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Screening and Follow-up in Obese subjects
Bariatric Sugery: When?
Gabriella Garruti
Department of Emergency and Organ Transplantation
Section of Internal Medicine, Endocrinology , Andrology
and Metabolic Diseases
(Chairman: prof. F. Giorgino)
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What is Overweight?
Overweight and Obesity:
When?
WAIST
BMI
Underweight
<18.5 Kg/m2
Normal-weight
18.5 - 24.9 Kg/m2
Overweight
25.0 – 29.9 Kg/m2
Obesity category
1st
30.0 – 34.9 Kg/m2
2nd
35.0 – 39.9 Kg/m2
3rd
> 40.0 Kg/m2
FAT distribution
Central obesity
Man:
> 94 (102) cm
Woman: > 80 (88) cm
IDF /(ATPIII)
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Obesity Treatment Pyramid
Surgery
Pharmacotherapy
Lifestyle
Modification
Diet
Physical Activity
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Guidelines for Selecting Obesity
Treatment2
BMI Category (kg/m )
Treatment
Diet, Exercise,
Behavior Tx
Pharmacotherapy
Surgery
25-26.9
27-29.9
30-34.9
35-39.9
>40
+
+
+
+
+
With comorbidities
+
+
+
+
With comorbidities
+
The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults.
October 2000, NIH Pub. No.00-4084 modified by Garruti 2008
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Only when Lifestyle is unhealthy
Bariatric surgery
Gastric Bypass (Roux-en-Y)
13.02.05
Gastric banding
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Bariatric surgery: what is?
The operations employed for morbid obesity are not
to be confused with plastic surgery
Real risk comes with each surgical procedure
Prospective patients should also be thoroughly
convinced that they have exhausted all other
reasonable avenues of weight loss before selecting
surgery
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Bariatric Surgery: When ?
Indications
kg/m2
1. BMI >40
or
BMI 35–39.9 kg/m2 and
life-threatening cardiopulmonary
disease, severe DIABETES, or
lifestyle impairment
2. Failure to achieve WL with
Medical Treatment
EAES /ASBS 2005
BMI 30-35 kg/m2
& life-threatening comorbidities
Sauerland et al. Surg Endosc 19:200
Buchwald et al. J Am Coll Surg 200:593
Controintraindications
1. History of noncompliance with medical care
2. Psychiatric illnesses: personality disorder, uncontrolled depression, suicidal
ideation, substance abuse
3. elevated ASA risk
NIH Consensus Development Panel. Ann Intern Med 1991;115:956.
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Indicazioni








Obesità di durata superiore a 5 anni
BMI > 40Kg/m2 o BMI >35Kg/m2 con comorbidità*
Età: da 18-65 anni
Fallimento Tx medica (dietetica, farmacologica,
comportamentale) per almeno 1 anno
Assenza di cause endocrine di obesità
Rischio anestesiologico max < ASA 2
Assenza di malattie psichiatriche e/o disturbi del
comportamento alimentare (DCA).
Compliance del paziente (follow-up)
NIH 1998- LIGIO 1999 EAES /ASBS 2005
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Indicazioni
BMI >35 con
comorbilità*









OSAS/Pickwick
Ipertensione arteriosa
Scompenso cardiaco
Diabete mellito tipo 2
Osteoartrosi
Colelitiasi
Dislipidemie



Insuff. venosa cronica arti inferiori
Impotenza/Irregolarità mestruali
/Infertilità
Iperuricemia
Irsutismo
Nefrolitiasi
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Bariatric Sugery: how important is the
multidisciplinary approach?
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Bariatric Sugery: how important is the
multidisciplinary approach?
Anesthesiologist, Cardiologist, Dietitian or Nutritionist,
Endocrinologist , Pneumologist, Psychiatrist, Surgeon
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Valutazione clinica e strumentale
prima della chirurgia







Esami ematochimici
Inquadramento endocrino-metabolico* e genetico
Rx torace
Ecografia addome superiore e inferiore
Doppler venoso arti inferiori
Emogasanalisi, spirometria, polisonnografia
Inquadramento psicologico-nutrizionale (psichiatra e
dietisti)
 Rx baritato (+Trendelenburg per ernia iatale)
 EGDS + biopsia per infezione H. pylori
 Consulenza cardio-anestesiologica
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Inquadramento endocrinometabolico e nutrizionale






Indagine alimentare, variabili antropometriche
Indici nutrizionali
HOMA/ OGTT per glicemia e insulinemia
Pattern ormonali:
– asse ipofisi-surrene/gonadi
– asse ipofisi-tiroide
– asse GH /IGF1
Ecografia tiroidea
Mineralometria ossea computerizzata “Total body”
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Is Diet dependent on …?
