ivaylo tzvetkov, krasimir shopov, jordan birdanov, ivan jurukov hospital doverie, sofia, bulgaria
TRANSCRIPT
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Ivaylo Tzvetkov, Krasimir Shopov, Ivaylo Tzvetkov, Krasimir Shopov, Jordan Birdanov, Ivan Jurukov Hospital Doverie, Jordan Birdanov, Ivan Jurukov Hospital Doverie,
Sofia, BulgariaSofia, Bulgaria
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• According to recent studies obese patients with type II diabetes who undergo bariatric surgery revert to normal blood glucose and insulin levels and develop a dramatic increase in insulin sensitivity.
• However, the mechanisms involved are unknown.• The Bariatric procedures, which develop such a rapid decrease
in blood glucose and insulin levels are the malabsortive procedures as gastric by pass, duodenal switch and bilio-pancreatic diversion.
• Laboratory studies with diabetic rats, which underwent bariatric procedures showed improved glucose tolerance and decreased fasting blood glucose.
Background
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• Type II diabetes continues to be associated with high rates of morbidity and mortality, leading to both financial and social burdens.
• Obese patients has normal blood glucose, glycosylated hemoglobin and insulin levels and fourfold increase in insulin sensitivity without continuation of diabetic medication 2 to 4 weeks after Bariatric surgery.
• Bariatric surgery is going to be more aggressive in the last five years and attempts to apply that kind of surgery even to patients with BMI of 30 kg/m2.
Background
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• Bariatric surgery for type 2 diabetes must be performed within accepted international and national guidelines. This requires appropriate assessment for the procedure and comprehensive and ongoing multidisciplinary care, patient education, follow-up and clinical audit, as well as safe and effective surgical procedures. National guidelines for bariatric surgery in people with type 2 diabetes and a BMI of 35 or more need to be developed and promulgated.
Background
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Classification Principal cut-off points Cut-off points for Asians
Normal range 18.5 - 24.9 18.5 - 22.9 23.0 - 24.9
Pre-obese 25.0 - 29.9 25.0 - 27.4 27.5 - 29.9
Obese class I 30.0 - 34.9 30.0 - 32.4 32.5 - 34.9
Obese class II 35.0 - 39.9 35.0 - 37.4 37.5 - 39.9
Obese class III ≥40.0 ≥40.0
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• The aim of the study is to reveal initial experience with Surgical Treatment of Type 2 Diabetes in patients with BMI over 35 kg/m.
• We tried to compare the effect of the main types of bariatric procedures: - restrictive as vertical gastroplasty by Champion technique and Sleeve gastrectomy - malabsortive procedures as Gastric by pass
on Diabetes type II in those patients and influence of surgery over the metabolic control of diabetes and its associated risk factors.
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• Two types of restrictive Bariatric surgical procedures were done:
- Vertical Gastroplasty by Champion technique - Sleeve Gastrectomy
• The malabsortive procedure was Gastric antecolic Mason type by pass.
• All surgical procedures were done laparoscopically – key hole surgery with short stay after operations and fast recovery.
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• Selection of patients was done to following criteria:
- BMI over 35kg/m- moderate or well controlled Diabetes type 2
with oral or on insulin therapy- controlled co-morbidity as arterial hypertension,
sleep apnea, reflux disease - lack of alcohol abuse or severe mental disorders
- contraindications for general anesthesia
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• 36 patients with Diabetes type 2 and Morbid Obesity were included in the study.
• Preoperative assessment included:- blood sugar control for 24 hours before
surgery, the same control on 1st and 3rd week after surgery, follow up of blood sugar 3,6 and 12 months after Bariatric Surgery
• Preoperative assessment of glycosylated hemoglobin and insulin levels 2 weeks before surgery. Their values 6,12,36 and 48 months after surgery were also followed up.
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• 29 patients underwent Laparoscopic Gastric bypass surgery. There were no major complications in that group and all were discharged within 5 days after the operation.
• Laparoscopic Sleeve Gastrectomy was done in 5 female patients aged from 51 to 60. There was only one complication in a 54 years old woman but recovery and outcome were uneventful.
