Transcript Michel Gagner MD, FRCSC, FACS

Surgery for Diabetes.
Clinical Professor of Surgery,
Florida International University , Miami, FL , Hopital
du Sacre-Coeur (University of Montreal),
Montreal, QC, Canada,
Hamad General Hospital, Doha Qatar.
Obesity & T2DM Prevalence
United States
World Wide
2007
*2015
2007
*2015
70 M
135 M
400 M
700 M
Severe obese 16 M
32 M
75 M
130 M
T2DM
30 M
180 M
320 M
Obesity
22 M
World Wide
Diabetic
180 Mil
In the United States
Obese
400 Mil
Obese
70 Mil
Diabetic
22 Mil
Severely
Obese
75 Mil
Diabetic&
Severely Obese
16.5 Mil
Severely
Obese
16 Mil
Diabetic&
Severely Obese
3 Mil
Diabetic &Obese
14 Mil
* 2015 estimates
based on review of
published health care
industry trends
Diabetic &Obese
54 Mil
Disease Overviews
T2DM
 180 million worldwide, 22 million in the U.S.
 54 million with pre-diabetes in the US
 Fifth largest cause of death in the U.S.
 Estimated 30% T2DM are not obese in the U.S.
 Estimated 70% T2DM are not obese outside the
U.S.
 Comorbidities include CVD, PVD, blindness,
lower limb amputation, kidney failure and
nervous system diseases
 No cures other than weight loss surgery
Disease Burden of Diabetes Mellitus
• Leading cause of blindness (12.5% of cases)
• Leading cause of ESRD (42% of cases)
• 50% of all non-traumatic amputations
• 2.5x increase risk of stroke
• 2-4x increase in cardiovascular mortality
• DM responsible for 25% of cardiac surgeries
• Mortality in DM: 70% due to Cardiovascular
disease
U.S. Annual Cost Estimates
 Twin Global Epidemics
 Major Drivers of Healthcare Costs Worldwide
T2DM (2002)
Obesity (2001)
$132 Billion
$117 Billion
- $92 Direct
- $61 Direct
- $40 indirect
- $56 indirect
 Surgery should be an accepted option in people who
have type 2 diabetes and a BMI of 35 or more.
 Surgery should be considered as an alternative
treatment option in patients with a BMI between 30
and 35 when diabetes cannot be adequately
controlled.
 In Asian, and some other ethnicities of increased risk,
BMI action points may be reduced by 2.5 kg/m2.
Ideal Operation?
 Easy to perform
 Low early mortality and morbidity
 Low Micronutrient deficiencies
 High resolution of T2DM
 Possible reoperation/conversion in case of failures
Surgery for Obesity in 2012
 4 operations
 Lap band
 Sleeve gastrectomy
 Gastric bypass
 Duodenal switch
Efficacy Outcomes for Weight reduction
0
-2
-4
Kg/m2 -6
-8
-10
-12
Total
Banding
Bypass
Plasty
BPD or DS
-14
-16
-18
BMI decrease
Buchwald et al. JAMA, 292(14), 2004
Efficacy for Improvement in Diabetes-Related
Outcomes by Surgical Procedure
%
100
90
80
70
60
50
40
30
20
10
0
Total
Banding
Bypass
Plasty
BPD or DS
Mean resolution
Buchwald et al. JAMA, 292(14), 2004
 Adjustable Gastric Banding and Conventional
Therapy for Type 2 Diabetes A Randomized
Controlled Trial
 John B. Dixon, MBBS, PhD; Paul E. O’Brien,
MD; Julie Playfair, RN; Leon Chapman, MBBS;
Linda M. Schachter, MBBS, PhD; Stewart
Skinner, MBBS, PhD; Joseph Proietto, MBBS,
PhD; Michael Bailey, PhD, MSc(stats);
Margaret Anderson, BHealthMan
 JAMA. 2008;299(3):316-323.
Percentage of Weight Loss Achieved Over the 2-Year Study Period (n = 60) and Individual Weight
Measures at Baseline and at 2 Years
Dixon, J. B. et al. JAMA 2008;299:316-323.
