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Efficacia della terapia chirurgica sulle complicanze
cardiovascolari nel diabete mellito tipo 2
Luigi Angrisani
Director - General and Endoscopic Surgery Unit
S.Giovanni Bosco Hospital, Naples, Italy
DIABETE MELLITO: COMPLICANZE CRONICHE
Microangiopatia
Retinopatia
Nefropatia
Neuropatia
Macroangiopatia
Coronarica
Cerebrale
Periferica
Diabete mellito e complicanze croniche
2-4 volte
rischio di PAD
2-4 volte
rischio di CAD
2 volte mortalità
per IMA a 5a.
20 volte rischio
di amputazioni
Diabete
Restenosi
dopo rivascol.
Prima causa
di cecità
Prima causa
di IRC
3 volte rischio
di ictus
“Il diabete è una malattia
cardiovascolare che si diagnostica
misurando la glicemia”
Y. Yarvinen
Macro-vascular Complications
 Ischemic heart disease
 Cerebrovascular disease
 Peripheral vascular disease
Diabetic patients have a 2 to 6 times higher risk for
development of these complications than the
general population
Macro vascular Complications
J Am Coll Surg. 2013 Apr;216(4):545-56
BACKGROUND
•Bariatric surgery (BAR) has been established as an
effective treatment for type 2 diabetes mellitus (T2DM) in
obese patients.
•Few studies have examined the mid- to long-term
outcomes of bariatric surgery in diabetic populations.
• No comparative studies have broadly examined major
macrovascular and microvascular complications in bariatric
surgical patients vs similar, nonbariatric surgery controls.
Johnson et al. J Am Coll Surg. 2013 Apr;216(4):545-56
STUDY DESIGN
• Large, population-based, retrospective cohort study of adult
obese patients with T2DM, from 1996 to 2009.
• Eligible patients undergoing bariatric surgery (BAR [n=2,580])
were compared with nonbariatric surgery controls (CON
[n=13,371]) for the outcomes of any first
- major macrovascular event (myocardial infarction, stroke, or allcause death) or
- microvascular event (new diagnosis of blindness, laser eye or
retinal surgery, nontraumatic amputation, or creation of permanent
arteriovenous access for hemodialysis), assessed in combination
and separately
- other vascular events (carotid, coronary or lower extremity
revascularization or new diagnosis of congestive heart failure or
angina pectoris).
Johnson et al. J Am Coll Surg. 2013 Apr;216(4):545-56
RESULTS
•Bariatric surgery is associated with a 60% to 70% reduction in the hazard
of any major macro- or microvascular complication of T2DM in moderately
to severely obese patients free of advanced cardiovascular and
microvascular disease at baseline.
•Macrovascular, microvascular, and other vascular events were all shown to
be substantially reduced in the Bariatric Surgery patients vs Controls.
•The magnitude of the estimated risk reductions ranged between 60% and
80% for all study outcomes and suggests that bariatric surgery may
significantly reduce the burden of end-stage diabetes related complications
for at least the first 5 to 10 years after surgery.
•Although the preponderance of available data is limited by a lack of level 1
evidence, bariatric surgery appears to be emerging as one of the most
effective treatments for ameliorating the excess cardiovascular disease
burden imparted by T2DM and obesity.
Johnson et al. J Am Coll Surg. 2013 Apr;216(4):545-56
PATHOPHYSIOLOGY
Weight loss likely plays an important role in the
long-term durability of diabetes remission among
bariatric patients, who exhibit improved remission
rates for at least 10 years after surgery compared
with control patients receiving optimal medical
therapy or usual care.
Johnson et al. J Am Coll Surg. 2013 Apr;216(4):545-56
STUDY’S LIMITATIONS
•Retrospective nature
•Lack of information on body weight and markers of glycemic
control preclude analysis of the proposed mechanisms for the
observed risk reductions.
•Lack of information on duration and severity of diabetes at the
time of study inclusion
Johnson et al. J Am Coll Surg. 2013 Apr;216(4):545-56
Cardiovascular risk reduction and bariatric surgery
Authors
Article type
Relative risk
reduction of CV
disease
Heneghan HM et al.
Am J Cardiol 2011
Systematic
review
40%
28%
Scott JD et al.
