Dr C. Rajeswaran FRCP(UK);MSC Consultant Physician Diabetes, Obesity and Endocrinology Chair, National Diabesity Forum

Bariatric surgery Remission or Cure for Diabetes ?

Obesity .. Condition in which body fat has accumulated to such an extent that health may be adversely affected (WHO, 2000)

Edmonton Obesity Staging System (EOSS)

Why do people gain weight?

•Metabolic •Hormonal •Psychological •Social •Genetics •Drug induced

Medical Complications of Obesity

Control of Appetite

Natural History of Diabetes

Years of Diabetes

*IGT = impaired glucose tolerance.

Obesity IGT* Diabetes Uncontrolled Hyperglycemia

Relative -Cell Function

100 (%)

-20 -10 0 10 20 30

PlasmaGlucose

Insulin Resistance

Insulin Secretion

120 (mg/dL)

Adapted from International Diabetes Center (IDC), Minneapolis, Minnesota.

Fasting Glucose

Post-Meal

Glucose

Natural History of Type 2 Diabetes

Glucoregulatory Role of Incretins

Promotes satiety and reduces appetite

-cells: Enhances glucose-dependent

insulin secretion

GLP-1: Glucagon-like peptide 1 Adapted from Flint A, et al. J Clin Invest. 1998;101:515-520; Adapted from Larsson H, et al. Acta Physiol Scand. 1997;160:413-422; Adapted from Nauck MA, et al. Diabetologia. 1996;39:1546-1553; Adapted from Drucker DJ. Diabetes. 1998;47:159-169.

Liver: ↓ Glucagon reduces hepatic

glucose output

a-cells: ↓ Postprandial

glucagon secretion

Stomach: Helps regulate gastric

emptying

GLP-1 secreted upon the ingestion of food

Types of Bariatric Surgery

• Adjustable Gastric Band

• Sleeve Gastrectomy

• Gastric Bypass

• Gastric balloon

• POSE

• Endobarrier

• VGBLOC

Remission of Diabetes?

Defined as:

• Fasting plasma glucose below 7 mmol/L in the absence of

medical treatment for at least 3 days.

• A 2-hour plasma glucose below 11.1 mmol/L following an OGTT.

• HbA1c below 6% after 3 months of last hypoglycemic agent usage.

Hypotheses!for!Diabetic!Control!Through!Bariatric!Surgery 42 a. Foregut!exclusion!hypothesis i. Nutrient!bypass!of!proximal!gut!prevents!secretion!of!GIP!which!promotes!insulin!resistance! ii. Proven!invalid!as!vertical!sleeve!gastrectomy!does!not!bypass!proximal!gut,!yet!still!results!in! diabetes!remission!and!weight!loss!similar!to!RYGB!and!biliopancreatic!diversion b. Hindgut!hypothesis i. Increased!delivery!of!nutrients!to!distal!ileum!causes!exaggerated!GLPM1/PYY!release!through! overstimulation!of!neuroendocrine!L!cells ii. Normalization!of!blood!glucose!within!months!following!duodenal!switch!procedure!without! restrictive!gastric!surgery!in!moderately!obese!diabetic!patients!(mean!BMI!33!kg/m2 ) 43

1. Hypotheses for Diabetic Control through Bariatric Surgery

•Foregut hypothesis •Hind gut hypothesis

2. Bariatric surgery and appetite regulating hormones PYY •Increased fasting & meal stimulated PYY levels following RYGB & sleeve gastrectomy • Increased postprandial PYY in RYGB but normal in gastric banding Gherilin Mixed results on ghrelin levels post bariatric surgery Leptin Leptin levels unchanged post RYGB and sleeve!gastrectomy

Bariatric surgery and Glycaemic control

Hypotheses!for!Diabetic!Control!Through!Bariatric!Surgery 42 a. Foregut!exclusion!hypothesis i. Nutrient!bypass!of!proximal!gut!prevents!secretion!of!GIP!which!promotes!insulin!resistance! ii. Proven!invalid!as!vertical!sleeve!gastrectomy!does!not!bypass!proximal!gut,!yet!still!results!in! diabetes!remission!and!weight!loss!similar!to!RYGB!and!biliopancreatic!diversion b. Hindgut!hypothesis i. Increased!delivery!of!nutrients!to!distal!ileum!causes!exaggerated!GLPM1/PYY!release!through! overstimulation!of!neuroendocrine!L!cells ii. Normalization!of!blood!glucose!within!months!following!duodenal!switch!procedure!without! restrictive!gastric!surgery!in!moderately!obese!diabetic!patients!(mean!BMI!33!kg/m2 ) 43

