Luigi Angrisani

Direttore – UOC di Chirurgia Generale ed Endoscopica

Ospedale “S.Giovanni Bosco” ASL Napoli 1 Centro

Presidente-Federazione Mondiale per la Chirurgia Bariatrica e Metabolica (IFSO)

III WORKSHOP CONGIUNTO SICOB – SID – SIO

CONFRONTO TRA LE DIVERSE

TECNICHE NEL TRATTAMENTO

CHIRURGICO DEL DIABETE TIPO 2

Where is the increase in diabetes occurring? Where is the increase in diabetes occurring?

Gregg EW, Cheng YJ, Narayan KM, et al. Prev Med. 2007;45:348-52.

Diabetes Care 2010;33:S4.

American Diabetes Association Clinical Practice Recommendations 2010.

In overweight and obese insulin-resistant

individuals, modest weight loss has been shown

to reduce insulin resistance. Thus, weight loss is

recommended for all overweight or obese

individuals who have or are at risk for diabetes.

ANTI-OBESITY PROCEDURES

N=1956

Jan 1996- Dec 2013

BIB N=475

OBALON N=8

LAP-BAND

N=342

DUODENAL SWITCH N=16

SLEEVE N=596

BYPASS N=510

BPD N=9

LAP-BAND

BYPASS

DUODENAL SWITCH

BPD

SLEEVE GASTRECTOMY

OBALON

BIB

ANGRISANI 2014

0

100

200

300

400

500

600

BIB LAP-BAND SLEEVE BYPASS BPD-DS

N= 111 BARIATRIC PROCEDURES IN N=95

OBESE TYPE II DIABETIC PATIENTS

Jan 1996- Dec 2013

Obese &T2DM

patients

All Obese

patients

ANGRISANI 2014

342

596

510

25

475

2

18 11 43 38 1

0 2 0 3

Obese with

BMI <35

&T2DM

patients

0

20

40

60

80

100

120

140

160

“S. GIOVANNI BOSCO” EXPERIENCE

N=1399 Pts

2000 2009 2003 2001 2002 2011 2010 2012 2013 2004 2005 2006 2007 2008

ANGRISANI 2014

Gastric Banding

Gastric Bypass

Sleeve Gastrectomy

Tutte le tecniche chirurgiche e

parachirurgiche in grado di procurare calo

ponderale comportano la remissione

parziale o completa del Diabete Mellito di

tipo 2.

CHIRURGIA BARIATRICA E

DIABETE MELLITO

ANGRISANI

2014

La percentuale di successo

(remissione/cura) del Diabete Tipo II nei

pazienti obesi è direttamente proporzionale

al BMI di partenza: ottimale negli Obesi

Patologici e Super Obesi

CHIRURGIA BARIATRICA E

DIABETE MELLITO

ANGRISANI

2014

Il recupero del peso perso nei Diabetici

Obesi sottoposti con successo a Chirurgia

Bariatrica comporta la ripresa della malattia

CHIRURGIA BARIATRICA E

DIABETE MELLITO

ANGRISANI

2014

PRE-

CHIRURGICHE (I LIVELLO)

PALLONE AD

ARIA

PALLONE AD

ACQUA PRE-

CHIRURGICHE (II LIVELLO)

CHIRURGICHE (I LIVELLO)

BENDAGGIO

GASTRICO

GERARCHIA DELLA CHIRURGIA DELL’OBESITA’

GERARCHIA DELLA CHIRURGIA DELL’OBESITA’

BYPASS

GASTRICO

CHIRURGICHE (IV LIVELLO)

CHIRURGICHE (II LIVELLO)

DIVERSIONE BILIOPANCREATICA / DUODENAL SWITCH

CHIRURGICHE (III LIVELLO)

GASTRECTOMIA

VERTICALE

The Lancet Diabetes & Endocrinology in press

The Lancet Diabetes & Endocrinology in press

The Lancet Diabetes & Endocrinology in press

OBES SURG 2012

SOARD 2012

SOARD 2012

• 33 morbidly obese T2DM patients underwent LSG

• Of the super obese patients, 7 underwent

biliopancreatic diversion 1 year after LSG and 2

others did after 36 months because of

insufficient weight loss irrespective of T2DM

remission

• 11 patients did not achieve 5 years follow-up.

Lee WJ, et al. Arch Surg 2011;146:143–8.

Annals of Surgery October 2013

Annals of Surgery October 2013

Among the surgical procedures, the glycemic outcomes were significantly better after

RYGB.