Primary and Secondary
Outcomes at 2 Years
Remission of Diabetes
was 73% vs 13%
JAMA. 2008;299(3):316-323.
Copyright restrictions may apply.
T2DM & THE METABOLIC EFFECTS OF BARIATRIC SURGERY
Laparoscopic Gastric Bypass &
T2DM
Fasting insulin (pM) over time
Fasting glucose (mM) over time
10
160
9
140
8
120
7
P<0.171
100
6
80
Diabetic 5
IGT
4
60
Normal 3
40
2
20
1
0
0
14
|
Pre-op
6d
3m
Diabetes
P<0.001
6m
9m
12m
Diabetic
IGT
Normal
Pre-op
6d
3m
6M
Adapted from Wickremesekra K. et.al. Obes Surg 2005
9M
12M
Rubino, Gagner, et al. Ann Surg 2004; 240(2):236-42
Rubino, Gagner, et al. Ann Surg 2004; 240(2):236-42
Rubino, Gagner, et al. Ann Surg 2004; 240(2):236-42
Patients requiring oral hypoglycemics
after surgery
40
35
30
25
LAGB
Bypass
BPD/DS
20
15
10
5
0
1 year
2 years
J Am Coll Surg. 2007 Nov;205(5):631-5.
T2DM & THE METABOLIC EFFECTS OF BARIATRIC SURGERY
The Entero-insular Axis
1967 – Gastric Bypass
Rehfeld J, 2004
19 |
T2DM & THE METABOLIC EFFECTS OF BARIATRIC SURGERY
The Entero-insular Axis
The Foregut Theory
 Exclusion of the duodenum results in
inhibition of a “putative”signal that is
responsible for insulin resistance and/or
abnormal glycemic control (T2DM)
Rubino et.al, Ann Surg, 2006
20
|
T2DM & THE METABOLIC EFFECTS OF BARIATRIC SURGERY
The Entero-insular Axis
The Hindgut Theory
 The more rapid delivery of undigested
nutrients to the distal bowel
upregulates the production of L-cell
derivatives like GLP-1
Mason E. Obes Surg 2005 15, 459-461
Rubino et.al, Ann Surg, 2006
21
|
T2DM & THE METABOLIC EFFECTS OF BARIATRIC SURGERY
The Adipo-insular Axis
 Epidemiologic/scientific evidence supports the
association of visceral adiposity and insulin
resistance/diabetes and mortality
 Moderate debate about significance of visceral versus
subcutaneous adiposity
 “Theoretical” mechanisms of action
 Increased release of free fatty acids into portal circulation
 Abnormal expression of fat-derived peptides
Gabriely I. Diabetes 2002
Nielsen S. J Clin Invest, 2004
22 |
T2DM & THE METABOLIC EFFECTS OF BARIATRIC SURGERY
The Adipo-insular Axis
Fat-derived peptides – “Adipokines”
 TNF-alpha – impairs insulin signaling pathways / suppresses adipocyte




differentiation
Leptin – enhances insulin action / anorexigenic
Resistin – Known to be elevated in obesity / IR – unknown action
Adiponectin - enhances insulin action / glucose clearance / fatty acid
oxidation
IL-1/ IL-6 – undefined activity
Pitombo C. Unpublished manuscipt
23 |
Endocrine Changes in Obesity
• Ghrelin (orexigenic hormone)
• Glucagon-like peptide-1 (GLP-1)
• Peptide tyrosine-tyrosine (PYY3-36)
Ghrelin
Produced in gastric fundus and intestine
 Appetite stimulant
 Elevated in states of hunger
 Rapid decline post-prandially
 Ghrelin secretion suppressed by RYGB
 Exclusion of gastric fundus?

