الغدد الصماء والسكري

EFFECTS OF BARIATRIC SURGERY ON TYPE 2 DIABETES

DR. Ahmed Al-Garzaie

EPOC – 1/ 6 / 2008

Presentation Contents

  • Meta analysis study of Henry Buchwald

            JAMA 2004

  • Recent Metabolic ( Diabetic ) Surgery
  • KFMMC results
  • The need for national multi-centric study

WHY A SURGEON PRESENT
A DIABETES

  • Is Diabetes a Surgical disease ?

EFFECTS OF BARIATRIC SURGERY ON TYPE 2 DIABETES: A SYSTEMATIC REVIEW AND METAANALYSIS

PROF. HENRY BUCHWALD

University of Minnesota

JAMA 2004

GOAL: To determine the impact of bariatric surgery procedures on type 2 diabetes mellitus in association with the weight reduction achieved

Diabetes metaanalysis in the 2004
Comorbidities Metaanalysis

  • Data Set:         136 studies

                                    179 treatment arms

                                    22,094 patients

                                    1990 – 2002 time span

  • Diabetes Resolved                              76.8%
  • Diabetes Resolved or Improved           86.0%

METHODS:

  1. Screening of all papers published in English, from January 1, 1990 to April 30, 2006, identified through electronic searches in MEDLINE, Current Contents, and the Cochran Library, supplemented by manual reference checks.
  2. All accepted studies were assigned a level of evidence ( Centre for Evidence-Based Medicine, Oxford, UK), and randomized controlled trials were rated for quality by the Jadad scoring method.
  • Clinical diabetes parameters:

                        Resolved

                        Resolved or Improved

                        Improved

                        Unchanged

                        Worsened

  • Metabolic diabetes parameters:

                        Serum Insulin (pmol/L)

                        HbA1c (%)

                        Fasting Glucose (mmol/L)

RESULTS:

            Data Set

                        621  studies (136 in 2004)

                        888  treatment arms (179 in 2004)

                        135,246 patients (22,094 in 2004)

  • RESULTS:  Study Characteristics

            Study Location

                        Europe                                                 44.4%

                        North America                                    43.2%

                        Australia/ New Zealand                      3.5%

                        South America                                    3.1%

                        Asia                                                     1.5%

                        Others                                                 4.5%

  • RESULTS: Study Characteristics

            Study Design:

                         RCT                                                   4.7%

                        n RCT – Prospective                           7.9%

                        Comparative – Retrospective              9.7%

                        UCS – Prospective                              30.2%

                        Single Arm – Retrospective                42.7%

                        Observational                                      4.0%

                        Case Control                                       0.3%

RESULTS: Study Characteristics

  • Level of Evidence

                                                            I                       1.6%

                                                            II                     12.7%

                                                            III                    37.6%

                                                            IV                    47.6%

  • RESULTS: Patient Characteristics –

 Total

                        Mean Age                               40.2 years

                        Mean BMI                              47.9 Kg/m2

                        Gender            Male                            19.9%

                                                Female             79.6%

                        Type 2 Diabetes                      22.3%

  • RESULTS:

                                    Weight Reduction Metaanalysis

                                                            %EBWL

                                                            Overall

Total   Gastric Banding        Gastroplasty              Gastric bypass           BPD/DS

56.0     46.2                             55.5                             59.7                             63.6                            

  • RESULTS:

                                    Weight Reduction Metaanalysis

                                                            %EBWL

                                                            < 2 Years

Total   Gastric Banding        Gastroplasty              Gastric bypass           BPD/DS

53.9     43.9                             54.6                             58.2                             56.0

  • RESULTS:

                                    Weight Reduction Metaanalysis

                                                            %EBWL

                                                            > 2 Years

Total   Gastric Banding        Gastroplasty              Gastric bypass           BPD/DS

59.0     49.0                             56.5                             63.3                             73.7

  • RESULTS: Diabetes Outcomes Metaanalysis

                                                            Overall

                                                Gastric                                  Gastric

                                    Total    Banding         Gastroplasty         Bypass           BPD/DS

% Resolved     76%        53.0                 69.7              80.3           95.1

% Resolved or 83.9        77.9                  77.2             83.4           99.0

  improved

% Improved    34%        39.6                  38.5             38.8           14.0

