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MALABSORPTIVE BARIATRIC SURGERY
in Low BMI Korean Patients
Ji Yeon Park
Soonchunhyang University Seoul Hospital, Korea
Body Mass Index (BMI)
Body weight / Height2
The most practical measure of a person’s adiposity
BMI (kg/m2)
WHO classification of weight status
25 ~ 29.9
Overweight
30 ~ 34.9
Mildly Obese (Class I obesity)
35 ~ 39.9
Moderately obese (Class II obesity)
40 ~ 49.9
Severely or extremely obese (Class III obesity)
>50
Super obese (Class IV obesity)
Indications for Bariatric Surgery
NIH Consensus statement 1991
 Decision based on a prudent evaluation of the risk/benefit ratio
Era of open surgery
A very few surgical options
Conventional Bariatric Procedures
Roux-en-Y gastric bypass (RYGB)
Biliopancreatic diversion (BPD)
Laparoscopic adjustable gastric banding (LAGB)
Sleeve gastrectomy (SG)
Biliopancreatic diversion with duodenal switch (BPD/DS)
Conventional Bariatric Procedures
Dixon et al. Lancet 2012; 379: 2300-11
Swedish Obesity Subjects (SOS) Trial
Long-term, prospective, controlled trial
4047 obese subjects
surgery group (n=2010) vs. control group (n=2037)
Recruitment : Sep 1987 ~ Jan 2001
BMI : Men ≥ 38, women ≥ 34
Gastric bypass (13%), banding (19%) & vertical banded gastroplasty (68%)
Follow-up: 12 ~ 25 years
Weight changes & Mortality
The SOS intervention study
Effects on Diabetes : Remission & prevention
The SOS intervention study
Adjusted hazard ratio
0.17 (0.13 - 0.21)
Carlsson et al. N Engl J Med 2012;367:695-704
Paradigm Shift
BARIATRIC
SURGERY
METABOLIC
SURGERY
Lower the BMI
& Body weight
Reduce HbA1c &
medications
Surgical Treatment for NIDDM
NIDDM 121 / 146 (82.9%)
IGT 150 / 152 (98.7%)
 Euglycemia
Surgery vs. Conventional Medical Therapy for T2DM
Single-center, nonblinded, randomized, controlled trial
Medical therapy vs. BPD vs. RYGB
60 pts
Age : 30 ~ 60 years
BMI ≥ 35
DM > 5 years
HbA1c ≥ 7.0%
Mingrone et al. N Engl J Med 2012;366:1577-85.
Outcomes at 2 years
Mingrone et al. N Engl J Med 2012;366:1577-85.
Difference in the rate of T2DM remission
At 2 years
Diabetes remission
Relative risk
Time to normalization
(months)
Medical therapy
RYGB
BPD
P-value
0
15 (75%)
19 (95%)
<0.001
7.5
(95% CI, 1.97 - 28.61)
9.5
(95% CI, 2.54 - 35.51)
<0.001
10±2
4±1
0.01
Mingrone et al. N Engl J Med 2012;366:1577-85.
STAMPEDE Trial
Randomized, non-blinded, single-center trial
intensive medical therapy vs. RYGB vs. SG
150 pts
age 20 ~ 60 years
type 2 diabetes
HbA1c >7.0%
BMI 27 ~ 43
Schauer et al. N Engl J Med 2012;366:1567-76
At 12 months
Schauer et al. N Engl J Med 2012;366:1567-76
Changes in Diabetes Control Over 3 Years
Predictors of HbA1c <6.5% at 36 months
Reduction in BMI (OR 1.33; 95% CI 1.15 – 1.56)
DM duration < 8 years (OR 3.3; 95% CI 1.2 – 9.1)
Schauer et al. N Engl J Med 2014;370:2002-13
Weight independent anti-diabetic effects of
malabsorptive procedures: evidences
Evidence 1
Rapid Kinetics of diabetic improvement after surgery
Evidence 2
Greater glycemic improvement than with equivalent weight loss from
other means
Evidence 3
hyperinsulinemic hypoglycemia
Evidence 1. Rapid improvement in insuline resistance
The change in insulin resistance occur within 6 days of the surgery, before any
appreciable weight loss has occurred!
Wickremesekera et al. Obesity Surgery, 2005, 15, 474-481
Evidence 2. Greater glycemic control after same weight loss
RYGB vs. hypocaloric diet
Laferrere et al. J Clin Endocrinol Metab, July 2008, 93(7):2479–2485
Evidence 3. Hyperinsulinemic hypoglycemia
RYGB Long lasting stimulation of β-cell mass and/or function..