Human Ghrelin
Research reported in New
England Journal of Medicine –
May 23, 2002
 Conducted by VA Puget Sound Health
Center & University of Washington – led
by Dr. David Cummings -Endocrinologist
 Compared blood samples after six month
period of time of two groups of obese
patients
 13 dieters & 5 gastric-bypass patients
 Dieters were on low-fat, low-calorie diet
Ghrelin and Gastric bypass
Peptide YY 3-36
 Found in distal GI tract (ileum)
 Synthesized and released from specialized endocrine
cells (L cells)
 Levels increase with nutrient ingestion/ “ileal brake”
 Peak at 1 hour
 Remain elevated for 6 hours
Caloric intake after PYY injection

Batterham et al. NEJM 2003
PYY3-36 and Gastric Bypass
PYY3-36 in LGB and LSG
n : 10
%EWL
Ann Surg 2008; Feb.
PYY
Effects of GLP-1 on food intake
Glucagon Like Peptide -1
Bypass
Sleeve
Medical
Ideal Operation?
 High resolution of T2DM
 Easy to perform
 Low early mortality and morbidity
 Low Micronutrient deficiencies
 Possible reoperation/conversion in case of failures
Laparoscopic sleeve gastrectomy:
Technique. 40 Fr.
Lap Band versus Gastric Sleeve in
BMI < 60 (mean 45)
120
100
P<0.01
80
60
Plasma
Ghrelin levels
40
fmol/ml
Band
Sleeve
20
0
0
1
Months
Langer et al.: Obesity Surgery 2005; 15(7):1024-29
6
Small Bowel Transit Time
-29%
-28%
Shah, Todkar et al. SOARD June 2009
Other Hormones
 Karamanakos
Elevated PYY 3-36 (Sleeve and Gastric
bypass n.s., Ghrelin reduction stronger after Sleeve.
P<0.0001). Ann Surg. 2008 Mar;247(3):401-7
 Ferreri (Tarragona) Elevated GLP-1
Short-term effects of sleeve gastrectomy on type
2 diabetes mellitus in severely obese subjects.
Obes Surg. 2008 Sep;18(9):1077-82
*At 12 months
85% resolution with
BOTH operations
Effectiveness of laparoscopic sleeve gastrectomy
on glycemic control in obese Indians with type 2
diabetes mellitus.
 53 patients (24 men and 29 women), age 46.5, BMI
45.2 hemoglobin A1c 8.4%
Surg Obes Relat Dis. 2009 Jul 10. [Epub ahead of print]
% use of medication (oral) after
sleeve gastrectomy vs Months
Laparoscopic sleeve gastrectomy for
diabetes treatment in nonmorbidly obese
patients: Efficacy and change of insulin
secretion.
 Oral glucose loads in 20 severe diabetic patients (body
mass index [BMI] >25 and <35, HbA1C >7.5%) before
and at 1, 4, 12, 26, and 52 weeks after sleeve
gastrectomy.
 Remission of type 2 diabetes was defined as fasting
glucose level <126 mg/dL and HbA1C <6.5% without
any glycemic therapy.
Lee WJ, Ser KH, Chong K, Lee YC, Chen SC, Tsou JJ, Chen JC, Chen CM.
Department of Surgery, Min-Sheng General Hospital, Taoyuan City, Taiwan.
Mean BMI vs Weeks
69% EWL
Mean HbA1c vs Weeks
C-peptide levels and % Diabetes
Resolution
Surg Obes Relat Dis. 2010 Nov-Dec;6(6):707-13.
Epub 2010 Aug 6.
Sleeve gastrectomy and type 2 diabetes mellitus:
a systematic review.
Gill RS, Birch DW, Shi X, Sharma AM, Karmali S.
 27 studies, 673 patients
 The baseline mean BMI 47.4 kg/m(2)
 The mean percentage of excess weight loss was 47.3%
(range 6.3-74.6%), with a mean follow-up of 13.1
months (range 3-36).
 DM had resolved in 66.2% of the patients, improved in
26.9%, and remained stable in 13.1%.
 The mean decrease in blood glucose and hemoglobin
A1c after sleeve gastrectomy was -88.2 mg/dL and 1.7%, respectively.
