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Metabolic Sequelae of Bariatric Surgery Dr Sumeet Shah Laparoscopic & Bariatric Surgeon Sir Ganga Ram Hospital

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Metabolic Sequlae of Obesity Surgery

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Page 1: Bariatric Surgery

Metabolic Sequelae of Bariatric Surgery

Dr Sumeet ShahLaparoscopic & Bariatric Surgeon

Sir Ganga Ram Hospital

Page 2: Bariatric Surgery

WEIGHT LOSS SURGERYWEIGHT LOSS SURGERY

Gastric BypassGastric Bypass

Page 3: Bariatric Surgery

Potential Consequences of Obesity

• Obesity is associated with a rise in many comorbid conditions, including:• Type 2 Diabetes• Hyperlipidemia• Hypertension• Obstructive Sleep Apnea• Heart Disease• Stroke• Asthma• Back and lower extremity weight- bearing degenerative problems• Cancer• Depression• AND MORE!

Page 4: Bariatric Surgery

Visceral Obesity

Heart Disease, Stroke Risk

Insulin Resistance & Hyperinsulinemia

Dense LDL HDL Cholesterol

Triglycerides

Source: NAASO, 2005

The emergence of metabolic disease: a direct clinical pathway from obesityThe emergence of metabolic disease: a direct clinical pathway from obesity

Page 5: Bariatric Surgery

Types of Bariatric Surgery

• Purely Restrictive• Gastric Balloons• Sleeve Gastrectomy• Gastric adjustable banding

• Restrictive > Malabsorptive• Short-limb/Roux-en-Y gastric bypass

• Malabsorptive > Restrictive• Biliopancreatic diversion (BPD)• BPD with duodenal switch• Long limb Roux-en-Y gastric bypass

Page 6: Bariatric Surgery

Weight Loss Benefits vs. Nutritional Risk

0

10

20

30

40

50

60

70

Band Gastroplasty GBP DS

EWLMortalityB12 def

Page 7: Bariatric Surgery

N Engl J Med. May 24 2007;356(21):2176-2183.

Page 8: Bariatric Surgery

Long Term Complications: Nutritional Deficiencies

• Nutritional deficiencies are uncommon with purely restrictive procedures unless• Eating habits are excessively restricted or

complications occur (emesis)• Folate is the most common deficiency after

restrictive procedures

Page 9: Bariatric Surgery
Page 10: Bariatric Surgery

• Hormonal Sequelae - Human body regulates nutrient intake over time by secreting hormones. Over 40 hormones play a role in regulation of feeding.

• Nutritional Sequelae

Metabolic Sequelae

Page 11: Bariatric Surgery

Metabolic Sequelae• Two types:

• Satiety hormones• Short-term• Help regulate meal size; daily intake• Secretion decreases meal size; reduces time to stop• Includes (among others) cholecystokinin, amylin,

glucagon-like-peptide 1 (GLP-1), enterostatin, and bombesin

• Adiposity hormones• Long-term• Related to energy stores• Secretion delays onset of beginning of meal• Includes insulin, leptin

Page 12: Bariatric Surgery

PROTEINS: GHRELIN

• A peptide secreted by Gastric mucosa on an empty stomach (Fasting Ghrelin Levels)

• Also releases growth hormone

• Ghrelin during fasting Appetite Food intake Fat utilization

• In Obesity, GHRELIN LEVELS ARE

Page 13: Bariatric Surgery

GHRELIN..

• Activates appetite stimulating neurons in Hypothalamus

• Short term appetite control

• Overproduction OBESITY• PRADER-WILLI SYNDROME

• Highest level of ghrelin ever measured in humans

Page 14: Bariatric Surgery

GHRELIN

• Ghrelin levels when weight is lost while dieting• Opposes the effect of dieting

• In Gastric Bypass and Sleeve Gastrectomy, GHRELIN LEVEL at least in the short term due to exclusion/ removal of the fundus

Page 15: Bariatric Surgery

Metabolic Sequelae

• Further investigation is needed, but the reason why certain types (i.e., RYGB/ Sleeve) of bariatric surgery are successful at reducing food intake and causing weight loss may be related to enhanced secretion of satiety signals (ghrelin or others).