Energy needs
Environment
Genes
(metabolism)
• Palatableness (taste receptors)
• Geography
• Nutrients availability
• Economic situation
Your Gut Has
• Culture
Taste Receptors
• Religion
ScienceDaily
(Aug. 21, 2007)
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The Desert’s perfect foods
In the Pima, survival mechanisms evolved to store fat extremely
efficiently (“thrifty genotype”)
This GENETIC MAKE-UP would have served the tribe well in the harsh
desert climes of the southwest
Today this so-called "thrifty gene" means 70% of the Arizona Pima
are obese and diabetics
Overweight
Normalweight
Obese
Lazar Science 2005 modified by Garruti
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Indagine alimentare
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62
41.8
99.2 154
2200
12%
28%
60%
20
3
X
X
X
pane, pasta, condimenti, rustici
verdura
Dieta a b.i.g 1200 Kcal/Die
Attività fisica (v. piramide attività fisica)
Giovanna Mallardi
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Diet & Energy needs
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Neuronal circuits in the hypothalamus
affect
Satiation (level of fullness during a meal
which regulates the amount of food
consumed)
Satiety (level of hunger after a meal is
consumed which regulates the frequency
of eating)
Schwartz et al. 2000 Nature
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Energy density: Volume versus calories
All foods have a certain number of calories within a
given amount (volume)
Foods with high energy density have a large number
of calories in a small volume
Alternatively foods with low energy density provide a
larger portion size with a fewer number of calories.
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Energy Density of Selected Foods
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Lettuce
Vegetable soup
Skim milk
Apple
Black beans
White fish
Yogurt
Vegetable lasagna
Roast chicken
White bread
Pretzels
Cheddar cheese
Salad dressing
Potato chips
Bacon
Butter
0
1
Klein S, et al. Gastroenterology. 2002
2
3
4
5
6
Energy Density (kcal/g)
7
8
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HEALTHY PYRAMID FOOD
(Harvard Medical School)
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Current Bariatric Surgical Procedures
Classification
Gastric restriction
Procedure
 Adjustable Gastric Banding
Primarily restrictive and  Roux-en-Y Gastric Bypass
partially
 Sleeve Gastrectomy
malabsorptive
Primarily malabsorptive
and partially
restrictive
 Biliopancreatic diversion
with duodenal switch
 Biliopancreatic diversion
 Distal gastric bypass
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Restrictive Gastric Surgery
Vertical
gastroplasty
Adjustable gastric
banding
Intragastric
balloon
(BIB)
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Laparoscopic Adjustable Gastric Banding
Access port (reservoir)
Gastric Band
LapBandTM
Connection tubing
Silicone band placed around
upper stomach to create a small
pouch. Outlet diameter can be
changed by infusing or
withdrawing saline from port.
American Society for Metabolic and Bariatric Surgery, www.asbs.org
Puglisi 2008
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Roux-en-Y gastric bypass
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Biliopancreatic Diversion with
Duodenal Switch
Sleeve gastrectomy with rerouting of
small intestine through “nutrient limb” and
“biliopancreatic limb”
Digestion and absorption are limited to
100 cm “common channel” of terminal
ileum
Causes marked weight loss, but can lead
to significant nutritional deficiencies
Marceau P. et al. World J Surg 1998;22:947-54
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Follow-up (post- LAGB and postGBP)
0 1 3
6
9
12
15
18
21
months
24
surgeon
EGDS Calibration
Rx ?
……?
Cardiologist, Dietitian or Nutritionist,
Endocrinologist , Pneumologist, Psychiatrist
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Energy Metabolism in mammals
Basal Metabolic Rate
[Obbligatory Thermogenesis (Th)]
Exercise-induced Th
Diet-induced Th
Major effects of
Bariatric Surgery
Weight
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Indagine alimentare
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41.8
99.2 154
1000
15%
57%
28%
30
3
X
X
X
X
X
?