Arch Surg. 2011 Feb;146(2):143-8.
Gastric Bypass vs Sleeve Gastrectomy for Type 2
Diabetes Mellitus: A Randomized Controlled Trial.
Lee WJ, Chong K, Ser KH, Lee YC, Chen SC, Chen JC,
Tsai MH, Chuang LM.
 60 patients enrolled, and 12-month follow-up. Remission of
T2DM was achieved by 28 (93%) in the gastric bypass group
and 14 (47%) in the sleeve gastrectomy group (P = .02).
 No equipoise, more weight loss from gastric bypass, makes it
suspicious that the sleeve group did not have a proper
sleeve???
 It makes the point that you CAN achieve resolution..without
duodenal exclusion
Ann Surg. 2008 Mar;247(3):401-7.
Randomized study: Sleeve vs
Gastric Bypass
80
70
60
50
40
Sleeve
30
Gastric Bypass
20
10
0
EWL 6 months (%)
Ann Surg. 2008 Mar;247(3):401-7
EWL 12 months (%)
Obes Surg. 2011 Aug 5. [Epub ahead of print]
Randomized Clinical Trial of Laparoscopic Roux-en-Y Gastric
Bypass Versus Laparoscopic Sleeve Gastrectomy for the
Management of Patients with BMI < 50 kg/m(2).
Kehagias I, Karamanakos SN, Argentou M, Kalfarentzos F
 There was no death in either group and there was no
significant difference in early and late morbidity (10%
in each group).
 Weight loss was significantly better after LSG in the
first years of the study and at 3 years %EWL reached
62% after LRYGB and 68% after LSG (p = 0.13).
 There was no significant difference in the overall
improvement of comorbidities.
 Vitamin B(12) deficiency which was more common
after LRYGB (P = 0.05).
5 years results of randomized
study
 No statistical difference in %EWL between gastric
bypass and sleeve gastrectomy
Physiol Behav. 2011 Jun 12.
Similar effects of roux-en-Y gastric bypass and
vertical sleeve gastrectomy on glucose regulation in rats.
Chambers AP, Stefater MA, Wilson-Perez HE, Jessen L, Sisley
S, Ryan KK, Gaitonde S, Sorrell JE, Toure M, Berger J, D'Alessio
DA, Sandoval DA, Seeley RJ, Woods SC.
 Control group (Sham)
 They ate less food and lost more weight, and they both
had improved glucose parameters.
 The most intriguing aspect of the findings is that the
two surgical procedures had such similar effects in
spite of quite different rearrangements of the
gastrointestinal system.
Obes Surg. 2011 Jun;21(6):738-43.
Impact of laparoscopic sleeve gastrectomy and laparoscopic
gastric bypass on HbA1c blood level and pharmacological
treatment of type 2 diabetes mellitus in severe or morbidly
obese patients. Results of a multicenter prospective study at 1
year.
Nocca D, Guillaume F, Noel P, Picot MC, Aggarwal R, El Kamel
M, Schaub R, de Seguin de Hons C, Renard E, Fabre JM.
 The average (BMI) in the LGBP group was 47.9 and
50.6 in the LSG group.
 At 1 year after surgery, the average HbA1c lost was 2,537
in the GBP group and 2,175 in the SG group. T2DM had
resolved (withdrawal of pharmacological treatment) in
60% of the LGBP group and 75.8% of the LSG
group.
Surg Obes Relat Dis. 2011 Jul-Aug;7(4):506-9. Epub 2011 Jan 28.
Is sleeve gastrectomy as effective as gastric bypass for remission
of type 2 diabetes in morbidly obese patients?
de Gordejuela AG, Pujol Gebelli J, García NV, Alsina EF, Medayo
LS, Masdevall Noguera C.
 A total of 90 patients (60 RYGB and 30 SG). The body
mass index was 46 kg/m(2) for the RYGB group and 57
kg/m(2) for the SG group. The fasting glycemia was
10.6 mmol/L and 8.1 mmol/L and the glycated
hemoglobin was 8.1% and 7.3% in the RYGB and SG
groups, respectively.