Remission rate of T2DM after RYGB vs LSG (P = 0.006), RYGB vs LAGB (P<0.001), and LSG

vs LAGB (P=0.04).

Annals of Surgery October 2013

Annals of Surgery October 2013

•Our study reports durable weight loss in type 2 diabetic patients with an overall T2DM

remission rate (complete and partial) of 50% with a median follow-up period of 6 years

after bariatric surgery.

•Although the term “cure” with respect to T2DM is still controversial, our study

demonstrated that 24% of all patients and 31% of gastric bypass patients achieved long-

term complete remission with an A1C less than 6.0% and that 27% of the gastric bypass

patients sustained that level of glycemic control off medication continuously for more

than 5 years.

Rates of Remission of Diabetes

Adjustable

Gastric Banding

Roux-en-Y

Gastric Bypass Biliopancreatic

Diversion

Buchwald H. JAMA, 2004

48% (Slow)

84% (Immediate)

>95% (Immediate)

CONCLUSIONI

Annals of Surgery October 2013

Lancet Diabetes Endocrinol Feb 2014

Randomised trials of surgical versus medical or lifestyle interventions, or

both, for type 2 diabetes and obesity

Lancet Diabetes Endocrinol Feb 2014

Lancet Diabetes Endocrinol Feb 2014

•The Diabetes Surgery Summit recommends surgery for patients with class 1 obesity

(BMI 30–35 kg/m²) only in cases where all medical and lifestyle interventions for type

2 diabetes have failed.

•The International Diabetes Federation deems surgery reasonable for patients with

class 1 obesity and type 2 diabetes who have failed to respond adequately to just

lifestyle changes and two oral antidiabetic drugs, placing surgery on the same

algorithmic level as thiazolidinediones, dipeptidyl peptidase-4 inhibitors,acarbose,

and basal insulin.

•Several communications have reported that regardless of BMI complete or

partial remission of type 2 diabetes mellitus (T2DM) is possible.

•These results mostly occur before weight loss, positioning metabolic surgery as

a good tool for controlling the current T2DMepidemic.

•Medical treatment is evolving, but is expensive and not risk-free.

•Surgery aimed mainly at diseases such as diabetes and not weight loss are

referred to as “metabolic surgery.”

•Metabolic surgery has been proven to be safe and effective and can effectively

treat T2DM in individuals with any BMI, including that below 35 kg/m2.

OBES SURG 2013

OBES SURG 2013

Dixon JB, O’Brien PE, Playfair J, et al. JAMA 2008

OBES SURG 2013

META-ANALYSIS

- 13 studies selected

- 357 patients evaluated.

-Bariatric procedures performed

Laparoscopic Roux-en-Y gastric bypass (4 studies)

Duodenal-jejunal bypass (3 studies)

Bilio-pancreatic diversion (3 studies)

Laparoscopic mini-gastric bypass (2 studies)

Laparoscopic ileal interposition with diverted sleeve gastrectomy (1 study)

Total weight loss 17.23 kg (p<0.00001).

Mean BMI reduction 5.18 kg/m2 (p<0.00001).

80% patients reached a HbA1c value <7% and these patients were off

T2DM medications.

Mean reduction in fasting plasma glucose levels was -4.4mmol/L (p

<0.00001)

mean reduction of HbA1c was 2.59% (p<0.00001) in 11 studies.

These important effects on glucose metabolism were accompanied by a

significant reduction in LDL-cholesterol and triglycerides levels.

A Position Statement from the International Federation for

the Surgery of Obesity and Metabolic Disorders (IFSO)

Luigi Angrisani

Director General and Endoscopic

Surgery Unit

S.Giovanni Bosco Hospital, Naples, Italy

Incoming President IFSO

BARIATRIC SURGERY IN CLASS I OBESITY.

Laparoscopic Adjustable Gastric Band (LAGB)

Roux-en-Y Gastric Bypass (RYGB)

Biliopancreatic Diversion (BPD)

Vertical Sleeve Gastrectomy (VSG)

BMI> or <35 & Type 2 Diabetes

Mini Gastric Bypass

Ileal interposition

“My daddy is a doctor and he treats

diabetes.”

“My daddy is a surgeon and he

cures it.”

Is T2DM a Surgical Disease?

Courtesy of Walter Pories, MD

•I dati riportati nell’annuario statistico ISTAT 2012 indicano che è diabetico il 5,5%

degli italiani (5,5% delle donne e 5,4 % degli uomini)

•Circa 3.000.000 di persone affette

DM TIPO 2:PREVALENZA IN ITALIA