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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)!
EU 17.8 25.1 41%
NA 19.7 33.9 72% LAC 13.3 33.0 148% SSA 7.1 18.6 161
%
Wild. S et al.: Global prevalence of diabetes: Estimates for 2000 and projections for 2030 Diabetes Care 2004 MEC 20.1 52.8 163% China 20.8 42.3 104%
India 31.7 79.4 151% World 2000 = 171 million 2030 = 366 million Increase 1 13% 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
MALASSORBITIVI
RESTRITTIVI
ü  Bendaggio gastrico
ü  Bypass gastrico
ü  Gastroplastica verticale
Alternativi
ü  Bypass digiunoileale
ü  Diversione biliopancreatica
ü  Bypass bilio-intestinale
ü  Palloncino intragastrico (BIB)
ü  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
ü  confezionamento di piccola tasca gastrica 20-30 ml sezione dello stomaco
ü  gastrodigiunostomia di 10-25 mm
ü  ansa alimentare alla Roux di 40-150 cm
ü  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.
ü  ansa alimentare di 200 cm o 250-300 cm, ansa comune di 50 cm o 75 cm o 100 cm
ü  gastrectomia orizzontale parziale (400- 500 ml) o verticale (“duodenal switch”)
ü  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 Dixon, J. B. et al. JAMA 2008;299:316-­‐323 Inclusion criteria Age: 20 – 60 years T2DM with HbA1c > 7% BMI: 27-­‐43 kg/m2 Primary Endpoint Proportion of patients with HbA1c ≤ 6% with or without diabetes medications 12 months after randomization 218 patients screened At the Cleveland Clinic 150 patients randomized To RYGB, SG, intensive medical therapy Inclusion criteria Age: 30 – 60 years T2DM with HbA1c ≥ 7% BMI: ≥ 35 kg/m2 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) 72 subjects screened HbA1c ≥ 7.5 % Duration of Diabetes ≥ 5 years 8 excluded after a brief explanation of the study 2 ineligible due to serious complications of diabetes 2 Geographical distance precluded involvement 20 assigned to medical treatment 1 withdrew after 1 month 1 withdrew after 3 months 18 completed the study 60 eligible subjects HbA1c ≥ 7.5 % 20 assigned to BPD 1 incisional hernia after 9 months 19 completed the study 20 assigned to RYGB 1 intestinal occlusion after 6 months 19 completed the study 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). Given that bariatric surgery is associated with both post-­‐operative mortality, ranging from 0.1 to 2% in relation to the type of bariatric operation, and with early and late complications (NEJM 2004), it cannot be extended to totality of obese and diabetic patients. Mechanisms of diabetes remission Weight loss Bile acid metabolism Acute calorie restric3on Incre3n effect Altered microbiota EUGLYCEMIC HYPERINSULINEMIC
CLAMP
Diabetologia 1997;40:599-605
M (µmol/kg/min)
120
100
80
60
40
20
0
1
2
3
Pre-BPD Post-BPD Pre-Diet
4
Post-Diet
80
Insulin sensitivity
(umol/kg/min)
70
60
50
CONTROLS ± 1 SD 40
30
20
10
0
0
5
10
15
20
25
Time after Surgery (months)
Blue diamonds = RYGB
Red dots = BPD
Am J Med. 2005 ;118:51-­‐7 30
Lean!
RY-GB!
BPD!
Insulin sensitivity!
(µmol.min-1 .kg-1)!
80
70
60
50
40
30
20
10
0
15
20
25
30
35
40
BMI (kg.m-2)
45
50
55
60
GLP1 (pmol/l)
RYGB
BPD
100
90
80
70
60
50
40
30
20
10
0
0
100
50
Time (minutes)
90
80
GLP1 (pmol/l)
100
70
60
50
40
30
20
10
0
0
50
100
Time (minutes)
150
200
150
200
CONCLUSIONI
Ø  La chirurgia metabolica è efficace nel normalizzare
il metabolismo glucidico nel paziente obeso e in
quello con BMI < 35
Ø I meccanismi
di
risoluzione del diabete sono
peculiari per ciascun tipo di intervento
Ø  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
FOREGUT
HYPOTHESIS
GLP-1
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 -­‐ JAMA. 2005;294(15):1909-­‐1917. 380 < 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 Weight loss Bile acid metabolism Acute calorie restriction Incretin effect Altered microbiota Marco Castagneto
Istituto di Clinica Chirurgica
Università Cattolica S. Cuore
Roma