current status of bariatric surgery in asia - 2013 international...
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Current Status of
Bariatric Surgery
in Asia
Go Wakabayashi, MD, PhD, FACS
Professor and Chairman
Department of Surgery
Iwate Medical University
Emerald hall A, 10:20-10:50, November 7, 2013
Nations Percentage
1
2
3
4
5
Kuwait
Sweden
Belguim
Israel
Australia
0.1642
0.0899
0.7722
0.0644
0.0520
Nations Percentage
1
2
3
3
5
Japan
Ukraine
India
Turkey
Ecuador
0.0001
0.0003
0.0004
0.0004
0.0010
Numbers of bariatric operations performed
as a percentage of the national population
High frequent (%) Low frequent (%)
Mean 0.0110% (n=340,768)
Buckwald H et al. Obes Surg 2013;23:427-436
Numbers of metabolic/bariatric surgeons
as a percentage of the national population
Nations Bariatric
surgeons
Percentage
Brazil
USA
France
Singapore
Taiwan
Japan
2,750
6,815
310
16
20
19
0.00140
0.00040
0.00047
0.00031
0.00009
0.00001
Mean 0.00022% (n=6,815)
Buckwald H et al. Obes Surg 2013;23:427-436
Types of metabolic/bariatric surgery
Sasaki A, Wakabayashi G, et al. J Gastroenterol 2013
65.1
4946.6
24.4
42.3
17.8
0
5.3
27.8
4.82 2.2
0
10
20
30
40
50
60
70
2003 2008 2011
RYGP
AGB
SG
BPD/DS
Trends in percentage of procedures worldwide
Buckwald H et al. Obes Surg 2013;23:427-436
8.4 9.1 9.6
80.4 82.5
32.6
04.1
55.1
30 0.50
10
20
30
40
50
60
70
80
90
2003 2008 2011
RYGB
AGB
SG
BPD/DS
Trends in percentage of procedures Asia/Pacific
Buckwald H et al. Obes Surg 2013;23:427-436
Annual changes of the number of laparoscopic bariatric procedures in Japan
(cases)
(yr)
0
20
40
60
80
100
120
140
160
180
Others
LSG+duodenal jejunal
bypass (LSG+DJB)
Laparoscopic sleeve
gastrectomy (LSG)
Laparoscopic adjustable
gastric banding (LAGB)
Laparoscopic Roux-en-Y
gastric bypass (LRYGB)
Laparoscopic bariatric procedures
in Japan (n=176, 2012)
LSG 57%
LSG+DJB 20%
LRYGB 14%
LAGB 7%
Others 2%
LSG is now a main bariatric procedure in Japan
15 15
2 21 1
15 15
3 3
1 1
0
2
4
6
8
10
12
14
16
Total LSG LRYGB LSG/JDB LAGB Open
2011
2012
Number of hospitals
Source Procedure No. of
patients
%EWL
12-month
%EWL
24-month
%EWL
36-month
JELTO
Deitel et al.
Garb J et al.
