Bariatric Surgery for Non-Bariatric
Patients
Alex Gandsas, MD, MBA
STATS
• 2010 – 25 million Americans suffered from T2DM
• 2030 – 336 million will be diagnosed with T2DM
• 2050 – T2DM could affect 33% of the US population
American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013;36:1033–46
Whiting DR, Guariguata L, Weil C, Shaw J. IDF diabetes atlas: global estimates of the prevalence of diabetes for 2011 and 2030.
Diabetes Res Clin Pract. 2011;94:311–21.
Diabetes
ADA
goals
Hypertension
Dyslipidemia
Hyperglycemia
A1C < 7%
BP < 130/80 mm Hg
Cholesterol < 100 mg/dL
High Morbidity & Mortality
Patient Selection – NHI 1991
• BMI of >40 Kg/m2
• BMI of 35 Kg/m2 with comorbid conditions
• No significant psychiatric illnesses
•Age of less than 60 years
• Medical treatment DOES NOT work
Gandsas
What Happens to patients with
BMI <35Kg/m2 ?
Diabetes
Dyslipidemias
Hypertension
Sleep Apnea
Importance of Glycemic control
• The UK Prospective Diabetes Study was the first trial to provide
evidence that appropriate glycemic control could lead to a
significant reduction in the risk of long term diabetes complication
• 4000 patients
• Two arms: Diet Vs Insulin/Po Meds
• 10 year F/U
• 12% reduction of diabetes related complication
• 25% risk reduction in microvascular complications
• 16% reduction of MI
(p<0.001)
Bianchi C, Del Prato S. Metabolic memory and individual treatment aims in type 2 diabetes outcome – lessons learned from large
clinical trials. Rev Diabet Stud. 2011;8:432–40.
There is strong evidence that metabolic
surgery is safe and provide better outcomes
for weight loss and diabetes
Metabolic surgery (food re-routing) may
promote glucose control unrelated to weight
loss.
This is observed days after the procedure,
long before weight loss is achieved.
Cohen R et al. Curr Atheroscler Rep. (2013)
Metabolic surgery outcomes in patients with a low BMI
Cohen R, et al. Role of metabolic surgery in less obese or non-obese subjects with type 2 diabetes: influence
over cardiovascular events. Curr Atheroscler Rep. 2013 Oct;15(10):355. doi: 10.1007/s11883-013-0355-3.
Effects of Gastric Bypass Surgery in Patients With
Type 2 Diabetes and Only Mild Obesity
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Long term follow up - (1 to 6 years)
All patients had uncontrolled T2DM
Mean pre-operative HgA1C was 9.7%
Mean duration of the disease was 12.5 years
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T2DM remission was observed in 88% of patients
Reduction of HgA1C to 5.9%
10 year decrease in Stroke (57%) and MI (84%)
B-cell sensitivity improved (C-peptide with glucose load)
Cohen R, et al. Effects of gastric bypass surgery in patients with type 2 diabetes and only mild obesity. Diabetes Care. 2012;35:1420–8.
Effects of Gastric Bypass Surgery in Patients
With Type 2 Diabetes and Only Mild Obesity
Cohen R, et al. Effects of gastric bypass surgery in patients with type 2 diabetes and only mild obesity. Diabetes Care. 2012;35:1420–8.
Effects of Gastric Bypass Surgery in Patients With
Type 2 Diabetes and Only Mild Obesity
• Hypertension was resolved in 58%
• Hypercholesterolemia was resolved in 64%
• Hypertriglyceridemia was resolved in 58%
• Mean blood pressure decreased progressively over 6 years
Cohen R, et al. Effects of gastric bypass surgery in patients with type 2 diabetes and only
mild obesity. Diabetes Care. 2012;35:1420–8.
Conclusions
• BMI alone is not a good tool for selecting patients
suffering from metabolic syndrome that can benefit
form metabolic surgery.
• There is significant scientific evidence of the efficacy of
metabolic surgery in patients with BMI <35