Dieta a b.i.g 1000-1200 Kcal/Die
Attività fisica (v. piramide attività fisica)
Maria A. Lucafo’ & Giovanna Mallardi
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Life-style modifications :
Anti-atherogenic Diet
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Suggested Energy Deficit based on Initial BMI
Initial BMI
(Kg/m2)
Suggested Approximate Initial
Energy Intake Energy Deficit
(kcal/d)
(kcal/d)
25-29.9
?
500
30-34.9
?
500
35-39.9
?
500-1000
>40
?
500-1000
>50
?
?
National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical
Guidelines on the Identification, Evaluation, and Treatment of Overweight and
Obesity in Adults – The Evidence Report. Obes Res. 1998;6(suppl 2):51S-209S
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Weight Loss, %
Weight Loss after Bariatric Surgery
or Medical Therapy*
BMI between
30 and 35 Kg/m2
Surgical (LapBand)
Nonsurgical
Baseline
6 mo
*VLCD, behavioral modification, and
pharmacotherapy
12 mo
18 mo
24 mo
Obrien et al. Ann Intern Med. 2006
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Parametri antropometrici dopo BIB
Mesi
WL(Kg)/SEM
WE(Kg)/SEM
%EWL/SEM
1° mese
9.5/1.1
46.5/7.4
20.2/4.2
2° mese
14.4/2.5
48.5/7.2
23.6/3.8
3° mese
13.6/2.5
45.1/6.6
24.6/5.0
6° mese
18.0/8.0
40.0/5.6
27.0/7.8
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Parametri antropometrici dopo LapGB
Mesi
WL(Kg)/SE
M
WE(Kg)/SE
M
%EWL/SEM
1° mese
6.0/1.0
46.0/7.7
13.0/2.3
3° mese
9.7/2.1
40.5/6.4
19.8/3.8
4° mese
9.3/3.7
39.6/5.3
19.7/3.3
8° mese
13.1/1.3
37.1/3.5
28.3/3.2
12° mese
11.8/2.3
38.8/3.76
26.2/5.4
18° mese
23.1/6.5
32.5/3.8
30.0/5.3
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Excess Weight Loss (EWL) and Compliance to
Comprehensive Medical Therapy* after Gastric Banding
% of subjects with low or high compliance
%EWL in subjects with low or
high compliance
low
high
*[life-style modifications (diet, exercise)
+ pharmacotherapy]
low
high
Lucafo’ MA, Rotelli MT, De Tullio A. 2008 unpublished
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Effect of Different Bariatric Surgical Procedures
on Weight Loss
Procedure
Approximate
Loss of Excess
Weight (%)
Laparoscopic gastric banding
45–65
Gastric bypass procedure
55–65
Biliopancreatic diversion (DS)
60–75
Klein et al. Gastroenterology. 2002;123:882-932
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Comorbidity outcomes after
Bariatric surgery
Comorbidity
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Improved/Resolved
Diabetes
Coronary artery disease
Hypercolesterolemia
Gastroesophageal reflux d.
Sleep apnea
Hypertension
Osteoarthritis
Hypertriglyceridemia
Depression
Adapted from Schauer et al. Ann Surg 2000
100%
100%
96%
96%
93%
88%
88%
86%
55%
Busetto et al. Obes Surg 2000 10: 569
Pontiroli et al JCEM 2002 87:3555
Scopinaro et al. Diabetes Care 2005; 28:2406
Busetto et al. NMCD 2008; 18:112
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THE EFFECTS OF GASTRIC BANDING ON RED BLOOD CELL
AGGREGATION & DEFORMABILITY IN MORBIDLY OBESE SUBJECTS
Puglisi Francesco, Capuano Palma, Giorgio Catalano, Garruti Gabriella, Trerotoli Paolo,
Tedeschi Michele, De Fazio Michele, Cicco Giuseppe, Giorgino Francesco, Memeo Vincenzo
N
Mean age (SD)
Range
Total
20
40.8 (12.2)
22-60
M
9 (45%)
36.4 (11.3)
22-51
F
11 (55%)
44.4 (12.3)
23-60
Mean Baseline weight
(SD)
Range
132.3 (23.4)
100-195
142.4 (26.9)
112-195
124 (17.3)
100-161
45.8 (5.9)
37.4-58.6
45.6 (6.5)
37.4-55.7
45.9 (5.8)
38.9-58.6
9 (45%)
8 (40%)
7 (35%)
7 (35%)
5 (25%)
4 (20%)
3 (33.3%)
5 (55.6%)
3 (33.3%)
3 (33.3%)
2 (22.2%)
1 (11.1%)
6 (54.5%)
3 (27.3%)
4 (36.4%)
4 (36.4%)
3 (27.3%)
3 (27.3%)
3 (15%)
3 (15%)
3 (15%)
2 (10%)
1 (5%)
1 (11.1%)
2 (22.2%)
0 (0%)
0 (0%)
0 (0%)
2 (18.2%)
1 (9.1%)
3 (27.3%)
2 (18.2%)
1 (9.1%)
Mean Baseline BMI (SD)
Range
Arterial hypertension
Hypertryglyceridemia
Smoke
Diabetes
Vascular dis.