LRYGB
LSG
LAGB
LSG
LRYGB
LAGB
147
102
55
19.606
1,615
5,768
76
66
43
62.7
61.5
42.6
77
68
58
64.7
69.7
50.3
74
-
55
64.0
71.2
55.2
Outcomes of major bariatric procedures
Abbreviations: JELTO, Japan Research Society for Endoscopic and Laparoscopic Treatment of
Obesity; LRYGB, laparoscopic Roux-en-Y gastric bypass; LSG, laparoscopic sleeve gastrectomy;
LAGB, laparoscopic adjustable gastric banding; %EWL, percentage of excess weight loss
Sasaki A, Wakabayashi G, et al. J Gastroenterol 2013
Morbidities LRYGB
(n=91)
LAGB
(n=59)
LSG
(n=215)
LSG/DJB
(n=84)
Total (%)
Intraoperative (%)
Postoperative (%)
Bleeding (reoperation)
Leakage
Anastomotic stenosis
Reoperation (%)
25.3
1.1
1.1
0
15.4
9.9
5.1
0
1.7
0
0
5.1
15.3
0.9
1.9
1.9
0
5.1
15.5
0
3.6
1.2
0
7.1
Morbidity rates after bariatric procedure in Japan
Abbreviations: LRYGB, laparoscopic Roux-en-Y gastric bypass; LAGB, laparoscopic adjustable
gastric banding; LSG, laparoscopic sleeve gastrectomy; LSG/DJB, laparoscopic sleeve gastrectomy
with duodenojejunal bypass
Sasaki A, Wakabayashi G, et al. J Gastroenterol 2013
Bypass
(n=162)
Sleeve
(n=23)
Banding
(n=32)
BMI (kg/m2)
Duration of diabetes (y)
No. of diabetes medication
Use of insulin (%)
48.8±7.65 (2–10)
2 (1–2)
29
50.7±10.610.5 (5–15)
2 (1–3)
48
47.5±7.58 (4–16)
1.5 (1–3)
41
EWL (%)
Short-term (2 years)
Long-term (≥ 5 years)
66.8±20.460.5±24.6
49.7±32.549.5±24.9
37.0±17.829.5±23.4
Long-term (≥ 5 years)
diabetes remission rate (%)
Complete
Partial
Improvement
Unchanged
31
30
31
8
9
22
52
17
0
9
35
56
Can diabetes be surgically cured?
Brethauer SA, et al. Ann Surg 2013
Source Procedure No. of patients Remission (%)
JELTO
Buchwald et al.
Hutter et al.
LRYGB
LSG
LAGB
LRYGB
LAGB
LRYGB
LSG
LAGB
64
35
19
989
205
4,452
249
2,558
88
91
63
83.8
47.8
79*
55*
44*
Remission and improvement rates of T2DM
Abbreviations: T2DM, type 2 diabetes mellitus; JELTO, Japan Research Society for Endoscopic
and Laparoscopic Treatment of Obesity; LRYGB, laparoscopic Roux-en-Y gastric bypass; LSG,
laparoscopic sleeve gastrectomy; LAGB, laparoscopic adjustable gastric banding
*Remission and improvement rates
Sasaki A, Wakabayashi G, et al. J Gastroenterol 2013
Diabetes Surgery Score
Variable Points on ABCD Index
0 1 2 3
BMI (kg/m2) ˂ 30 30-39 40-49 ≥ 50
C-peptide (mmol/L) 0.9-1.9 2.0-3.9 4.0-5.9 ≥ 6.0
Duration of DM (years) ˃ 10 5-10 2-4.9 ˂ 2
Age (years) ≥ 40 ˂ 40
33 3343 46 41
57
83 87100 100 100
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10
Remission (%)
Overall
65.3%
Lee WJ et al. J Surg Obes Relat Dis 2013
Laparoscopic Sleeve Gastrectomy
Laparoscopic sleeve gastrectomy for T2DM
(Iwate Medical University)
LSG
(n=12)
Sex (Male / Female) 5/7
Age(years) 40.1± 13.9 (23–64)
Initial BMI(kg/m2) 42.5± 4.3 (37–52)
Duration of diabetes(years)Use of insulin (n)
Hypoglycemic medication (n)
3.2± 3.2 (0.5–5)
5
6
Initial C-peptide(ng/ml) 4.0± 2.1 (1.9–8.5)
Diabetes Surgery Score * 6.7± 1.6 (4–10)
Mean ± SD (range)* Lee WJ, et al. Surg Obes Relat Dis 2013
1
10
100
Initial Pre 2W 1M 6M 1Y