Service et al. N Engl J Med 2005;353:249-54
Mechanisms of Diabetic Resolution
after malabsorptive procedures
restriction
Weight loss
malabsorption
Better glycemic control
Improved insulin resistance
Brain-Gut Axis
Entero-Insular Axis
Possible Mechanisms of Diabetic Remission
Other than Weight loss…
 The starvation hypothesis
 The ghrelin hypothesis
 The hindgut stimulation hypothesis
 The foregut exclusion hypothesis
The Starvation Hypothesis
Acute restriction of energy intake
 transiently improves glycemia…
Buchwald et al. JAMA. 2004;292(14):1724-1737
The Ghrelin Hypothesis
Diet induced weight loss
Gastric bypass is associated with markedly suppressed ghrelin levels, possibly contributing to
the weight-reducing effect & improvement in glucose tolerance of the procedure.
Cummings et al. N Engl J Med 2002;346:1623-30
The Hindgut Hypothesis
Rapid & early delivery of undigested
nutrients to the distal ileum
Stimulation of the secretion of L-cell
derivatives like GLP-1, PYY
Mason et al. Obesity Surgery, 15, 459-461
Korner et al. Surg Obes Relat Dis 2007;3:597– 601
Control of glucose homeostasis : GLP1 & GIP actions
Drucker et al. J. Clin. Invest. 117:24–32 (2007)
Ileal interposition
Patriti et al. Surgery 2007;142:74-85
The Foregut Hypothesis
Anti-incretin factors & Incretins
Rubino et al. Ann Surg 2002. Vol. 236, No. 5, 554–559
Proximal Small Intestine in T2DM
Rubino et al. Ann Surg 2006; 244: 741-749
Reoperation : GJ  Duodenal exclusion
Rubino et al. Ann Surg 2006; 244: 741-749
The Foregut & Hindgut Hypothesis
Rapid
exposure to
distal bowel
Duodenal
exclusion
Rubino et al. Ann Surg 2002. Vol. 236, No. 5, 554–559
Novel Bariatric Techniques : metabolic surgeries
Duodenojejunal bypass (DJB)
Duojejunal bypass with SG
Ileal interposition
Mini-gastric bypass (MGB) or
single-anastomosis gastric bypass (SAGB)
Endoluminal Sleeves
Then…
what about in low BMI population?
Shift in Emphasis
BARIATRIC
SURGERY
METABOLIC
SURGERY
Lower the BMI
& Body weight
Reduce HbA1c &
medications
Impact of Class I Obesity on Health
 Mortality?
• considerably less impact than classes II and III obesity
• unclear
 Increased risk of comorbidities
T2DM, HTN, dyslipidemia, metabolic synd., OSA, PCOS, depression, NAFL
 Increased risk of many cancers
 Impaired physical & mental health-related QoL
 Increased psychosocial burden, esp. in women
Previous Studies on Class I Obesity

Overall weight loss was excellent in patients with class I obesity after all
the most established bariatric procedures.

Better excess weight loss in this group of patients compared to
patients with morbid obesity.

Length of follow-up is short (<2 years) in most of the studies.
 long-term risk / benefit ratio of surgery ????
Bariatric & Metabolic Surgery
for the patients with a BMI < 35
Bariatric surgery: an IDF statement for
obese type 2 diabetes. 2011
ASMBS Clinical Issues Committee.
Bariatric surgery in class I obesity (BMI 30
– 35 kg/m2). 2013
Beyond BMI
in the Selection/Prioritization of
Obese patients for Surgery
Position statement from IFSO, 2014
Indication to bariatric surgery in class I obesity
Comorbidity burden >> BMI levels
Obesity scoring system
phenotypization beyond BMI levels for guiding therapeutic choices
Proposed Classification of BMI in Adult Asians
Guidelines for Bariatric Surgery for Asians
BMI <35 vs. BMI ≥35
-STAMPEDE trial-
Schauer et al. N Engl J Med 2014;370:2002-13
Surgery vs. Intensive Medical Weight Management
for T2DM & BMI<35
Randomized pilot trial