 No significant differences were seen in the amount of
weight loss after 2 years between the 2 techniques.
T2DM resolution
Bariatric Surgery versus Intensive Medical Therapy in Obese
Patients with Diabetes
Philip R. Schauer, M.D., et al.
N Engl J Med 2012; 366:1567-1576 April 26, 2012
 hemoglobin level of 7.5±1.8% in the medical-therapy group,
 6.4±0.9% in the gastricbypass group (P<0.001), and 6.6±1.0% in
the sleeve-gastrectomy group (P=0.003).
 Weight loss was greater in the gastric-bypass group
 and sleeve-gastrectomy group (−29.4±9.0 kg and −25.1±8.5 kg,
 respectively) than in the medical-therapy group (−5.4±8.0 kg)
 (P<0.001 for both comparisons).
 The primary end point was 12% in the medical-therapy group
versus 42% in the gastric-bypass group (P=0.002) and 37% in
 the sleeve-gastrectomy group (P=0.008).
60 patients (BMI < 35) randomized to best
medical treatment vs surgical therapy
(Gastric bypass or BPD)
5 years duration of diabetes, HbA1c >7%
End point remission at 2 years
End point remission at 2 years
Remission at 2 years was 0% in medical
group, 75% in gastric bypass and 95% in
BPD
Hypothesis
 Accelerated stimulation of ileum by transposing a
segment into the proximal small bowel may signal
earlier release of PYY 3-36 & GLP-1
 Combined with gastric Sleeve restriction,
decreased ghrelin levels
 this combination may produce a more optimal (less
nutritionally deficient) option for bariatric surgery
Ileal Transposition
AJP Endocrinol Metab, 228; p E449, 2005
Body weights after IT
GLP-1 levels after IT
PYY levels after IT
Best of both worlds
 Decrease in Ghrelin
 Increase in PYY-3-36 and GLP-1
 Double effect on Neuropeptide Y
 SGIT
 NO micronutrients deficiencies
Weight progression of Pigs
Weight SGIT
80.0
70.0
(kg)
60.0
50.0
T1
40.0
T2
30.0
T3
T4
20.0
10.0
0.0
0
1
2
3
4
5
6
7
Weeks
8
9
10
11
12
13
Weeks
T4 Sham Control: Ileal reanastomosis
T1 Ileal transposition Alone
T2 SGIT: Sleeve Gastrectomy with ileal Transposition
T3 RYGP: Roux en Y Gastric Bypass
14
15
Mineral absorption
%
P<0.05
P<0.05
Weight change
•131.8 ± 2.6%
•117.8 ± 8.6%
•100.4 ± 6.7%
•88.4 ± 12.8%
•p<0.001 compares to SHAM
•° p<0.001 compares to IT
Fasting glucose
•288.5 ± 76.3
•218.5 ± 52.7
•119 ± 36,8
•134.7 ± 38.7
• * p<0.001 compares to SHAM
International Surgical Week 2007, Montreal August 29,2007
Glucose tolerance test (Zucker Diabetic)
Boza et al, DDW 2007
Insulin tolerance test
Procedur
e
SHAM
RYGB
IT
0 minutes
444 ± 19
209 ± 9.9
125.3±
p value
30 minutes
p value
60 minutes p value
NS*
<0.001*
417 ± 80
213.1 ± 61.6 <0.001*
105.7 ± 24.2 <0.001*
373.3± 48.1
189.3± 33.2 <0.001*
146± 54
<0.001*
La transposition iléale avec ou sans gastrectomie par laparoscopie chez l'homme (TIG) :
La troisième génération de chirurgie bariatrique
GAGNER M.
L'échec sévère d'un switch duodénal chez un sujet de 155 kg avec un IMC de 50 kg/m2
aboutissant à un amaigrissement incontrôlable (66 kg, IMC 23,6kg/m2), avec carence
malabsorptive, n'a pu être corrigé que par l'interposition duodénale d'un segment d'iléon
terminal. Cette efficacité thérapeutique fait proposer par l'auteur la technique de la
transposition duodénale de l'iléon, associée à une gastrectomie en manchette (sleeve).