3. Bariatric surgery and Incretin hormones Increased GLPM1 by a factor of 5 one month post RYGB Postprandial GLP-1 increased following RYGB but unchanged following gastric banding Persistent post prandial increases of GLP-1 20 years after duodeno-jejunal bypass

4. Glycaemic control through weight loss Achieved within days to months after operation, before major weight loss Average remission of type 2 diabetes i. Biliopancreatic diversion / duodenal switch = 95% ii. RouxMenMY gastric bypass = 80% iii. Gastric banding = 57%

Bariatric surgery and Glycaemic control

Gastric balloon

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Abstract

•Morbid obesity (defined as having a body mass index [BMI]

> 40 kg/m2, or BMI > 35 kg/m2 with obesity-related comorbidities)

is a medical disorder associated with increased morbidity and

mortality.

•Management guidelines published by the National Health and

Medical Research Council and by similar US and UK bodies have

recommended surgery as the most effective treatment available for

selected patients with morbid obesity.

•A recent meta-analysis of obesity surgery has documented its safety

and effectiveness in resolving some of the major medical

comorbidities that occur in obese patients.

•To date, no intervention other than surgery has proven either

effective or cost-effective in treating severe obesity and its associated

medical conditions.

•Targeting patients with metabolic complications of obesity (eg, type

2 diabetes) could lead to substantial cost savings for the public health

system.

•Currently, Medicare pays for privately insured patients to undergo

obesity surgery, while uninsured patients are denied access to surgery

in public hospitals. This raises significant equity issues that should be

addressed.

Arecent review and meta-analysis by Buchwald et al1 summarises

succinctly the impact of bariatric (obesity) surgery on morbid obesity

(Box 1) and its related comorbidities. The percentage excess weight loss

in patients who have had bariatric surgery is reported to be 50%–70%,

and “cure” or significant amelioration of diabetes, hypertension,

hyperlipidaemia and obstructive sleep apnoea is experienced by over

80% of patients, on average, for each condition. The meta-analysis

confirms that bariatric surgery is a safe and effective intervention, with

positive effects persisting for years or decades. This leads us to consider

the current difficulties in providing obesity surgery for Australian

patients.

Obesity is now epidemic in the Western world, due to a complex range of

environmental and genetic factors.3 The AusDiab survey showed a

combined prevalence of overweight and obesity of about 60% in

Australian adults.4 It would be fair to assume, therefore, that overweight

and obesity are now more prevalent risk factors for disease than

smoking. Extrapolating from overseas data, the yearly number of deaths

in Australia attributable to obesity is in the order of 12 000–17 000.5,6

Over the past 20 years, the prevalence of both obesity and diabetes in

Australia has doubled,4 and the upward trend is projected to continue.

Unfortunately, poor results of non-surgical intervention mean that there

is rarely an exit for patients entering the obese cohort.

Treatment strategies for obesity have been exhaustively evaluated, both

at a primary-care level and as intensive medical therapies instituted for

high-risk patients. Primary-care interventions have either been

ineffective or of insufficient duration to assess long-term results.7-9 The

National Health and Medical Research Council (NHMRC), after an

extensive evaluation of available therapies,10 concluded that obesity is

associated with significant morbidity and mortality and that medical

treatments for obesity generally result in weight loss of less than 10 kg of

variable duration. While a sustained 3–5 kg weight loss may be

acceptable for an “overweight” or “Class I” obese patient (Box 1),

recommending non-surgical therapy to morbidly obese patients needing

more significant weight loss is unsupported by evidence. Surgery is

documented as the only consistently effective therapeutic intervention for

the morbidly obese.1,10,11

The fact that surgery is not widely advocated by clinicians managing

severely obese patients may, in part, be explained by the chequered

history of some procedures that have been introduced with enthusiasm,

rapidly disseminated, then later abandoned because of either dangerous

side effects (eg, jejuno-ileal bypass) or ineffective weight loss (eg,

gastroplasty). The number of patients happy to undergo often untested

procedures with unknown long-term consequences is testament to the

desperation faced by those afflicted with obesity.