Parikh et al. Ann Surg 2014;260:617–624
RYGB vs. Nonsurgical therapy
in patients with T2DM and BMI <35 kg/m2
Serrot et al. Surgery 2011;150:684-91
RYGB for Diabetes
and BMI < 35
66 patients
BMI 30 – 35 kg/m2
DM duration 12.5 ± 7.4 years
HbA1c 9.7 ± 1.5%
Cohen et al. Diabetes Care 2012
Estimated 10-year cardiovascular risk
after RYGB in mild obesity
Cohen et al. Diabetes Care 2012
Effect of duodenal exclusion in low BMI population
SAGB (MGB) vs. SG
Randomized controlled trial
30 SAGB + 30 SG
HbA1c>7.5 %
BMI 25 - 35 Kg/m2,
C-peptide ≥1.0 ng/mL
Duration of T2DM > 6 months
Baseline characteristics
Duration of DM : 6.4 years (4.2–8.5 )
BMI 30.6 kg/m2 (25.1–34.7)
HbA1c 10.0% (7.5–15.0)
Lee W-J et al. Arch Surg. 2011;146(2):143-148
Effect of duodenal exclusion at 12 months
SAGB vs SG
Lee W-J et al. Arch Surg. 2011;146(2):143-148
SAGB (MGB) vs SG : 5 yr f/u
Lee W-J et al. OBES SURG (2014) 24:1552–1562
SAGB (MGB) vs SG : 5 yr f/u
Incretin effect
Lee W-J et al. OBES SURG (2014) 24:1552–1562
Our Experience
RYGB in low BMI population
At Soonchunhyang University Seoul Hospital
RYGB : Low BMI vs. high BMI
403 patients
Low BMI (n=137)
High BMI (n=266)
p-value
40.1 ± 10.6
36.2 ± 11.1
0.001
Male
17 (12.4)
55 (20.7)
0.040 chi
Female
120 (87.6)
211 (79.3)
Body weight (kg)
84.9 ± 9.8
111.2 ± 17.2
<0.001
BMI (kg/m2)
32.0 ± 1.9
40.8 ± 4.4
<0.001
Excess weight (kg)
29.5 ± 8.4
55.1 ± 15.7
<0.001
Diabetes
45 (32.8)
89 (33.5)
0.902
Hypertension
45 (32.8)
91 (34.2)
0.784
Dyslipidemia
94 (68.6)
171 (64.3)
0.386
Confirmed
5 (3.6)
35 (13.2)
0.004
Suspicious
4 (2.9)
15 (5.6)
17 (12.4)
32 (12.0)
0.912
8 (5.8)
31 (11.7)
0.061
1.6 ± 1.3
1.8 ± 1.3
0.183
Age (years)
Sex
January 2011 ~
February 2014
Comorbidities
Sleep apnea
Arthropathy
PCOS
No. of comorbidities
Weight loss outcomes
Low BMI (n=137)
High BMI (n=266)
p-value
13.5 ± 8.7
14.5 ± 8.1
0.278
Body weight (kg)
65.4 ± 9.5
80.3 ± 15.1
< 0.001
BMI (kg/m2)
24.7 ± 2.9
29.6 ± 4.5
< 0.001
%EWL (%)
83.2 ± 33.1
64.3 ± 20.8
< 0.001
9 (8.7)
30 (15.4)
0.106
Follow-up duration (months)
At last follow-up
EWL < 50% at 1 year (n, %)
Changes in body weight
Comorbidity Resolution
Low BMI
High BMI
p-value
DM duration (years)
5.9 ± 6.0
4.0 ± 5.6
0.086
Preop HbA1c
8.3 ± 1.5
7.8 ± 1.4
0.053
Preop C-peptide
5.0 ± 2.5
6.2 ± 2.9
0.019
Predictors of diabetic remission after RYGB
Univariate analysis
Multivariate analysis
OR
95% CI
p-value
Adjusted OR
95% CI
p-value
Age < 50 years
2.968
1.159 – 7.602
0.023
5.729
0.866 – 37.882
0.070
Preoperative BMI ≥ 40 kg/m2
5.440
1.881 – 15.736
0.002
5.063
0.990 – 25.886
0.051
Duration of diabetes < 5 years
4.832
2.047 – 11.405
<0.001
5.096
1.008 – 25.762
0.049
Preoperative Insulin requirement
5.143
1.998 – 13.241
0.001
1.311
0.205 – 8.383
0.775
FBS < 200 mg/dL
2.380
0.960 – 5.898
0.061
HbA1c < 8.5 %
3.846
1.593 – 9.285
0.003
20.031
2.759 – 145.421
0.003
C-peptide ≥ 3 ng/mL
5.606
1.627 – 19.311
0.006
38.804
3.562 – 422.782
0.003
2.450
1.325 – 8.983
0.011
17.748
2.470 – 127.531
0.004
Preoperative laboratory results
At last follow-up
EWL ≥ 50 % *
MALABSORPTIVE PROCEDURES
in low BMI Korean population
Purpose
Metabolic resolution >> weight loss
RYGB or SAGB (malabsroptive procedures)
Effective comorbidity resolution and weight loss
Malabsoptive vs. Restrictive procedures
Better diabetic resolution after BYPASS
Different response of diabetic resolution?
Difference in preoperative diabetic characteristics
Patient selection : DM duration, preoperative C-peptide…
Long-term follow-up is necessary......
THANK FOR YOUR KIND ATTENTION.