Joint diseases
Hypoventilation
syndrome
Heart diseases.
Anxiety-depression
Thyroid dysfunction
Gallbladder stones
AI: aggregation index; EI: elongation index
Box plot comparing EI 3 PA at baseline
and 3 and 6 months after surgery.
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THE EFFECTS OF GASTRIC BANDING ON RED BLOOD CELL
AGGREGATION & DEFORMABILITY IN MORBID OBESE PATIENTS
Puglisi Francesco et al.
T0
T3
p-values
T6
T3 vs T0
T6 vs T0
AI %
0.74 (0.04)
0.72 (0.05)
0.67 (0.06)
0.013
0.000
AI t1/2
1.34 (0.36)
1.38 (0.3)
1.49 (0.29)
0.3447
0.189
EI 0.03 Pa
0.042 (0.016)
0.039 (0.016)
0.043 (0.023)
0.32
0.757
EI 3 Pa
0.379 (0.065)
0.412 (0.056)
0.449 (0.067)
0.049
0.0001
EI 30 Pa
0.646 (0.043)
117.85
(25.775)
0.669 (0.064)
109.75
(25.007)
0.11
0.0274
Weight
0.584 (0.128)
132.305
(23.446)
0.0001
0.0001
BMI
45.813 (5.977)
0.0001
0.0001
Tot Chol
207.8 (23.305)
40.813 (6.867) 37.965 (6.792)
185.15
196.6 (16.529)
(18.883)
0.0045
0.0001
HDL Chol
48.25 (11.201)
50.15 (10.277) 53.5 (8.918)
128.21
LDL Chol
132.05 (21.197)
(26.388)
122.2 (23.294)
138.85
Tryglicerides 154.75 (51.759)
(38.232)
129.7 (37.542)
0.197
0.0048
0.086
0.0042
0.0161
0.0038
0.16
0.38
Glycaemia
103.7 (15.058)
99.65 (10.937) 97.65 (7.436)
27.171
(13.507)
24.29 (12.446)
AI:
aggregation
index; EI: elongation index 0.001
Insulin
33.66 (17.155)
0.0001
Bs
3M
6M
Box plot comparing AI% 3 at baseline
and 3 and 6 months after surgery
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BMI DISTRIBUTION IN A COHORT
OF TYPE 2 DIABETIC SUBJECTS
GARRUTI G., VITA MG, GIAMPETRUZZI F et al. 2008 unpublished
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LapGB
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LIMITI
 Anestesia (vs Tx medica integrata)
 Limitato calo ponderale (vs Tx chirurgica malassorbitiva)
 Obbligatorio “counseling”
 Alimentazione semiliquida per ~ 1 settimana
(600 - 800Kcal/die) (vs Terapia medica ed chirurgica malassorbitiva)
 Durata del pasto:> 40 min
 Intervallo tra cena e bed-time: 2 h
VANTAGGI
 Dieta ipocalorica bilanciata (proteine 19,4%;
glucidi 56,2% ; lipidi 24,4%) + integratori
 Graduali modificazioni dell’immagine corporea
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Complications after Gastric Bypass
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The bypassed portion of intestine is where the majority
of calcium and iron absorption takes place
LONG-TERM COMPLICATIONS
anemia
osteoporosis
Other clinically important deficiencies
Vitamin B 1 (thiamine)
Vitamin B 12
lack of gastric intrinsic factor (GIF)
Lifelong follow-up with a daily multi-vitamins and mineral supplementation are
strongly recommended to prevent nutritional complications
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GBP & Dumping syndrome
Gastric bypass operations may also cause
"dumping syndrome"
food or liquids travel too rapidly through the small intestine
(sweets are often the culprit)
Dumping symptoms include
nausea
weakness
sweating
faintness
Symptoms dissipate after the patient rests???
