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MALABSORPTIVE BARIATRIC SURGERY in Low BMI Korean Patients Ji Yeon Park Soonchunhyang University Seoul Hospital, Korea

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Body weight / Height 2 The most practical measure of a persons adiposity BMI (kg/m 2 )WHO classification of weight status 25 ~ 29.9Overweight 30 ~ 34.9Mildly Obese (Class I obesity) 35 ~ 39.9Moderately obese (Class II obesity) 40 ~ 49.9Severely or extremely obese (Class III obesity) >50Super obese (Class IV obesity)

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NIH Consensus statement 1991 risk/benefit ratio Decision based on a prudent evaluation of the risk/benefit ratio Era of open surgery A very few surgical options

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Roux-en-Y gastric bypass (RYGB)Laparoscopic adjustable gastric banding (LAGB) Biliopancreatic diversion (BPD)Biliopancreatic diversion with duodenal switch (BPD/DS) Sleeve gastrectomy (SG)

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Dixon et al. Lancet 2012; 379: 2300-11

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Long-term, prospective, controlled trial 4047 obese subjects surgery group (n=2010) vs. control group (n=2037) Recruitment : Sep 1987 ~ Jan 2001 BMI : Men 38, women 34 Gastric bypass (13%), banding (19%) & vertical banded gastroplasty (68%) Follow-up: 12 ~ 25 years

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The SOS intervention study

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Adjusted hazard ratio 0.17 (0.13 - 0.21) Carlsson et al. N Engl J Med 2012;367:695-704

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BARIATRIC SURGERY Lower the BMI & Body weight METABOLIC SURGERY Reduce HbA1c & medications

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NIDDM 121 / 146 (82.9%) IGT 150 / 152 (98.7%) Euglycemia

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Mingrone et al. N Engl J Med 2012;366:1577-85. Single-center, nonblinded, randomized, controlled trial Medical therapy vs. BPD vs. RYGB 60 pts Age : 30 ~ 60 years BMI 35 DM > 5 years HbA1c 7.0%

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Outcomes at 2 years Mingrone et al. N Engl J Med 2012;366:1577-85.

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Difference in the rate of T2DM remission At 2 years Medical therapy RYGBBPDP-value Diabetes remission015 (75%)19 (95%)7.0% BMI 27 ~ 43

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At 12 months Schauer et al. N Engl J Med 2012;366:1567-76

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Changes in Diabetes Control Over 3 Years Schauer et al. N Engl J Med 2014;370:2002-13 Predictors of HbA1c

Indication to bariatric surgery in class I obesity Comorbidity burden >> BMI levels Obesity scoring system phenotypization beyond BMI levels for guiding therapeutic choices Position statement from IFSO, 2014

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Schauer et al. N Engl J Med 2014;370:2002-13

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Parikh et al. Ann Surg 2014;260:617624 Randomized pilot trial

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Serrot et al. Surgery 2011;150:684-91

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66 patients BMI 30 35 kg/m2 DM duration 12.5 7.4 years HbA1c 9.7 1.5% Cohen et al. Diabetes Care 2012

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Estimated 10-year cardiovascular risk after RYGB in mild obesity Cohen et al. Diabetes Care 2012

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Lee W-J et al. Arch Surg. 2011;146(2):143-148 Randomized controlled trial 30 SAGB + 30 SG HbA1c>7.5 % BMI 25 - 35 Kg/m 2, C-peptide 1.0 ng/mL Duration of T2DM > 6 months Baseline characteristics Duration of DM : 6.4 years (4.28.5 ) BMI 30.6 kg/m2 (25.134.7) HbA1c 10.0% (7.515.0)

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Effect of duodenal exclusion at 12 months SAGB vs SG Lee W-J et al. Arch Surg. 2011;146(2):143-148

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Lee W-J et al. OBES SURG (2014) 24:15521562

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At Soonchunhyang University Seoul Hospital

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RYGB RYGB : Low BMI vs. high BMI Low BMI (n=137)High BMI (n=266)p-value Age (years) 40.1 10.636.2 11.10.001 Sex Male 17 (12.4)55 (20.7)0.040 chi Female 120 (87.6)211 (79.3) Body weight (kg) 84.9 9.8111.2 17.2

Purpose Metabolic resolution >> weight loss RYGB or SAGB RYGB or SAGB (malabsroptive procedures) Effective comorbidity resolution and weight loss Malabsoptive vs. Restrictive procedures Better diabetic resolution after BYPASS Different response of diabetic resolution? Difference in preoperative diabetic characteristics Patient selection : DM duration, preoperative C-peptide Long-term follow-up is necessary......

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THANK FOR YOUR KIND ATTENTION.