Après les opérations "restrictives" et "malabsorptives", il s'agit de la naissance de la
troisième génération de procédures bariatriques à visée hormonale; cette action est
basée essentiellement sur la stimulation hormonale précoce des hormones
anorexigènes PYY 3-36, GLP et OXM au niveau de l'iléon terminal transposé, et sur la
diminution de l'hormone anti-anoréxigène Ghreline par la gastrectomie, avec donc peu
de "restriction" et pas de "malabsorption". Cette voie thérapeutique nouvelle est appelée
à un grand développement mais ses résultats doivent être confirmés par des recherches
expérimentales et par des études complémentaires chez l'animal et chez l'obèse. Revue
Le Journal de coelio-chirurgie
2005, no54, pp. 4-9
Laparoscopic SGIT: Sleeve Gastrectomy
with Ileal Transposition in Humans
Different types
Of Transposition
Possible !
a) Inter Esophago-Gastric
b) Inter Gastro-Gastric
c) Inter Duodenal
d) Inter Jejunal
Gagner M: J CoelioChirg
2005.
Ileal Interposition in BMI less than 35 (n=39)
De Paula, Surg Endsoc 2007
Diabetes Control
 SGIT provided a weight control comparable to
standard gastric bypass without malabsorption
 SGIT induced high levels of GLP1 after the meal test
 The diverted form is very close to a duodenal switch
2010
Ileal Interposition –
Sleeve Gastrectomy
Ileal Interposition –
Diverted Sleeve Gastrectomy
1
Ileal Interposition –
Sleeve Gastrectomy
Ileal Interposition –
Diverted Sleeve Gastrectomy
1
Ileal Interposition –
Sleeve Gastrectomy
Ileal Interposition –
Diverted Sleeve Gastrectomy
2
Ileal Interposition –
Sleeve Gastrectomy
Ileal Interposition –
Diverted Sleeve Gastrectomy
2
Ileal Interposition –
Sleeve Gastrectomy
Ileal Interposition –
Diverted Sleeve Gastrectomy
3
Ileal Interposition –
Sleeve Gastrectomy
Ileal Interposition –
Diverted Sleeve Gastrectomy
3
Ileal Interposition –
Sleeve Gastrectomy
Ileal Interposition –
Diverted Sleeve Gastrectomy
4
4
Issues
 Reproducibility
 Four anastomosis and a stump (leaks)
 Four Internal hernias
 Diverted Sleeve gastrectomy plus ileal
interposition..... Duodenal switch
 More human studies need to be done, especially
compared to a short DS which is easier
A Duodenal Switch !!!
Duodeno-ileostomy
A Duodenal Switch !!!
Sleeve Gastrectomy
A Duodenal Switch !!!
Biliopancreatic
limb(excluded
duodenum+prox jejunum)
A Duodenal Switch !!!
Common channel
Efficacy for Improvement in DiabetesRelated Outcomes by Surgical Procedure
%
100
90
80
70
60
50
40
30
20
10
0
Total
Banding
Bypass
Plasty
BPD or DS
Mean resolution
Buchwald et al. JAMA, 292(14), 2004
Duodeno-Jejunal Bypass (DJB) for Type-2
Diabetes mellitus
 Goto-Kakizaki rats (spontaneous Type-2 DM)
 DJB vs Sham
 Plasma Glu 159 mg/dL to 96.3 at 3 weeks.
 40% reduction
 Proximal gut origin?
Rubino F et al. Ann Surg 2004; 239(1):1-11
??
??
Pause
 Should the rat study been confirmed by other groups?
 Should a larger mammals study been done before
doing this in Humans?
 Should an ulcerogenic operation been done (MannWilliamson)?
Duodeno-Jejunal Bypass (DJB) for Type-2
Diabetes mellitus
 Duodeno-jejunal bypass for the treatment of type-2
diabetes in patients with Body Mass Index of 22-34
kg/m2: a report of 2 cases.