Current bariatric surgical techniques have evolved to produce highly safe

and effective treatments for obesity and are now considered mainstream.

Perhaps no other type of surgical procedure has been as extensively

scrutinised. Multiple studies have shown that bariatric surgery leads to

long-term weight loss with low morbidity and mortality. Indeed, obesity

surgery has become one of the most frequently performed major surgical

procedures in the United States (with over 120 000 projected cases for

2004), and is the second most frequent upper gastrointestinal surgical

procedure (after cholecystectomy) performed in Australia (unpublished

Health Insurance Commission data).

Bariatric surgery has been evaluated by the NHMRC,10 the UK National

Institute for Clinical Excellence (NICE)11,12 and the US National

Institutes of Health (NIH).13 These three agencies have explicitly

recommended that surgery be made available to selected morbidly obese

patients (Box 2). On the basis of a cost-effectiveness analysis of gastric

bypass surgery, the NICE has recommended that National Health Service

trusts actively promote bariatric surgery. Similar analyses in the United

States are prompting the US government to consider more widespread

payment, through Medicare, to allow surgery in uninsured patients.

Worldwide, about 65% of bariatric surgical procedures performed each

year are variations of the gastric bypass (Box 3), with the laparoscopic

band (Box 4) being the second most common procedure. The latter

procedure is the most common performed outside the United States.14

In Australia, we have an unusual situation in which Medicare pays for

bariatric surgery and postsurgical care for privately insured patients,

while non-insured patients are denied the same services in public

hospitals. As the prevalence of obesity is significantly greater in lower

socioeconomic classes, there are obviously a significant number of obese

people excluded from treatment that has been recommended by the

NHMRC.10 A surgical approach to obesity treatment is also supported

by the Australian Safety and Efficacy Register of New Interventional

Procedures — Surgical (ASERNIP-S)15 and the Medical Services

Advisory Committee (MSAC).16 The recommendations of the

ASERNIP-S and the MSAC were to continue provision of funding for

gastric banding in particular, but bariatric surgery in general was also

supported.

The reason bariatric surgery was allowed to proceed in the UK National

Health Service was a cost analysis showing that gastric bypass was

cheaper than other interventions on a quality-adjusted-life-year (QALY)

basis.

Gastric bypass surgery is the only intervention, to date, that has been

shown to be cost-effective for treating severe obesity.17,18 It results in

lower morbidity, mortality and cost in operated compared with non-

operated patients.19,20 Although laparoscopic gastric banding did not

appear as cost-effective as gastric bypass when evaluated by the

NICE,11,12 modelling analysis suggests it could be cost-effective.21

This seems likely, given the good weight control and comorbidity

resolution observed in Australian studies of gastric banding.22 The

MSAC report16 costed gastric banding at just over $9000 and gastric

bypass at just over $8000 per procedure — figures that accord fairly well

with our own estimates (unpublished data), except that our bypass costs

were $1000–$2000 higher than banding costs because they included

hospital and intensive care unit/high-dependency unit stays. These

figures do not take into account the apparent high rate of band

removal/replacement,23-25 also reported in Health Insurance

Commission data, that would need to be included in cost calculations

(Box 5).

Patients with diabetes are of particular interest as a potential target

population for bariatric surgery. All studies to date have shown a cure

rate of at least 80% for type 2 diabetes after gastric bypass surgery.27-30

There are currently over 900 000 Australians with type 2 diabetes, with

the number projected to rise to over 1.2 million by 2010.31 The yearly

cost of managing each patient with diabetes averages $10 900 (ranging

from $9095 to $15 850, depending on the presence of complications).32

This means that a patient with diabetes having bariatric surgery in a

public hospital is likely to have the procedure pay for itself within a year.

Existing federal–state funding arrangements are not conducive to

promoting obesity surgery as a cost-saving measure. While most of the

costs of managing people with diabetes and serious obesity-related

comorbidities are borne by the federal government, state-government-

funded hospitals bear the costs of surgery. It is unlikely that state

governments, without benefiting from the overall savings, would be

swayed by cost-effectiveness arguments. The current inequities may,

therefore, continue.