Surg Obes Relat
Dis 2013
Retrospective
cohort study
25-50%
40%
Sjostrom L
JAMA 2012
Prospective
matched cohort
study
33%*
15%
*47 % in diabetic subgroup
Percentage of
diabetic patients
CONCLUSIONS
Bariatric surgery is associated with a 65%
reduction in major macrovascular and
microvascular events in moderately
and severely obese patients with T2DM.
Johnson et al. J Am Coll Surg. 2013 Apr;216(4):545-56
Micro vascular
Complications
Diabetic Retinopathy (DR)
 DR is the leading cause of blindness in the working
population of the Western world
 The prevalence increase with the duration of the
disease (few within 5 years, 80 – 100% will have some
form of DR after 20 years)
 Maculopathy is most common in type 2 patients and
can cause severe visual loss
•Rapid and significant improvement in diabetes control is known to
worsen diabetic retinopathy (DR).
•38/ 119 patients had surgeries T2DM preoperatively.
- 9% new DR after surgery
- 9% progression of pre-existent DR after surgery
- 59% no DR before and after surgery
- 14% stable DR through surgery.
- 9% regression of DR after surgery.
•Changes in DR are unpredictable after bariatric surgery.
•A small but significant proportion (18%) of patients with diabetes and
bariatric surgery tended to develop new DR or worsen their
retinopathy.
Diabetic Nephropathy (DN)
 Diabetes has become the most common cause of end
stage renal failure in the US and Europe
 About 20 – 30% of patients with diabetes develop
evidence of nephropathy
 The prevalence of DN is higher in Black Americans
than in Whites (Figures for South Africa is not
available)
Conclusions
•Bariatric surgery reduces overall mortality in obese subjects
•Bariatric surgery reduces cardiovascular events in nondiabetic population
•Bariatric surgery can provide a significative percentage of
treated patients with prolonged remission of T2DM
•Bariatric surgery seems to be associated with a significant
reduction in major macrovascular and microvascular events
in moderately and severely obese subjects with T2DM.
Angrisani 2013
SICOB National Registry
Pts BMI < 35 (1998 – 2012)
SICOB National Registry
Pts BMI < 35 (1998 – 2012)
ANTI -OBESITY PROCEDURES
n= 1932
Jan 1996 - Dec 2012
100
495
326
510
24
459
Lap Band System®
Bioenterics Intragastric Balloon®
Sleeve Gastrectomy
Gastric Bypass
BPD-Duodenal Switch
Revisions
ANGRISANI 2013 Naples, Italy
93 Bariatric Procedures in 70
Obese Type 2 Diabetics
464
500
429
318
400
300
118
200
100
0
41
GBP
23
Sleeve
22
10
Band
General and Endoscopic Surgery Unit
“S. Giovanni Bosco” Hospital - Naples - Italy
Director: Luigi Angrisani
Diabetic Pts
16
BIB
Total
3
BPD/DS
CHIRURGIA DEL DIABETE
•L’efficacia delle tecniche chirurgiche è
inversamente proporzionale al BMI di partenza
•Tra le tecniche chirurgiche (BPD, bypass
gastrico, sleeve gastrectomy, bendaggio
gastrico) quelle più complesse sono anche le
più efficaci (e nello stesso tempo rischiose)
•Il
meccanismo
fisiopatologico
sostanzialmente basato sul calo ponderale.
è
Angrisani 2013
STAMPEDE trial: conclusions
Schauer PR et al NEJM 2012
STAMPEDE trial
STAMPEDE trial
•Bariatric surgery is associated with a 60% to 70% reduction in the hazard
of any major macro- or microvascular complication of T2DM in moderately
to severely obese patients free of advanced cardiovascular and
microvascular disease at baseline.
•Macrovascular, microvascular, and other vascular events were all shown to
be substantially reduced in the Bariatric Surfgery patients vs Controls.
•The magnitude of the estimated risk reductions ranged between 60% and
80% for all study outcomes and suggests that bariatric surgery may
significantly reduce the burden of end-stage diabetes related complications
for at least the first 5 to 10 years after surgery.
•Although the preponderance of available data is limited by a lack of level 1
evidence, bariatric surgery appears to be emerging as one of the most
effective treatments for ameliorating the excess cardiovascular disease
burden imparted by T2DM and obesity.
Johnson et al. J Am Coll Surg. 2013 Apr;216(4):545-56
Johnson et al. J Am Coll Surg. 2013 Apr;216(4):545-56
CHIRURGIA BARIATRICA E COMPLICANZE DEL
DIABETE