iii workshop congiunto sicob sid sio · iii workshop congiunto sicob ... parachirurgiche in grado...
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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
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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.
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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.
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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
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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
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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
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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
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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
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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
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PRE-
CHIRURGICHE (I LIVELLO)
PALLONE AD
ARIA
PALLONE AD
ACQUA PRE-
CHIRURGICHE (II LIVELLO)
CHIRURGICHE (I LIVELLO)
BENDAGGIO
GASTRICO
GERARCHIA DELLA CHIRURGIA DELL’OBESITA’
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GERARCHIA DELLA CHIRURGIA DELL’OBESITA’
BYPASS
GASTRICO
CHIRURGICHE (IV LIVELLO)
CHIRURGICHE (II LIVELLO)
DIVERSIONE BILIOPANCREATICA / DUODENAL SWITCH
CHIRURGICHE (III LIVELLO)
GASTRECTOMIA
VERTICALE
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The Lancet Diabetes & Endocrinology in press
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The Lancet Diabetes & Endocrinology in press
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The Lancet Diabetes & Endocrinology in press
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OBES SURG 2012
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SOARD 2012
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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.
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Lee WJ, et al. Arch Surg 2011;146:143–8.
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Annals of Surgery October 2013
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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).
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Annals of Surgery October 2013
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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.
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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)
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CONCLUSIONI
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Annals of Surgery October 2013
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Lancet Diabetes Endocrinol Feb 2014
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Randomised trials of surgical versus medical or lifestyle interventions, or
both, for type 2 diabetes and obesity
Lancet Diabetes Endocrinol Feb 2014
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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.
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•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
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OBES SURG 2013
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Dixon JB, O’Brien PE, Playfair J, et al. JAMA 2008
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OBES SURG 2013
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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)
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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.
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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.
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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
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“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
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•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