Currently, Australia is far behind many Western countries in developing

strategies to reduce the future burden of obesity and treat people who are

severely afflicted. We have had no open-forum discussions between

stakeholders and government of the kind that produced the recent UK

House of Commons report on obesity.33 We have no primary-care

equivalent of the UK Counterweight Project,8 and no effective

treatments available to those who can not afford either drug therapy or

surgery. Surgery for obesity is regarded by many people, including

clinicians, to be akin to cosmetic surgery, a perception that is likely to

persist while it remains solely in the domain of the private system.

Although managing obesity is going to be a problem of major

proportions, the longer we wait, the more difficult it will be to find

solutions that suit the Australian population. The first step will be to

acknowledge the severity of the problem and to offer treatment for the

morbidly obese based on best available evidence. To do otherwise is to

either ignore the evidence or simply discriminate against the obese.

1 Obesity definitions*2

Competing interests

Drs Talbot and Jorgensen received travel assistance from Johnson and

Johnson Medical to attend an obesity surgery meeting in 2004. All three

authors are bariatric surgeons with public hospital appointments.

References

1.Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a

systematic review and meta-analysis. JAMA 2004; 292: 1724-1737.

<PubMed>

2.World Health Organization. Obesity: preventing and managing the

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4.Cameron AJ, Welborn TA, Zimmet PZ, et al. Overweight and

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<eMJA full text> <PubMed>

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6.Banegas JR, Lopez-Garca E, Gutierrez-Fisac JL, et al. A simple

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7.Moore H, Summerbell CD, Greenwood DC, et al. Improving

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BMJ 2003; 327: 1085-1089. <PubMed>

8.The Counterweight Project Team. A new evidence-based model for

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9.James J, Thomas P, Cavan D, Kerr D. Preventing childhood obesity

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Canberra: NHMRC, September 2003. Available at:

www.health.gov.au/internet/wcms/publishing.nsf/Content/obesitygui

delines-guidelines-adults.htm/$FILE/adults.pdf (accessed Feb 2005).

11.Clegg A, Sidhu MK, Colquitt J, et al. Clinical and cost

effectiveness of surgery for people with morbid obesity.

Southampton: National Institute for Clinical Excellence, 2001.

Available at: www.nice.org.uk/pdf/AssessmentReport-

Surgeryforobesity.pdf (accessed Mar 2005).

12.NHS National Institute for Clinical Excellence. Guidance on the

use of surgery to aid weight reduction for people with morbid

obesity. Technology Appraisal Guidance No. 46. London: NICE, July

2002. Available at: www.nice.org.uk/pdf/Fullguidance-PDF-

morbid.pdf (accessed Feb 2005).

13.US National Heart, Lung, and Blood Institute. Clinical guidelines

on the identification, evaluation, and treatment of overweight and

obesity in adults. Bethesda, MD: NHLBI, 1998. Available at:

www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm (accessed Feb

2005).

14.Buchwald H. 50 years of bariatric surgery. Obes Surg 2004; 14:

898.

15.Chapman A, Game P, O’Brien P, et al. Systematic review of

laparoscopic adjustable gastric banding in the treatment of obesity.

Update and re-appraisal. Adelaide: Australian Safety and Efficacy

Register of New Interventional Procedures — Surgical, Royal

Australasian College of Surgeons, June 2002. Available at:

www.surgeons.org/asernip-

s/systematic_review/LAGBreviewUp0602.pdf (accessed Feb 2005).

16.Medical Services Advisory Committee, Australian Department of

Health and Ageing. Laparoscopic adjustable gastric banding for

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www.msac.gov.au/pdfs/reports/msacref14.pdf (accessed Feb 2005).

17.Gallagher SF, Banasiak M, Gonzalvo JP, et al. The impact of

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cost analysis. Obes Surg 2003; 13: 245-248. <PubMed>

18.Craig BM, Teng DS. Cost-effectiveness of gastric bypass for

severe obesity. Am J Med 2002; 113: 491-498. <PubMed>

19.Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases

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20.Sampalis JS, Liberman M, Auger S, Christou NV. The impact of

weight reduction surgery on health-care costs in morbidly obese

patients. Obes Surg 2004; 14: 939-947. <PubMed>

21.Clegg A, Colquitt J, Sidhu M, et al. Clinical and cost effectiveness

of surgery for morbid obesity: a systematic review and economic

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22.Dixon JB, O’Brien PE. Changes in comorbidities and

improvements in quality of life after LAP-BAND placement. Am J

Surg 2002; 184(6B): 51S-54S. <PubMed>

23.Biertho L, Steffen R, Branson R, et al. Management of failed

adjustable gastric banding. Surgery 2005; 137: 33-41. <PubMed>

24.Tweddle EA, Woods S, Blamey S. Laparoscopic gastric banding:

safe and modestly successful. ANZ J Surg 2004; 74: 191-194.

