Marco Castagneto Istituto di Clinica Chirurgica Università Cattolica S. Cuore Roma
Source: CDC, 2006 E-2108.ppt
Globesity Epidemic
From: Excess Deaths Associated With Underweight, Overweight, and Obesity JAMA. 2005;293(15):1861-1867. doi:10.1001/jama.293.15.1861
From: Years of Life Lost Due to Obesity JAMA. 2003;289(2):187-193. doi:10.1001/jama.289.2.187
By 2020 half of the US population will be obese 175 m
7 kg 3 kg
Global Projections for the Diabetes Epidemic: 2000-2030 (in millions) NA 19.7 33.9 72% LAC 13.3 33.0 148% Wild. S et al.: Global prevalence of diabetes: Estimates for 2000 and projections for 2030 Diabetes Care 2004 SSA 7.1 18.6 161 % EU 17.8 25.1 41% MEC 20.1 52.8 163% India 31.7 79.4 151% World 2000 = 171 million 2030 = 366 million Increase 1 13% China 20.8 42.3 104% A+NZ 1.2 2.0 65%
Diabetes care across Europe reported in 2002 did not deliver glycaemic targets. Purple shows percent of people 6.5%; yellow 6.5-7.5%; blue >7.5%. From Liebl A. et al. Diabetologia. 2002;45:S23-S28.
CHIRURGIA BARIATRICA CLASSIFICAZIONE DEGLI INTERVENTI RESTRITTIVI Bendaggio gastrico Bypass gastrico Gastroplastica verticale MALASSORBITIVI Bypass digiunoileale Diversione biliopancreatica Bypass bilio-intestinale Alternativi Palloncino intragastrico (BIB) Pacemaker gastrico
BENDAGGIO GASTRICO Vantaggi: Semplice esecuzione tecnica (anche per via laparoscopica). Morbilità ridotta. Calo ponderale discreto. Svantaggi: Necessità di elevata compliance del paziente. Incidenza di complicanze specifiche (slippage, decubito del band, infezione del port perforazione gastrica). Scarso successo a medio e lungo termine
BYPASS GASTRICO Vantaggi: Buon calo ponderale. Eseguibile anche in laparoscopia. Buon trattamento del Diabete Mellito. Svantaggi: Difficoltà di studio dello stomaco escluso. Incerti risultati a lungo termine confezionamento di piccola tasca gastrica 20-30 ml sezione dello stomaco gastrodigiunostomia di 10-25 mm ansa alimentare alla Roux di 40-150 cm ansa biliare di 40-100 cm, ansa comune di 180-240 ( extended, long limb )
DIVERSIONE BILIO-PANCREATICA Vantaggi: Calo significativo (>70% del sovrappeso) e mantenimento a distanza del peso perduto. Possibile esecuzione in laparoscopia. Ottimo controllo del Diabete Mellito Svantaggi: Possibili complicanze (diarrea, anemia, squilibri metabolici) legate al mancato follow-up. Tecnicamente complesso. ansa alimentare di 200 cm o 250-300 cm, ansa comune di 50 cm o 75 cm o 100 cm gastrectomia orizzontale parziale (400-500 ml) o verticale ( duodenal switch ) colecistectomia
Surgery. Gynecology & Obstetrics; February 1955
La chirurgia nell obesità grave Buchwald H, JAMA, 2004 Bariatric surgery. A systematic review and meta-analysis 136 lavori, 22094 pts 76-84% di risoluzione del DMT2 DPB 98,9% BPG 83,7% GPV 71,6% BG 47,9 %
PRIMARY END POINT The primary end point of the study related to glycemic control at 2 years after randomization. This were assessed as the proportion of participants achieving remission (exceptional glycemic control) of type 2 diabetes, defined as fasting plasma glucose levels less than 126 mg/dl (to convert to mmol/l, multiply by 0.0555) in addition to HbA1c values less than 6.2% without the use of oral hypoglycemics or insulin.
