basic concepts and rationale of metabolic surgery alper Çelik, m.d. associate professor of surgery...
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Basic Concepts and Rationale of Metabolic Surgery
Alper Çelik, M.D.Associate Professor of Surgery
Turkish Metabolic Surgery Foundationwww.metabolicsurgeryistanbul.com
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1st Question?
• Did initial vertebrates have an appendix epiploica?
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HerbivoreVoluminous and hypocaloric dietDistant hindgutLarge and Long GI Tract
CarnivoreHypercaloric dietClose hindgutSmall and Short GI Tract
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Who consumes the diet with higher caloric index?
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The goat has a bigger stomach that than the dog’s stomach.
And longer intestines also.
the dog is not restricted.
The dog is adapted!
Is Sleeve gastrectomy a restrictive or adaptive procedure? Reflections o the concept of Restriction and Adaptation.
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It is the same with Fish !!
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Tadpole intestine – transparency vision
It is the same with Amphibians !!
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The tadpole gut shortens dramatically during metamorphosis
Schreiber A. M. et.al. PNAS 2005;102:3720-3725
Copyright © 2005, The National Academy of Sciences
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Shortening of gut during metamorphosis
Poorer plant food Richer animal food (insects)
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Bats with large digestive tract
Bats
Bats with small digestive tract
Herbivore
“vampires"
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Folivores & Frugivores
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From: Aiello & Wheeler. Current Anthropology 36(2), 1995.
The human abdominal cavity became smaller, when compared to primitive
Australopithecus afarensis (a herbivore)
richer diet
(less fiber)
HumanAustralopitecus
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Change in Food Industry
• Refined food• Saccharification• Coca-colanisation!!!• And their metabolic outcomes.
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50cm
100cm
Duodenal Switch
150-200cm
“Metabolic” Gastric bypass
The distance dilemma
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50cm
100cm
Duodenal Switch
150-200cm
“Metabolic” Gastric bypass
Better metabolic results
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50cm
100cm
Duodenal Switch
150-200cm
“Metabolic” Gastric bypass
Worse nutritional results
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With richer dietsit seems wise
to diminish the proximal gut and
to bring the ileum closer
But exclusions
might not be the best
solution
because they bring
malabsorption
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Hunger Food going fast to the gut
Ghrelin Glp-1PyyOxm
Ghrelin Glp-1PyyOxm
Gastric emptying is blocked Gluttony
Intestinal Satiety
Gastric Satiety
=Full Satiety
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Mechanical RestrictionBands, rings, narrow anastomoses
Static and permanentAn obstacle to food passageActive at the first biteLimits ingestion
Functional Restriction
CircumstancialAppears at the end of the mealAt the last biteLimits stocking
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Gluttony is not a sin.
It is an instinct present in animals
Gluttony and large stomachs are
adaptations to type of food
and to scarcity
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“Functional Restriction”
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Why Functional Restriction?
• Because, we the surgeons do not have the right to end one form of addiction and replace it with another (iron, calcium, vitamins, etc.).
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There are two options that can provide;
• Ileal Proximalisation without significant malabsorption:
• Ileal Transposition and Transit Bipartition
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DSIT By Alper Celik, M.D.
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Transit Bipartition
Neuroendocrine component
Easy and safe anastomosis
No bypass or excluded intestinal segmenti!No absorptive or nutritional problem!
Santoro et al. Rev bras videocir 2004; 2(3):130-138.
Obes Surg 2006; 16:1371-79Obes Surg 2008; 18:1343–1345 Ann Surg. 2012;256(1):104-10.
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Therefore;
• Our aim in Metabolic Surgery should be to provide:• Ileal Proximalisation
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Without Significant Malabsorption
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Thank you very much