<PubMed>

25.Camerini G, Adami G, Marinari GM, et al. Thirteen years of

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28.Schauer PR, Burguera B, Ikramuddin S, et al. Effect of

laparoscopic Roux-en-Y gastric bypass on type 2 diabetes mellitus.

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29.MacDonald KG, Long SD, Swanson MS, et al. The gastric bypass

operation reduces the progression and mortality of non-insulin

dependent diabetes mellitus. J Gastrointest Surg 1997; 1: 213–220.

<PubMed>

30.Scopinaro N, Adami GF, Marinari GM, et al. Biliary pancreatic

diversion. World J Surg 1998; 22: 936-946. <PubMed>

31.McCarty DJ, Zimmet P, Dalton A, et al. The rise and rise of

diabetes in Australia, 1996: a review of statistics, trends and costs.

Canberra: Department of Health and Family Services, 1996.

32.Colagiuri S, Colagiuri R, Conway B, et al. DiabCo$t Australia:

assessing the burden of type 2 diabetes in Australia. Canberra:

Diabetes Australia, 2003.

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session 2003–04. London: Stationery Office, 2004. Available at:

www.publications.parliament.uk/pa/cm200304/cmselect/cmhealth/23

/23.pdf (accessed Feb 2005).

(Received 28 Oct 2004, accepted 15 Feb 2005)

Department of Surgery, University of New South Wales at St George

Hospital, Kogarah, NSW.

Michael L Talbot, MB ChB, FRACS, Senior Lecturer; John O Jorgensen,

MB BS, FRACS, Visiting Surgeon; Ken W Loi, MB BS, FRACS,

Lecturer.

Correspondence: Dr Michael L Talbot, Department of Surgery,

University of New South Wales, Level 3, Pitney Building, St George

Hospital, Kogarah, NSW 2217. m.talbotATunsw.edu.au

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Anna Peeters, Reannan L Cashen and Paul E O’Brien. Inequalities in the provision of bariatric surgery for morbid obesity in Australia Med J Aust

2005; 182 (11): 598-599. [Letters] <http://www.mja.com.au/public/issues/182_11_060605/letters_060605_fm-7.html>

Paul E O’Brien, Wendy A Brown and John B Dixon. Obesity, weight loss and bariatric surgery Med J Aust 2005; 183 (6): 310-314. [Clinical

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The Medical Journal of Australia eMJA

©The Medical Journal of Australia 2005 www.mja.com.au PRINT ISSN:

0025-729X ONLINE ISSN: 1326-5377

An adjustable prosthesis is placed at the upper part of the stomach. The stoma of the prosthesis is

calibrated with saline introduced via a subcutaneous access port. (Diagram courtesy of Johnson

and Johnson Medical.)

Gastric Band

Mode of action of Gastric banding

• Band is placed at top of stomach which creates a small pouch

• Reduction in intake, quicker and longer satiety

• Proposed that compression of vagal afferent nerves in band area mediates satiety effect (O’Brien, 2010)

• Activation of peripheral satiety mechanism without

physically restricting meal size (Burton& Brown, 2011)

Sleeve Gastrectomy

70% of Stomach removed

Mode of Action of Sleeve

• Restrictive

• Alters hormone signals from stomach to

brain

IFSO/NICE Obesity Guidelines

• BMI >40kg/m2 or BMI >35kg/m2 with co-morbidities that could be improved with weight loss

• All appropriate non surgical measures have failed to achieve clinically significant weight loss

• Intensive management in specialist obesity service

• Commit to the need for long term follow up

• Fast track for people with BMI >50kg/m2

No alcoholism or major psychiatric illness

• Need to be abstinent

• Consult a psychiatrist if necessary

– Schizophrenia, borderline personality, active suicidal ideation, uncontrolled depression (?absolute contraindications)

Evidence

• Swedish Obese Subjects - Mortality: up to 40% lower risk over 10years

(Sjöström et al.,2007)

• Diabetes: >70% remission after 2 years (in recently diagnosed)

(Sjöström et al.,2004) (Dixon et al., 2008)

Bariatric Surgery and Diabetes

• Meta-analysis (Buchwald et al – 2009)

Overall remission rate of 78%

• < 2 years since surgery 80%

• >2 years since surgery 75%

• Results seen with all operations, yet most dramatic with the gastric bypass

If treated within 5 years of Diabetes diagnosis—higher long term remission rates (Brethauer et al, 2013)

Bypass and Diabetes

• Bypass shows more promising resolution of diabetes than the sleeve or band.

