1. Efecto metabólico de la manga gástrica Camilo Boza MD FACS Assitant Professor of Surgery Pontificia Universidad Católica de Chile

3. clinicaltrials.gov Bariatric surgery for the treatment of Diabetes

4. Diabetes Resolution

5. Co-morbid conditions after Gastric Bypass BMI >35 n:1500 Preoperative (%) 1 year (Res/Imp) 5 year (Res/Imp) Hypertension 35.8 60/32 60/30 T2 Diabetes 11.5 76/20 80/20 Insulin resistance 60.4 88/11 100/0 Dyslipidemia 55 87/12 93/7

6. Restrictives techniques Weight loss Weight loss Hormonal effect AGB Sleeve

7. Wilcoxon Sign-Rank Test—Geometric mean (interquartile range). Dixon et al. Diabetes Care . 2002;25:358-363 .

8. Resolution of Diabetes Metanalysis n: 22.400 Total LAGB GBP BPD/DS % Resolved 82.1 55.3 80.5 99.4 % Resolved or Improved 100.0 – 100.0 – % Improved 20.4 – 20.4 – % Unchanged 0.3 – 0.0 0.7 Insulin (pml/L) -98.0 -99.6 -40.2 -125.0 HbA1c (%) -2.1 -1.4 -2.2 – Glucose (mmol/L) -4.4 -2.5 -3.9 -5.4

9. Boza et al, Surgical endoscopy 2009

10. Boza et al, Surgical endoscopy 2009

11. Sleeve gastrectomy Restriction Fast gastric emptying Rise in gut hormones Role of Ghrelin

12. % Diabetes Resolution Vidal, Lacy , Obesity Surgery 2007 BMI:49

13. % Diabetes Resolution Sleeve gastrectomy versus Bypass Boza et al, ASMBS 2010

14. Sleeve gastrectomy versus Bypass Boza et al, ASMBS 2010 Bypass Sleeve Pre Res Imp Pre Res Imp Chol ≥ 200 mg/dL 44,2 71,2 0,0 41,9 47,1 0,0 Trygl ≥ 150 mg/dL 40,7 71,4 0,0 42,0 65,7 0,0 IR 47,3 93,5 5,5 33,6 81,0 16,2 Arterial Hyp 26,8 58,2 22,3 23,5 57,5 34,8 T2DM 5,5 86,6 6,6 3,9 90,9 9,1

15. Diabetes Resolution Basso, Surg Endosc 2009

16. % Diabetes Resolution Basso, Surgical endoscopy 2009

17. % Diabetes Resolution Shaa, SOARD 2009 36 months after surgery

18. % Sleeve Gastrectomy and Diabetes Shaa, SOARD 2009 36 months after surgery

19. % Sleeve Gastrectomy and Diabetes Shaa, SOARD 2009 36 months after surgery

20. Why ?

21. % Melissas Vaciamiento Melissas, Obesity Surgery 2007 T1/2 Gastric Emptying

22. PYY after Sleeve and Bypass Valderas, 2009 SOARD 2009 Bypass Sleeve Med Treat

23. Glp1 Melissas Vaciamiento Peterli, Annals of Surgery 2007 Bypass Sleeve

24. GLP1 after Sleeve and Bypass Valderas, Boza 2010 Bypass Sleeve Med Treat

25. AUC for GLP1 after Sleeve and Bypass Valderas, Boza 2010

26. Sleeve gastrectomy as a Metabolic Surgery Camilo Boza MD FACS Assitant Professor of Surgery Pontificia Universidad Católica de Chile

27. Guess the BMI BMI 42. No metabolic Syndrome

28. Guess the BMI BMI 30. Metabolic Syndrome and Diabetes

29. Sleeve gastrectomy for the treatment of T2DM in patients with BMI 30-35 n:12 Age (years) 47,4 (21-59) Male Gender (%) 9 (75%) BMI (kg/m2) 33,7 (32,1-34,6) Glucosa (mg/dl) 137 (83-187) Years of Diabetes 2,5 (1-7) HA1C (%) 7,3 (6,3-8,9)

30. Sleeve gastrectomy for Diabetes in BMI 30-35 n:12 Preop 1 año Postop ∆ p BMI (kg/m 2 ) 33,7 (32,1-34,6) 27,5 (21,8-30) - 6,2 0,01 Medication % 75 17 - 58 --- Glucosa (mg/dl) 137 (83-187) 93,5 (80-172) - 43,5 0,01 Hb A1c (%) 7,3 (6,3-8,9) 5,8 (4,9-6,9) - 2,4 0,06 Homa - IR 6,46 (1,6-14,2) 1,8 (1,7-6,5) - 4,7 0,06 Insulin 25,4 (9,3-45) 9,9(6,7-16,9) -15,5 0,04

31. 12 Month Diabetes resolution Resolution (HbA1c normal sin medicación) 70% Better control 13,3 % No change 16,7%

32. BMI evolution for Sleeve 30-35

33. Bypass versus Sleeve for Diabetes BMI 25-35 BMI 25-35 Lee, 2012