Page 16: Bariatric Surgery

Role of Incretins

GIP

• Released from K cells in duodenum

• Modest effect on gastric emptying

• No significant inhibition of glucagon secretion

• No significant effects on satiety or body weight

GLP-1

• Released from L cells in ileum

• Potent inhibition of gastric emptying

• Potent inhibition of glucagon secretion

• Reduction of food intake and body weight

Page 17: Bariatric Surgery

Role of Incretins

GIP

• Potential effects on beta cell growth & survival

• Stimulate insulin secretion via beta cell

• Inactivation by DPP-4

GLP-1

• Significant effects on beta cell growth and survival

Page 18: Bariatric Surgery

Regulation of Food Intake

BrainBrain

NPYAGRPgalanin

Orexin-ADynorphinECS/CB1

StimulateStimulateα-MSHCRH/UCNGLP-I

CARTNE5-HT

InibitInibit

Central SignalsCentral Signals

Glucose

CCK, GLP-1,Apo-A-IVVagal afferents

Insulin

Ghrelin

Leptin

Cortisol

Peripheral signalsPeripheral signals Peripheral organsPeripheral organs

+

+

Gastrointestinaltract

Adiposetissue

FoodIntake

Adrenal glands

External factorsEmotions, DrugsFood characteristicsLifestyle behaviorsEnvironmental cues

Page 19: Bariatric Surgery

Modified from Marx, Science 2003 February 7; 299: 846-849. (in News)

Gastrointestinal Peptides Hormones

food intake regulation

digestion and metabolism

Anti-obesity potential

Anti-diabetes potential

Vagusnerve

Ghrelin

InsulinAmylin

Glucagon

Leptin

PYY

GLP-1

CCK

Page 20: Bariatric Surgery

Effect on Comorbid Conditions

• Diabetes• 76.8% - Completely resolved• 86.0% - Resolved or improved

• Hyperlipidemia• 70% - Improved

• HTN• 61.7% - Resolved• 85.7% - Resolved or improved

• Obstructive Sleep Apnea• 83.6% - Resolved• 85.7% - Resolved or improved

Buchwald H, et al. Bariatric Surgery: A Systematic Review and Meta-analysis. JAMA, 14:1724-37, 2004

Page 21: Bariatric Surgery

Metabolic Changes and Diabetes

• Many metabolic changes contribute to improvement and/or resolution of DM

• Recovery of acute insulin response• Decreases of inflammatory indicators (C-reactive

protein and interleukin 6)• Improvement in insulin sensitivity correlated

w/increases in plasma adiponectin• Changes in the enteroglucagon response to

glucose• Reduction in ghrelin levels • Improvement in beta cell function

Page 22: Bariatric Surgery

Risk of Vitamin and Mineral Deficiencies Post-op

• Calcium and Vitamin D• Reduced absorption d/t bypassed duodenum, proximal

jejunum (R-en-Y)• Life-long supplements mandatory

• Iron• Absorption decreased d/t decreased contact of food with

gastric acid; reduced conversion of iron from ferrous to ferric form (MVI)

• Vitamin B12• Absorption decreased d/t decreased contact with intrinsic

factor• 60% of patients require long term supplementation of

B12• Thiamine

• Connection to Wernicke’s syndrome• Cases not well documented

Page 23: Bariatric Surgery

Review: what gets absorbed where?

Page 24: Bariatric Surgery

Recommended managementDietary modification• Reduce food volume consumed, chew food very

well, slow pace of eating• Do not consume fluids with food

• 30 minutes before or after meal• Protein rich-food should be major component of

each meal• Cheese, fish, poultry, eggs & meat• 40-60g/day after RYGB• 60-90g/day after BPD-DS

• Avoid empty calories

Page 25: Bariatric Surgery

Recommended management

Dietary supplements• All patients should receive

• Multivitamin with iron• Vitamin B12, B complex with thiamine • Vitamin C• Calcium

• Additional supplements may be needed for menstruating or pregnant women

• Depending on procedure, patient may need fat soluble vitamin supplements (BPD)

Page 26: Bariatric Surgery

Recommended management

Am J Med Sci. Apr 2006;331(4):219-225.

Page 27: Bariatric Surgery

In Summary……

• Role of Gut and G I hormones • Fat as Endocrine organ• Nutritional Sequlae• Resolution of diabetes mellitus and

improvement in lipid profile central in providing metabolic role to bariatric surgery