Fasting glucose (mg/dl) HbA1c(%) HOMA-IR
37
12
36
11
43
12
BMI (kg/m2)
Patient (n)
41
12
Glucose metabolism after LSG
31
11
160
91
12.4
8.8
5.1
2.3
88
5.8
5.0
(Mean)28
8
0
20
40
60
80
100
120
140
160
180
200
pre 30 60 90 120
Pre 1 month (BMI 43) Pre 3 days(BMI 41)
Post 1 month (BMI 36) Post 6 months (BMI 31)
Serum insulin values after 75g OGTT
pmol/l
min
Mean
0
10
20
30
40
50
60
70
80
pre 30 60 90 120
Pre 1 month (BMI 43) Pre 3 days(BMI 41)
Post 1month (BMI 36) Post 6 months (BMI 31)pmol/l
min
Mean
GLP-1 values after 75g OGTT
0
50
100
150
200
250
300
350
400
450
500
pre 30 60 90 120
Pre 1 month (BMI 43) Pre 3 days(BMI 41)
Post 1month (BMI 36) Post 6 months (BMI 31)pg/ml
min
Mean
GIP values after 75g OGTT
Ghrelin↓
Insulin ↑
GLP-1 ↑
LSG
Dumping
Glucose ↓
Body weight ↓ Inflammation ↓
Mechanism of diabetes remission after LSG
Restrictive procedure
Liver
Glucose production ↓
*1
*1 Sun Y, et al. Cell Metab 2006;3: 379-386
*2 Basso N, et al. Surg Endosc 2011; 25: 3540-3550
HCl ↓
GRP ↑GLP-1 ↑
*2
Laparoscopic single-anastomosis
duodenal-jejunal bypass with sleevegastrectomy
Lee WJ et al. Obes Surg 2013
Laparoscopic SADJB-SG appears to be an ideal metabolic/bariatric surgery,
whereas the efficacy is non-inferior to gastric bypass.
2,383
1,944
1,673 * 1,610 *
0
500
1000
1500
2000
2500
3000
Pre Ope 1M 6M
Total Right lobe Left lobeml
* p˂0.001
Changes of NAFLD liver volume by CT
Mean
� Bariatric surgery should be considered for the treatment of obesity for
acceptable Asian candidates with BMI≥ 35 with or without co-
morbidities
� Bariatric/GI metabolic surgery should be considered for the treatment
of T2DM or metabolic syndrome for patients who are inadequately
controlled by lifestyle alternations and medical treatment for
acceptable Asian candidates with BMI≥30
� The surgical approach may be considered as a nonprimary alternative
to treat inadequately controlled T2DM, or metabolic syndrome, for
suitable Asian candidates with BMI≥27.5.
IFSO-APC Consensus statements 2011
Kasama K, et al. Obes Surg 2012;22:677-684
Two-stage surgery in a morbid obese patient: Laparoscopic
pylorus-preserving pancreaticoduodenectomy after laparoscopic
sleeve gastrectomy
Hasegawa H, Sasaki A, Nitta H, Wakabayashi G. Surg Obes Relat Dis 2013
Laparoscopic-assisted PPPD (BMI 29)
Laparoscopic sleeve gastrectomy
6 months
Complete remission of T2DM (BMI 25)
10 months
63 year-old-woman (BMI 40 kg/m2)
NET+T2DM (insulin treatment)
0
50
100
150
200
pre 30 60 90 120
pre LSG
1POM
6POM
post PPPD
0
50
100
150
200
250
pre 30 60 90 120
0
10
20
30
40
50
60
pre 30 60 90 120
0
200
400
600
800
pre 30 60 90 120
Glucose IRI
GLP-1 GIP
mg/dl µU/dl
pmol/dl pg/dl]
min
min
min
min
Changes of glucose, insulin, GLP-1, and GIP levels
GLP-1 actions in peripheral tissues
GLP-1 acts directly on the endocrine pancreas, heart, stomach, and brain,
whereas actions on liver and muscle are indirect.
The biology of incretin hormones
Drucker DJ. Cell Metabolism 2006; 3:153-165
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