3. No Disclosures

4. Laparo-Obeso Centre
‘Metabolic Surgery’ is here to stay
RCTs : STAMPEDE –Shauer et al
:MINGROVE et al
Long Term results: COHEN ET AL
Newer STUDIES: COSMID

5. Laparo-Obeso Centre
COSMID
Randomized Controlled Trial
Comparison Shah SS- Ruby Hall Clinic , Pune.
Of Cummings DE- Washington University,
USA
Surgery vs.
Kim K –Celebration Hosp, USA
Medicines Buffington C –Celebration Hosp, USA
for
Indian Yajnik CJ – KEMH, Pune
Diabetes Phadke U –Ruby Hall Clinic, Pune

6. Laparo-Obeso Centre
METABOLIC PROCEDURES:
SG
IT
SGIT
DJB
DJB + SG
EDOLUMINAL SLEEVE
SG + Duodeno-ileostomy
SG + Enterectomy
MGB
GBP
BPD

7. Laparo-Obeso Centre
Sleeve Gastrectomy- Other Gastric Pouches:
Physiological Restriction, -Restriction,
Rapid Transit. -Dumping

8. Laparo-Obeso Centre
BENEFITS OF GASTRIC COMPONENT:
•Restriction,
•Increase Transit,
•Vagotomy,
•Ghrelin,
•Duodenal exclusion,
or
Modified stimulation
•Change in ‘ph’ of chyme,
•?Change in microflora.

9. Laparo-Obeso Centre
Metabolic Surgery for Type II DM:
Diabetes  Gastroparesis
GLP 1  Physiological Gastroparesis
? Gastric Atony / Dilatation
? Only Intestinal Procedure
Stomach 
 ? Pacemaker for
intestines

10. Laparo-Obeso Centre
Prospective controlled study of effect of laparoscopic
sleeve gastrectomy on small bowel transit time and gastric
emptying half-time in morbidly obese patients with type 2
diabetes mellitus
Shashank Shah, M.S., Poonam Shah, M.D.,
Jayashree Todkar, M.S., Michel Gagner, M.D.
Conclusion:
A decreased gastric emptying half-time and SBTT after SG
can possibly contribute to better glucose homeostasis in
patients with T2DM.
SOARD March 2010 138-141

11. Markedly reduced fasting and postprandial
ghrelin levels in addition to increased PYY
levels after LSG are associated with
greater appetite suppression and excess
weight loss as compared with LRYGBP
…………… prospective , double blind study.
Ann Surg 2008 March 247
Karamanakas
Laparo-Obeso Center

12. PYY(3-36)
• DPP IV activity is increased in obese
• Obesity decreases both basal and meal stimulated PYY
levels.
• Specific Y2 receptor agonist
• Suppresses appetite and stimulates weight loss through
hypothalamic mediated mechanism
• Increases insulin sensitivity (Van den Hoek et al Am J Physio Endocrino,Met ab 2007)
PYY levels increase after
SG Laparo-Obeso Center

13. SG MECHANISMS

14. Laparo-Obeso
Sleeve Gastrectomy:Mechanisms-
Centre
volume (restriction) • GLP
Restriction by pylorus • Satiation
Ghrelin (fasting and meal • Gastric emptying
stimulus)
• Small bowel
PYY transit time
All Complimentary to Intestinal ………..
Anti-Diabetic effects

15. Laparo-Obeso Centre
GASTRIC COMPONENT:
Sleeve Gastrectomy for Type II DM
SG  CAN BE CONVERTED 
Gastric Component Preserved
&
Intestinal Component Added.

16. Laparo-Obeso Centre
A ‘Gastric’ Component is essential for
better outcomes of Metabolic Surgery

17. Laparo-Obeso
Centre
T
H
A
N
K
Y
O
U