• Parikh et al (2013)—Meta-analysis (1389pts)

– Remission rates (1 year):

• 33% Lap band

• 54% Sleeve

• 64% Gastric Bypass

• Buchwald et al (2009)

– Resolution of T2DM

• 57% Lap band patients

• 80% Gastric bypass patients

Bypass and Diabetes

• Unique to bypass—Diabetes resolution can come before weight loss

• Rubino et al (2006) – animal studies

– Bypassing a short segment of proximal intestine directly ameliorates T2DM, independent of food intake, body weight, etc.

– Potentially undiscovered factors from proximal small bowel contributing to pathophysiology of DM

LAGB and Diabetes

• Sultan et al (2010: SOARD 6:373-376.)

– 102 patients LAGB (5 year mean EWL 48.3%)

– 88% preop on meds for DM, 46.5% on @5yrs

– 14.9% preop on insulin for DM, 8.5% @ 5yrs

– HbA1c: 7.53 avg preop; 6.58 avg 5 yrs later

– DM resolved in 40% of LAGB at 5 years

– Combined improvement/remission rate was 80% at 5 years

LAGB and Diabetes

• Dixon et al (2012: Obesity Reviews 13:57-67)

– Remission improvement rates varied from 53-70% within 2 years after LAGB placement

Restrictive Procedures and Diabetes

Bariatric procedures have been shown to be superior to

conservative therapy in the management of Type 2 diabetes

• Schauer et al (2012: N Engl J Med 366: 1567-1576)

• Dixon et al (2011: SOARD 7: 433-447) –

Long term Remission

Association of Bariatric Surgery With Long-term Remission of Type 2 Diabetes and With Microvascular and Macrovascular Complications

Lars Sjöström et al

JAMA. 2014;311(22):2297-2304.

Ideal candidate for diabetes remission

• High insulin and/or high glucose at baseline predicted favourable treatment effects

• High baseline BMI predicts poor outcome

• Increased rate of diabetes remission with higher C-peptide levels

• Shorter duration of diabetes

• Lower HbA1C

• Insulin independence

Benefits of Bariatric surgery

•BP reduction

•Reduced risk of cancer

•Improved quality of life

•Improved exercise tolerance

•Reduced cardio vascular risk

•Improvement in sleep apnoea

•Improvement in fertility

•Increased confidence and self esteem

Metabolic complications of bariatric surgery

1. Acid-base disorder 2. Bacterial overgrowth (primarily with BPD, BPD/DS) 3. Pseudo-obstruction 4. Nocturnal diarrhea 5. Proctitis 6. Acute arthralgia 7. Electrolyte abnormalities (primarily with BPD, BPD/DS) Low

Ca, K, Mg, Na, P 8. Arrhythmia, myopathy 9. Enteral or parenteral repletion 10. Fat-soluble vitamin deficiency Vitamin A—night vision 11. Vitamin D—osteomalacia 12. Vitamin E—rash, neurologic 13. Vitamin K—coagulopathy 14. Folic acid deficiency Hyperhomocysteinemia

15. Anaemia 16. Foetal neural tube defects 17. Osteoporosis Fractures 18. Oxalosis Kidney stones 19. Secondary hyperparathyroidism 20. Vitamin D deficiency 21. Thiamine deficiency Wernicke–Korsakoff encephalopathy 22. Beriberi 23. Vitamin B12 deficiency Neuropathy 24. Zinc deficiency 25. Selenium deficiency

Metabolic complications of bariatric surgery

•Post operative worsening of retinopathy

•Recurrent hypoglycaemia leading to cognitive impairment

•Nesidioblastoma

Other complications

Spot the difference

Summary

• Remission of Type 2 and not Type 1 diabetes can be expected with Bariatric surgery.

• Prolonged duration of disease has been associated with poorer remission rates of diabetes after bariatric surgery

• Even if Type 2 diabetes remission is achieved patients should be followed yearly with HbA1C and should have retinal screening done

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