This talk was given to General Practioners about Bariatric Surgery

1. Javed Iqbal,
FCPS, FRCS
Professor of Surgery
Quaid-e-Azam Medical College,
Bahawalpur, Pakistan

2. What's new in surgery
for the Diabetics

3.  “240 million people worldwide are living with
diabetes;
 380 million by 2025”
 “It kills one person every 10 seconds”

4. The usual domain of the surgeons in
Diabetes
 Diabetic foot
 Infections.
 Neuropathies.
 Vascular narrowing

5. The Surgical Cure of
Diabetes

6. The Key Questions.
 Is there a surgical cure?
 Can we cut out Diabetes?

7. Background.
 The Historical Perspectives of gastrointestinal
anastomosis.
 The Rebirth of Bariatric surgery

8. Metabolic Surgery
Treatment of metabolic derangements with
alterations of the gut anatomy
remission of diabetes

9. The Evidence
 There is overwhelming evidence indicating
that several types of bariatric operations
promote profound weight loss and cause
complete remission of type 2 diabetes.
Pories and Swanson, Ann surg 222:339-350
Sjostrom and Larsonet al NEJM 357: 741-752

10. Association of Diabetes and Obesity
DIABETES + OBESITY = DIABESITY
DIABETES OBESITY 90%
WEIGHT LOSS
T2D
WEIGHT GAIN T2D

11. How can we correct it ?
 Dietary control
 Lifestyle changes.
 Medical management

12. Why Surgery ?
 Non Surgical methods of weight loss are
associated with higher failure rates.
 NIH consensus Panel 1991 recommendation:
“Surgery is the only long term sustainable
weight loss method”
 *American Diabetic association has also
recommended weight loss surgery in
Diabetics with BMI 35 or above.
 *ADA clinical practice recommendations 2008

13. Benefits of surgical weight loss
(morbidity and mortality improvement)
 Weight loss is associated with resolution of
co morbidities.
◦ DM=>80%
◦ Hypertension=>60%
◦ Hyperlipidemia=>60-95%
◦ Obstructive Sleep Apnoea => 80-80%
◦ Pories and Swanson, Ann surg 222:339-350
 Swedish obese subjects study shows clear benefit
of survival for surgery patients from
cardiovascular events.(24%)
 Sjostrom and Larsonet al NEJM 357: 741-752

14. BARIATRIC SURGERY AND
DIABETES
 Bariatric patients would have a sustained
weight loss and thus would have a complete
resolution of diabetes
 T2D even if are not obese still would achieve
resolution after SG or GBP
Schauer&Burguera AnnalsSurgery 2003;238:467-84
Gann ss& Horgensen ANZ J Surgery 2007;77:958-62

15. BARIATRIC SURGERY
 Gastric Banding
 Sleeve Gastrectomy
 Gastro-Biliary Bypass

16. Bariatric Surgeries

17. Mechanisms of Diabetes Resolution
after Gastrointestinal Bypass
Surgery
Enhanced secretion of something good for
glucose homeostasis ?
Reduced production of something bad for glucose
homeostasis ?

18. What is The Mechanism?
 Sudden reduction in caloric intake
 Reduced Ghrelin Levels
 Increased production of bile acids
BA + TGR 5 c AMP dependant THAE Increased Energy Expenditure

19. The Query
Weight loss surgery patients experience a
reduction in or resolution of diabetic
symptoms immediately following surgery,
before weight loss has had a chance to take
place.

20. THE ANSWER
The Immediate control
The Entero insular Axis
 The Francesco Rubino Experiment.
The Foregut Hypothesis
 The Hindgut Hypothesis
The role of GLP-I& GIP

22. The exclusion of the
duodenal nutrient
passage may offset an
abnormality of
gastrointestinal
physiology responsible
for insulin resistance
and type 2 diabetes

23. Nutrients reach the distal
ileum within 5 min of the
ingestion of food and this
stimulates the secretion of
GLP1 by L cells
located in this area

24. The Entero Insular Axis
Anti-Incretins DPP-4
INCREASED INSULIN AVAILABILTY
GLP-1 Insulin Production
Incretins GIP b-cell Neogenesis
PYY Statiety.

26. THE ANSWER
Long Term Resolution
Decreased adipose tissue leads to
modulation of the Adipo Insular Axis
Adipocytokines.
Leptin.
Adiponectin. Decreased Insulin Resistance
Resistin.

27. The Net Effect
 Decreased insulin destruction
 Increased Insulin Production
 Decreased Insulin Resistance

28. WHO WOULD HAVE
THOUGHT IT?
An Operation Can be The most
effective Therapy For Adult Onset
Diabetes Mellitus

29. Where do we stand?

30.  Workshop in Rome
 Workshop with Mufazzal Lakhdawala
 Spent some time with Prof. Mumtaz Maher
 Extensive hands of course with Prof Karl
Miller
 Acquired all necessary equipments
 Extensive training hand-swen gut surgery
 Developed a team
 Regularly performing sleeve gastrectomy

36. How much it costs?
Nothing is more costly than a healthy
life