diarrhea
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Regulation of Food Intake
Brain
External factors
Central Signals
Stimulate
NPY
Orexin-A
AGRP
dynorphin
galanin
Peripheral signals
Glucose

CCK, GLP-1
Apo-A-IV
Vagal afferents
Inibit
α-MSH
CRH/UCN
GLP-I
Ghrelin
Leptin
Cortisol
CART
NE
5-HT
Emotions
Food characteristics
Lifestyle behaviors
Environmental cues
Peripheral organs
Gastrointestinal
tract
Food
Intake
Insulin
+

+
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Adipose
tissue
Adrenal glands
Schwartz et al. 2000 Nature
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Adipose Tissue depots are a
marvelous source of adipocyte
precursors
stem cells
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Bariatric surgery and Glycaemia
Any surgical procedure
 normalizes hyperglycemia
 restores insulin sensitivity
 prevents progression from IGT to DM
 reduces mortality from DM
Gastric bypass and Biliopancreatic diversion
 restores euglycemia and normal insulin
long before any significant weight loss
Changes in hormones secretion from the GI tract
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Bariatric Surgery in DM2:
When?
“Should surgeons treat diabetes in severely
obese people ?”
J.H. Pinkney, Sjöström C.D., Gale E.A.M. Lancet 2001 357: 1357.
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Incretins and anti-incretins in DM2
Rubino et al 2004 Ann Surg 240(2): 236–242
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Incretins and anti-incretins in DM2
after GBP
Rubino et al. Ann Surg. 2004; 240(2): 236–242
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Duodeno-jejunal bypass (DJB) and Diabetes
[A] Simple gastrojejunostomy
Enhanced delivery of nutrients
to the hindgut without excluding
nutrient flow through the
proximal intestine
No improvement of Diabetes in
diabetic GK animals.
Exclusion of the
duodenum is
critical for the
effect on diabetes
[B] DJB
creates similar shortcuts of
nutrients as in gastrojejunostomy
Rubino et al. Diab. Care 2008
- includes the exclusion of the
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DPP-4 Inhibitors or Incretin Enhancers
• Swiss pharmaceutical
firm, Novartis,
demonstrated in clinical
studies that its
investigational drug
vildagliptin improves the
function of pancreatic
islets in both animals and
humans.
• Vildagliptin, a novel
investigational Incretin
Enhancer, previously
known as LAF237,
inhibits DPP-4, resulting
in an increase of
circulating levels of GLP1, a crucial incretin
Dipeptidyl peptidase IV (DPP4)
enzyme that breaks
down gut peptides
especially GLP-1
Gastric inhibitory
polypeptide (GIP), also
known as the glucosedependent insulinotropic
peptide
Drucker, D. J. J. Clin. Invest. 2007;117:24-32
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Different effect of GBP on GIP in
diabetic and nondiabetic patients
Rubino et al. Ann Surg. 2004; 240(2): 236–242
Bariatric Surgery in DM2 & MbS:
When?
Indications
BMI >40 kg/m2 or BMI 35–39.9 kg/m2 and
life-threatening cardiopulmonary diseases
Systematic comparative
severe DIABETES
EAES /ASBS 2005
studies with new therapeutic
compounds
- CB1 antagonists
BMI 30-35 kg/m2
& life-threatening comorbidities
- CCK enhancers
- DPP4 inhibitors
Sauerland et al. Surg Endosc 19:200
Buchwald et al. J Am Coll Surg 200:593
- Incretin enhancers
- Glitazones
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Acknowledgements
Surgery
Internal Medicine &
Endocrinology
V. MEMEO
F. PUGLISI
P. CAPUANO
M. TEDESCHI
M. A. LUCAFO’
F. GIORGINO
G. MALLARDI
A. BELLOMO DAMATO
F. BRESCIA
G. STEFANELLI
G. MALLARDI
A. DE TULLIO
Anesthesia
P. CARAVETTA
Endoscopy
O. CAPUTI IAMBRENGHI
Psychiatry
L. ZAVOIANNI
Pneumology
N. PALUMBO
O. RESTA
Clinical Nurtition
Laboratory of D.E.T.O.
M. T. ROTELLI
Cardiology
A. VENEZIANI
G. DE PERGOLA
L. MANDOI
A. RAFFO
Internal Medicine
R. GIORGINO