Effect of Metabolic Surgeryon diabetes and

hypertension

Effect of Metabolic Surgeryon diabetes and

hypertension

ObjectivesObjectives

brief overview of Bariatric surgery

management of bariatric surgery patients and complications

effects of bariatric surgery on diabetes

brief overview of Bariatric surgery

management of bariatric surgery patients and complications

effects of bariatric surgery on diabetes

Metabolic SyndromeMetabolic Syndrome

Central obesity. (defined as waist circumference ≥ 40 inches for men and ≥ 35cm for women)

raised TG level: ≥ 150 mg/dL

reduced HDL cholesterol: < 40 mg/dL

raised blood pressure: systolic BP ≥ 130 or diastolic BP ≥ 85 mm Hg, or treatment of previously diagnosed hypertension

raised fasting plasma glucose (FPG) ≥ 100 mg/dL or previously diagnosed type 2 diabetes

Central obesity. (defined as waist circumference ≥ 40 inches for men and ≥ 35cm for women)

raised TG level: ≥ 150 mg/dL

reduced HDL cholesterol: < 40 mg/dL

raised blood pressure: systolic BP ≥ 130 or diastolic BP ≥ 85 mm Hg, or treatment of previously diagnosed hypertension

raised fasting plasma glucose (FPG) ≥ 100 mg/dL or previously diagnosed type 2 diabetes

Metabolic SyndromeMetabolic Syndrome

54 Million Americans!A quarter of the world’s adults have metabolic syndrometwice as likely to die from, and three times as likely to have a MI or CVAa five-fold greater risk of developing type 2 diabetes

54 Million Americans!A quarter of the world’s adults have metabolic syndrometwice as likely to die from, and three times as likely to have a MI or CVAa five-fold greater risk of developing type 2 diabetes

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Type 2 diabetes and glycemic disorders Dyslipidemia- Low HDL- Small, dense LDL particles- Hypertriglyceridemia

Hypertension

Impaired thrombolysis- PAI-1

Endothelial dysfunction/inflammation - CRP, MMP-9

Microalbuminuria

VisceralObesity

InsulinResistance

Free Fatty Acids

Ath

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scle

rosi

sThe Metabolic Syndrome:A Network of Atherogenic Factors

Medical Sequelae of Obesity

HypertensionLipid disordersDiabetesIschaemic heart diseaseCardiomyopathyPulmonary hypertensionAsthmaObstructive sleep apneaGallstonesNASH (Non-alcoholic steatohepatitis)Urinary incontinence

GERD

Arthritis/back pain

Infertility/menstrual problems

Obstetric complications

DVT and thromboembolism

Depression

Immobility

Breast/bowel/prostate/endometrial cancer

Venous stasis ulcers

Intertrigo

Accident prone

Body Mass IndexBody Mass Index

BMI > 25: Over weight, 2/3rd US

BMI > 30: Obese, 1/3rd US

BMI > 40: Morbid Obese, 6% US (18 million Americans)

BMI > 25: Over weight, 2/3rd US

BMI > 30: Obese, 1/3rd US

BMI > 40: Morbid Obese, 6% US (18 million Americans)

CriteriaCriteria

BMI > 40

BMI > 35 plus 1 or 2 co-morbidities

T2D , Hypertension

OSA, NASH

Hyperlipidemia, Pseudo tumor cerebri

Considerably impaired quality of life

BMI > 40

BMI > 35 plus 1 or 2 co-morbidities

T2D , Hypertension

OSA, NASH

Hyperlipidemia, Pseudo tumor cerebri

Considerably impaired quality of life

• Bariatric surgery or weight-loss surgery refers to surgery

usually performed in patients with a body mass index (BMI) of

40 kg/m2 or greater and those with a BMI between 35 and 40

kg/m2 and a major medical comorbidity in order to:

• Support weight loss

• Treat or prevent obesity-related comorbidities (e.g., diabetes, hypertension, cardiovascular disease, obstructive sleep apnea)

• The most common types of bariatric surgery include:

• Laparoscopic adjustable gastric banding (LAGB)

• Roux-en-Y gastric bypass (RYGB)

• Sleeve gastrectomy

• Biliopancreatic diversion with duodenal switch (BPD/DS)

•Studies show that bariatric surgery causes significant weight loss and is more effective at improving diabetes in the short term (up to 2 years) than nonsurgical interventions (diet, exercise, other behavioral interventions, and medications).

•Diabetes improvement starts rapidly after surgery, before significant weight loss has occurred.

•The mechanism for postoperative metabolic improvements has not been fully elucidated and may be, in part, independent of weight loss.

•This suggests that bariatric surgery may improve metabolic comorbidities even in patients who are not morbidly obese.

Free fatty acids and insulin resistance – Theories

Impaired insulin signaling (muscle) / glucose transportIncreased oxidative stress (reactive oxygen species) Inhibition of insulin suppression of glycogenolysis in liverDirect endothelial damageImpairment of beta cell functionAlterations in blood pressure

The Adipo-insular Axis

OutcomesOutcomes

Non-Surgical management: only 5-10% success

T2D remission: up to 72% at 2 years

RYGB sustained remission of 62% at 6 years

All-cause mortality reduced by 40% 7 years after RYGB

Cause specific mortality reduction:

T2D 92%, Cancer 60%, CAD 56%

Non-Surgical management: only 5-10% success

T2D remission: up to 72% at 2 years

RYGB sustained remission of 62% at 6 years

All-cause mortality reduced by 40% 7 years after RYGB

Cause specific mortality reduction:

T2D 92%, Cancer 60%, CAD 56%

Pre-op work upPre-op work up

Cardiology, Pulmonary, Psychiatry

Home sleep study

Blood test

Clinical nutrition evaluation

smoking cessation

Pregnancy counseling

Cardiology, Pulmonary, Psychiatry

Home sleep study

Blood test

Clinical nutrition evaluation

smoking cessation

Pregnancy counseling

Thank youThank you