22/10/2013 1 Nieuwe chirurgische technieken: what the future holds

22/10/2013 1 Nieuwe chirurgische technieken: what the future holds

22/10/2013
Nieuwe chirurgische
technieken:
what the future holds
Future is the end of an evolution
•
•
•
•
What is the evolution?
Future is surgery?
Which surgery?
When surgery?
OBESITY
Mechanical
Rationale
BARIATRIC
SURGERY
Matthias Lannoo
Abdominale heelkunde
VBG/MASON
BARIATRIC
SURGERY
DISEASE
Behavioral
problem
- Genetically determined
- Metabolic alteration
- Chain reaction
- Exces lipid =catalysator
NEUROHORMONAL
by modification of the
gastrointestinal tractus
Gastric banding
NEUROHORMONAL
by modification of the
gastrointestinal tractus
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Evolution of Bariatric surgery in Belgium
BANDING
GASTRIC BYPASS
Mechanical view
Gut talks to the brain view
RYGBP
Hunger & Satiety
Hunger & Satiety
“Atkinson’s experiment”
PYY and GLP-1 levels after RYGB in rats
Hunger & Satiety
PYY and GLP-1 levels after RYGB in humans
PYY
p<0.001
GLP-1
Sham
Bypass
p<0.001
Atkinson RL et al, Am J Physiology 1982
Bueter M et al, Physiology & Behaviour 2011
Le Roux CW et al, Ann Surg 2006 & 2007
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Hunger & Satiety
during Food restriction
p<0.001
p<0.001
p<0.01
p<0.01
p<0.001
MECHANISMEN: DIABETES
Hunger & Satiety
after Food restriction
Blocking gut hormones with Octreotide
RYGB
Islet
Insulin deficiency
LAGB
p<0.001
Pancreas
Alpha cell
produces
excess
glucagon
Excess
glucagon
Diminished
insulin
Beta cell
produces
less insulin
Diminished
insulin
Hyperglycemia
Muscle and fat
Liver
Sham ad lib
Excess glucose output
RYGB ad lib RYGB food restricted
Bueter M, Lutz TA, le Roux CW et al., unpublished
MECHANISMEN: DIABETES
Food preference in Sleeve
 Insulin
Ingestion
of food
GI tract
Le Roux CW et al, Ann Surg 2006 & 2007
SLEEVE GASTRECTOMIE
Glucose dependent
Insulin resistance
(decreased glucose uptake)
from beta cells
(GLP-1 and GIP)
Release of
incretin gut
hormones
Active
GLP-1 and GIP
Pancreas
Beta cells
Insulin
increases
peripheral
glucose
uptake
Blood
glucose control
Alpha cells
 Glucagon
Increased insulin
and decreased
glucagon
reduce
hepatic
Adapted from Brubaker PL, Drucker DJ Endocrinology 2004;145:2653–2659; Zander M et al Lancet 2002;359:824–830;
glucose output
Ahrén B Curr Diab Rep 2003;3:365–372; Buse JB et al. In Williams Textbook of Endocrinology. 10th ed. Philadelphia,
from alpha cells
(GLP-1)
Glucose dependent
Saunders, 2003:1427–1483.
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RESULTATEN: DIABETES
Is sleeve gastrectomy restrictive
Is Sleeve gastrectomy restrictive?
• R
RYGBP
DURATION OF DIABETES IS IMPORTANT
Rosenthal et al Surg Obes Relat Dis
2009 Epub corrected proof
SLEEVE
REMARKABLE ANALOGY WITH RYGBP
Karamanakos et al Ann of Surg 2008;247(3):401-7
20
Nicola Basso OBES SURG (2010) 20:50–55
DUMPING
DUMPING
early
late
high calory
adequate
neg feedback
+ weightloss
feedback is difficult
information is important
normal food
Hypoglycemia
Nesidioblastosis
inadequate
anorexia
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Dumping and RYGB
Marginal Ulcera
- Incidence : 1.5 % - 12 %
- Symptoms
- epigastric pain
- anemia
- perforation
- pouch – gastric fistula
Cave : NSAID
hypoglycemia after RYGB
Laparoscopic Conversion of the Gastric Bypass
into a Normal Anatomy
Jacques Himpens,MD;Giovanni Dapri,MD;Guy Bernard Cadière,MD,PhD
Gastric Bypass: complications
-
gastric stenosis
marginal ulcera
internal obstruction + SBO
gastric pouch dilation
Dumping
Vitamin deficiencies
MARGINAL ULCERA
CAVE
HELICOBACTER PYLORI
COCA COLA
NSAID’S
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Internal Hernia + SBO
incidence : 0 – 8 % after laparoscopic procedures
diagnosis : CT - scan
DUMPING
Interne hernia
• Pijn li hypochonder, dysfagie nausea, zelden braken!