Dixon, J. B. et al. JAMA 2008;299:316-323
Inclusion criteria Age: 20 60 years T2DM with HbA1c > 7% BMI: 27-43 kg/m 2 218 patients screened At the Cleveland Clinic 150 patients randomized To RYGB, SG, intensive medical therapy Primary Endpoint Proportion of patients with HbA1c 6% with or without diabetes medications 12 months after randomization
Inclusion criteria Age: 30 60 years T2DM with HbA1c 7% BMI: 35 kg/m 2 Primary Endpoint Proportion of patients with fasting plasma glucose < 5.6 mmol/l (100 mg/dl) and HbA1c < 6.5% without diabetes medications for at least 1 year (duration of the study 2 years)
Panel A : Kaplan Meier unadjusted estimates of the cumulative incidence of type 2 diabetes in the bariatric-surgery group and the control group. The light shading represents the 95% confidence interval. The adjusted hazard ratio with bariatric surgery was 0.17 (95% confidence interval, 0.13 to 0.21). Panel B: Kaplan Meier unadjusted estimates of the incidence of type 2 diabetes in subgroups defined in the control group according to receipt or no receipt of professional guidance to lose weight and in the surgery group according to the method of bariatric surgery: gastric banding, vertical banded gastroplasty (VBG), or gastric bypass (GBP).
Mechanisms of diabetes remission Acute calorie restriction Weight loss Incretin effect Bile acid metabolism Altered microbiota
Insulin sensitivity (umol/kg/min) 80 70 60 50 40 30 20 10 0 0 5 10 15 20 25 30 Time after Surgery (months) CONTROLS ± 1 SD Blue diamonds = RYGB Red dots = BPD Am J Med. 2005 ;118:51-7
Insulin sensitivity (µmol. min -1. kg -1 ) Lean RY-GB BPD 80 70 60 50 40 30 20 10 0 15 20 25 30 35 40 45 50 55 60 BMI (kg. m -2 )
GLP1 (pmol/l) GLP1 (pmol/l) RYGB 100 90 80 70 60 50 40 30 20 10 0 BPD 0 50 100 150 200 Time (minutes) 100 90 80 70 60 50 40 30 20 10 0 0 50 100 150 200 Time (minutes)
CONCLUSIONI La chirurgia metabolica è efficace nel normalizzare il metabolismo glucidico nel paziente obeso e in quello con BMI < 35 I meccanismi di risoluzione del diabete sono peculiari per ciascun tipo di intervento Se la funzione beta-insulare è fortemente compromessa, l efficacia degli interventi è limitata
Prof. R. Bellantone Prof. M. Raffaelli Prof. G. Nanni Dr. C. Callari Prof. G. Mingrone Prof. S. Salinari Dr. A. Bertuzzi Prof. F. Rubino Prof. E. Ferrannini Dr. A. Mari Dr. M. Manco Dr. D. Gniuli Dr. C. Guidone Dr. A. Iaconelli Dr. L. Leccesi Mrs. A. Caprodossi
ASSE ENTERO-INSULARE Effetto insulinotropico: 60% della funzione ß-cellulare GIP GLP-1 FOREGUT HYPOTHESIS HINDGUT HYPOTHESIS
Annual inpatient and outpatient bariatric case volume. Geoffrey P. et al. Recent trends in bariatric surgery case volume in the United StatesS urgery Volume 146, Issue 2 2009 375-380 JAMA. 2005;294(15):1909-1917. < 1% of morbidly obese subjects is operated in the US
Before BPD 4 years after BPD
APOLLO 13 1970 RYGB 1968 Shuttle Ferry space shuttle Enterprise 2012
Mechanisms of diabetes remission Acute calorie restriction Weight loss Incretin effect Bile acid metabolism Altered microbiota
Marco Castagneto Istituto di Clinica Chirurgica Università Cattolica S. Cuore Roma