%Unchanged  14.9        21.2                  12.0             21.2            1.9

% Worsened   1.1            3.8                    -                  0.3                -

Insulin (pml/L)   -97.4     -68.6                          -102.9                        -114.6         -135.4

HbA1c (%)      -1.3          -0.5                -1.6                -2.0              _

Glucose (mmol/L) -1.4                -0.6                -0.7                -1.8                -2.8

RESULTS: Diabetes Outcomes Metaanalysis

            Patients Resolved Associated With Weight Reduction Achieved and Procedure Performed

                                                Gastric                                  Gastric

                                    Total    Banding         Gastroplasty     Bypass   BPD/DS

%EBWL         56.0       46.2               55.5                 59.7             63.6

% Resolved     76.8       53.0               69.7                 80.3              95.1

     overall

% Resolved     79.2       43.7               71.4                 81.6              94.0

      < 2 yrs

% Resolved     73.3       58.3               67.5                 70.9            95.9

      > 2yrs

DIABETES METAANALYSIS
SUMMARY

  • 1.         Bariatric surgery causes resolution of type 2 diabetes:
  • 76.7% in entire metaanalysis
  • 82.1% in diabetic patients only cohort.
  • 2.         Bariatric surgery causes resolution or improvement of type 2 diabetes:
  • 83.9% in entire metaanalysis
  • 100.0% in diabetic patients only cohort
  • 3.         The resolution and or improvement of type 2 diabetes is associated with the degree of weight reduction achieved and, thereby, the bariatric procedure performed:
  • Adjustable gastric banding < gastroplasty < gastric bypass < BPD/DS in entire metaanalysis
  • Adjustable gastric banding < gastric bypass < BPD/DS in diabetic patients only cohort
  • 4.         Weight and diabetes parameters showed little difference at <2 years and > 2 years, thus, these effects appear to be lasting

5.         Insulin, HgA1c, and fasting glucose values declined substantially after bariatric surgery, giving laboratory metabolic substantiation to the clinical findings

DIABETES METAANALYSIS
CONCLUSION

  • Bariatric surgery is effective therapy for type 2 diabetes

There are no medical or surgical diseases :    There are conditions and their treatments”

                                                            H. BUCHWALD

CONCLUSION

Bariatric surgery can be performed safely, with an extremely low operative ( < 30 days) mortality, and be effective, “curative” therapy for about 70% to 90% of type 2 diabetics.

Diabetes Surgery Summit
Rome, Italy ( March 29-31, 2007)

Gastrointestinal surgery ( Bariatric Surgery ) should be considered for the treatment of type 2 diabetes in patients who are appropriate surgical candidates with BMI >35 and who are inadequately controlled by lifestyle and medical therapy

Gastrointestinal surgery may be appropriate for T2D in patients who are appropriate surgical candidates, with BMI of 30 to 35 and who are inadequately controlled by lifestyle and medical therapy

Anatomic modification of various regions of the GI tract likely contribute to the amelioration of T2DM trough distinct physiological mechanisms.

Mechanisms of Surgical Treatment of T2DM

The exclusion of the duodenal nutrient passage may offset an abnormality of gastrointestinal physiology responsible for insulin resistance and type 2 diabetes

( Proximal ) Hypothesis

( Distal Hypothesis )

Nutrients reach the distal ileum within of the ingestion of food and this stimulates the secretion of GI  hormones by cells located in this area

Enhancing delivery of nutrients to the hindgut without excluding nutrient flow through the proximal intestine (via a simple gastro-jejunostomy [A]) does not improve diabetes diabetic GK animals. The DJB (B), which creates similar shortcuts of nutrients as in gastro-jejunostomy, but also includes the exclusion of the proximal intestine from the flow of nutrients, improves glucose tolerance and fasting glucose  in diabetic GK rats. This experiments shows that the exclusion of the duodenum is critical for the effect on diabetes.

Mechanism of Diabetes resolution after Gastrointestinal Bypass Surgery

  1. Enhanced secretion of ( something good ) for glucose homeostasis ?

 

                                                            or

2.         Reduced production of ( Something bad ) for glucose homeostasis ?

( Weight Loss Surgery )

Or

( Diabetes Surgery )?