GBP compared to controls (global and all-cause)

? Greater reduction in CV mortality with GBP reported in diabetics

Bariatric surgery can be performed safely in patients with IHD, but no reduction in CV events or deaths compared to controls (limitations of study: low BMI, small sample size, primarily restrictive procedures (VBG))

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