• LaparoscopicVertical Gastroplasty by Champion technique was applied in 2 cases, one male and one female patients with BMI between 39 and 43kg/m2. There were no complications in those cases and patients were discharged 4 days after surgery.
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• About 26 patients had inadequate controlled Diabetes type 2 one month before surgery with mild raised values of blood sugar and HbA1c was between 8 and 11% in 14 of them.
• 21 patients were on Insulin therapy before surgery and the other 15 patients on oral treatment and diet.
• Insulin blood levels were raised in 28 patients before surgery.• About 34 patients had 1 month before surgery poorly to
controlled arterial hypertension.• All 36 patients had reflux disease with mild symptoms as
regurgitation and heart burning, 11 of them had also hiatal hernias type I found on preoperative upper endoscopy and barium X-rays investigations
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• Sugar blood tests showed significantly drop off 1 week after surgery in 31 patients. They had results from 5,1 to 7,4 mmol/l
• The other 5 patients had sugar blood results from 7,0 to 8,5 mmol/l in the first postoperative week and only in 2 patients with Vertical Gastroplasty sugar blood levels remained between 6,5 to 7,2 mmol/l one year after surgery.
• The results of HbA1c dropped to 6,0- 7,0% in 2 to 3 months after surgery and remained on that levels in 33 patients 1 year after surgery.
• Insulin levels were normal in all patients 3 to 6 months after surgery.
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• 34 patients did not need any medical treatment about Diabetes type 2 within 15 to 18 months after surgery.
• The other two patients were only on oral therapy and diet for treatment of Diabetes type 2.
• The blood pressure was normal in 27 patients 6 months after surgery. The other 9 patients reduced oral intake of medications for that co-morbidity significantly (p> 0,05).
• About 14 patients had improvement of arterial blood supply of lower limbs 4 to 6 months after bariatric surgery done by doppler duplex scan.
• The quality of life in all patients was assessed by themselves with 8 to 10 points according to VAS 6 months to 1 year after surgery
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Remission based on fasting plasma glucose <7.0 mmol/l and not on hypoglycaemic therapy
After Bariatric Malabsortive Surgery
Control Group with Lap-Band and Vertical Gastroplasty
2-year incident 0,5 % 2,5%
4-year incident 2,0% 4,5%
2-year remission 92% 68%
4-years remission 75% 46%
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• Our data supports recent investigations and multi-central studies about recommendations for surgical treatment of morbid obese patients with BMI over 35kg/m2 and Dabetes type 2.
• Laparoscopic Bariatric surgery has a history of more than 15 years with good outcome and low rate of complications as in laparoscopic cholecystectomy.
• LRYGB procedures influence the gut hormonal milieu and provide an early non-weight related improvement in glycaemic control of type 2 diabetes according to our study.
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• Diabetes type 2 remits or improves in the majority of patients after bariatric surgery. The procedures producing greater excess weight loss as Gastric bypass and Sleeve Gastrectomy lead to higher remission rates.
• We need a Bulgarian official survey and consent between surgeons and endocrinology specialists to establish national guidelines for treatment of Morbid obese patients with Diabetes type 2.
• The societies of Bulgarian surgeons and endocrinology specialists have to make further steps to inform the society and Ministry of Health that surgical treatment of Diabetes type 2 is not a myth or an experiment with commercial issues as it was said a year ago by a representative of the National Health Insurance Fund but a medical based evidence for a new treatment option of Diabetes type 2 all over the world.
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• HbA1c <6,0%• No hypoglycaemia• Total cholesterol < 4 mmol/l, LDL cholesterol < 2 mmol/l• Triglycerides <2,2 mmol/l• Blood pressure < 135/85 mmHg• Over 15% weight loss
• With reduced medication from the pre-operated state or without other medications (where medications are continued, reduced doses from pre-surgery with minimal side effects would be expected)
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Ivaylo Tzvetkov, Krasimir Shopov, Ivaylo Tzvetkov, Krasimir Shopov, Jordan Birdanov, Ivan Jurukov Hospital Doverie, Jordan Birdanov, Ivan Jurukov Hospital Doverie,
Sofia, BulgariaSofia, Bulgaria
Thank you for your attention