Cohen R et al.SOARD 2007; 3(2):195-7
Prospective study
 35 patients
 Mean OR time 46 minutes (33-78)
 Hosp. Stay : 30 hours
 1 mortality
 Complications 14.2% (obstruction, pancreatitis,
bleeding)
 37% prolonged nausea , and half needed readmission
Cohen Ret al: Hospital Sao Camilo, Sao Paulo, Brazil
Minimal improvement in Glycemic
Homeostasis-12 months after DJBypass
 7 subjects, BMI 22-33
 Glu 209 to 154 mg/dL
 Cho and Trig inc.
 ? Clinical improv.
Ferzli GS, et al: World J Surg 2009; 33:972-979
Diabetic medication
requirements, preop and 1 year
Ferzli GS, et al: World J Surg 2009; 33:972-979
Ann Surg. 1923 Apr;77(4):409-22.
 Laparoscopic sleeve gastrectomy and
duodeno-jejunal bypass. A new surgical
procedure for weight control in a porcine
model.
 Gianmattia del Genio1, M.D, PhD, Michel Gagner2,
M.D., F.A.C.S., F.R.C.S.C., Federico CuencaAbente3, M.D., Laurent Biertho3, M.D., Maurizio
Grillo1, M.D., PhD, David Nocca, M.D3..
 Obes Surg. 2008 Oct;18(10):1263-7. Epub 2008 Jun
18.
Preliminary results of Human
experience with Sleeve+DJB
 21 patients over 19 months period
 108 kg , or BMI 41 kg/m2
 Weight loss of 37 kg or % EWL 96
 One leak
 Resolution of DM was 96%
 Resolution/improvement of
hypertension was 86%
Kasama K et al.: Obes surg 2009; 19:1341-45
Obes Surg. 2011 Aug 27. [Epub ahead of print]
Is Laparoscopic Duodenojejunal Bypass with Sleeve an Effective
Alternative to Roux En Y Gastric Bypass in Morbidly Obese
Patients: Preliminary Results of a Randomized Trial.
Praveen Raj P, Kumaravel R, Chandramaliteeswaran C, Rajpandian
S, Palanivelu C.
 57 patients Randomized.
 The mean BMI and % EWL at 3, 6, and 12 months
between the groups were not statistically significant.
 The operating times were higher in the DJB group.
 The rate of resolution of diabetes, hypertension, and
dyslipidemias were also similar with no statistical
significance.
 There was 100% resolution of dyslipidemias in both
groups.
Glp 1 Ileal versus Duodenal Bypass
Getting closer to the best
surgery for Type-2 Diabetes
 SGIT very close to Short Duodenal
switch, very close to Sleeve with
Duodeno-jejunal Bypass !!!
Type-2 DM will recur after GB if
weight regain?
 153/172 (89%) had type-2 DM resolution after Gastric
Bypass
 66/172 (43%) had recurrence
 They had a drop of EWL from 66% to 49%.
 Males have a more durable pattern.
 *IN SPITE OF DUODENAL EXCLUSION
Chikunguwo et al. SOARD 2009; 5:S1
Sleeve Gastrectomy: Beyond 5 years (5-9 years studies)
Can Laparoscopic Sleeve Gastrectomy
replace Gastric Bypass for type 2 DM?
 Easier procedure to perform
 Less mortality and morbidity
 Similar weight loss and resolution of co-morbidity
(5years).
 Minimal nutritional impact
 Minimal long-term complications (ulcer, bowel
obstruction)
 No remnant to follow (access to bile duct, gastric ca?)
 Easier to revise or convert for weight regain
 Can be used in staged approaches
Surgery has the potential to
cause a resolution of type-2
diabetes in 320 million patients
in 2015…
 We have a manpower problem, as it takes 10 years to
create a surgeon, and another 10 years for great
experience and expertise!
 A simpler procedure is needed!
th
4
Sleeve Consensus meeting,
December 6-7-8th, 2012
ICSSG.COM