• CT toont slechts indirecte tekens of niets
DUMPING
early
late
high calory
feedback is difficult
information is important
adequate
neg feedback
+ weightloss
• Drempel exploratieve laparoscopie is
normal food
Hypoglycemia
Nesidioblastosis
inadequate
ZEER LAAG
late dumping early?
OGTT
Laparoscopic Conversion of the Gastric Bypass
into a Normal Anatomy
Jacques Himpens,MD;Giovanni Dapri,MD;Guy Bernard Cadière,MD,PhD
Glycemia < 60 mg/dl
250
Glycemia (mg/dl)
Dumping gewenst of complicatie?
anorexia
HR > 10 bpm
200
Htc + > 3%
150
100
50
0
0
30
60
90
120
150
180
Time after glucose ingestion (min)
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RYGB
• Diet is healthiest of all bariatric surgery patients
MALABSORPTION after RYGB
“doctor: I’don’t like burgers anymore”
• There is restriction but no vomiting
• Especially fat malabsorption
• Enhanced by longer biliopancreatic limb
• Carbohydrate are absorbed in the roux limb and as FFA in
• But some patients make diet mistakes
the colon
• DIET DEPENDENT (to fat)
Sleeve
• Diet is healthiest of all bariatric surgery patients
“doctor: I don’t like burgers anymore”
• There is restriction but no vomiting
• But some patients make diet mistakes
• Dumping is far more less
D'Hondt M, et al. Surg Endosc. 2011 Aug;25(8):2498504.
37
Biliopancreatic diversion
38
39
D'Hondt M, et al. Surg Endosc. 2011 Aug;25(8):2498-504.
MALABSORPTION
Biliopancreatische diversie
- elongation common limb ( 150 – 180 cm )
- conversion to gastric bypass
AL
BPL
CL
Scopinaro
Duodenal switch
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INDICATIONS : <35 BMI type 2 DM
“MINI” gastric bypass
Banded gastric bypass
LAGB vs RYGBP BMI 30<>35 DM TYPE 2
% resolution
3-6 months
6-12 months
3-6 months
6-12 months
RYGBP
50
55,2
BMI
27,2
27,1
Lap Banding
31,8
27,5
31
30,9
P
0,0579
0,0199
<0,0001
0,0002
•
Adjustable or non adjustable
•
Restriction
•
Incretin effect is
transit time higher
•
Vomiting
From Sites Participating in the ASMBS BSCOE Program as Reported in the BOLD
Eric J. DeMaria, MD, Walter J. Pories, MD¶ Annals of Surgery • Volume 252, Number 3, Sept. 2010
Endobarrier
Plasma Bile Acid Profile after RYGB
ILEAL INTERPOSITION
• Higher plasma bile acids after RYGB (although exact
mechanism unknown)
• Correlated with better metabolic profile
• Bile acids increase energy expenditure in BAT1
1 Watanabe et al., Nature 2006
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Results Ileal interposition
Results Ileal interposition
ILEAL INTERPOSITION
An ileal interposition with a diverted sleeve gastrectomy is an
effective operation for the treatment of type 2 diabetes mellitus
patients with BMI 21-29.
49
50
Depaula AL, Surg Endosc 2008 Oct 2.
WEIGHT LOSS is IMPORTANT
gastric plication
Failed conservative treatment
SURGERY
WEIGHT REGAIN IS STRONGLY ASSOCIATED WITH RELAPSE OF DM
Lower preoperative BMI is also contributing factor
Possible mechanisms:
-Increased calory intake
-Increased fat mass
-Adaptation of the gut
Further research is needed
BANDING OF THE
GASTROJEJUNOSTOMY
Surg Obes Relat Dis. 2010 DiGiorgi M, Bessler M.
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CONCLUSION
• EVOLUTION =
o
o
o
Better characterization of the metabolic patient(not BMI)
Patient tailored surgery
Better follow up
FUTURE = SURGERY
SLEEVE GASTRECTOMIE
KNOWLEDGE
• FUTURE =
o
o
Disease and patient specific
Less invasive techniques/ pharmcotherapy
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