screening and follow-up in obese subjects bariatric sugery: when? gabriella garruti department of...

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)

Et lucem sed aliam reddit…

Bari 27 novembre 2009

What is Overweight?

Underweight <18.5 Kg/m2

Normal-weight 18.5 - 24.9 Kg/m2

Overweight 25.0 – 29.9 Kg/m2

Obesity category1st 30.0 – 34.9 Kg/m2

2nd 35.0 – 39.9 Kg/m2

3rd > 40.0 Kg/m2

BMIOverweight and Obesity: Overweight and Obesity:

When?When?

WAIST FAT distribution Central obesity

Man: > 9494 (102) cmWoman: > 8080 (88) cm

IDF /(ATPIII)

DietDiet Physical ActivityPhysical Activity

Lifestyle Lifestyle ModificationModification

PharmacotherapyPharmacotherapy

SurgerySurgery

Obesity Treatment Pyramid Obesity Treatment Pyramid



Guidelines for Selecting Obesity Treatment

Treatment 25-26.9 27-29.9 30-34.9 35-39.9 >40

Diet, Exercise, Behavior Tx + + + + +

Pharmaco-therapy

With co-morbidities + + +

SurgeryWith co-

morbidities

+

The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. October 2000, NIH Pub. No.00-4084 modified by Garruti 2008

+

BMI Category (kg/mBMI Category (kg/m22))


13.02.05

Gastric Bypass (Roux-en-Y)

Only when Lifestyle is unhealthyOnly when Lifestyle is unhealthy

Gastric banding

Bariatric surgery



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

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

Bariatric surgery: what is?



Indications1. BMI >40 kg/m2 or

BMI 35–39.9 kg/m2 and life-threatening cardiopulmonary disease, severe DIABETES, orlifestyle impairment

2. Failure to achieve WL with Medical Treatment

Controintraindications1. History of noncompliance with medical care2. Psychiatric illnesses: personality disorder, uncontrolled depression, suicidal

ideation, substance abuse3. elevated ASA risk

NIH Consensus Development Panel. Ann Intern Med 1991;115:956.

Bariatric Surgery: When ?

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



Obesità di durata superiore a 5 anniObesità di durata superiore a 5 anni BMI BMI >> 40Kg/m 40Kg/m2 2 o BMI o BMI >>35Kg/m35Kg/m22 con comorbidità* con comorbidità* Età: da 18-65 anniEtà: da 18-65 anni Fallimento Tx medica (dietetica, farmacologica, Fallimento Tx medica (dietetica, farmacologica,

comportamentale) per almeno 1 annocomportamentale) per almeno 1 anno Assenza di cause endocrine di obesità Assenza di cause endocrine di obesità Rischio anestesiologico max < ASA 2Rischio anestesiologico max < ASA 2 Assenza di malattie psichiatriche e/o disturbi del Assenza di malattie psichiatriche e/o disturbi del

comportamento alimentare (DCA). comportamento alimentare (DCA). Compliance del paziente (follow-up)Compliance del paziente (follow-up)

NIH 1998- LIGIO 1999 EAES /ASBS 2005


Indicazioni


BMI BMI >>35 con 35 con comorbilità* comorbilità*

OSAS/PickwickOSAS/Pickwick Ipertensione arteriosa Ipertensione arteriosa Scompenso cardiacoScompenso cardiaco Diabete mellito tipo 2Diabete mellito tipo 2 OsteoartrosiOsteoartrosi ColelitiasiColelitiasi DislipidemieDislipidemie

Insuff. venosa cronica arti inferiori Insuff. venosa cronica arti inferiori Impotenza/Irregolarità Impotenza/Irregolarità

mestruali /Infertilitàmestruali /Infertilità IperuricemiaIperuricemia IrsutismoIrsutismo NefrolitiasiNefrolitiasi

Indicazioni




Bariatric Sugery: how important is the multidisciplinary approach?



Bariatric Sugery: how important is the multidisciplinary approach?

Anesthesiologist, Cardiologist, Dietitian or Nutritionist, Anesthesiologist, Cardiologist, Dietitian or Nutritionist, Endocrinologist , Pneumologist, Psychiatrist, SurgeonEndocrinologist , Pneumologist, Psychiatrist, Surgeon


http://www.vanth.org/vibes/images/normalECG2.PNG

http://www.sixthman.net/blog/wp-content/uploads/2009/05/brain-763982-11.jpg

http://hillcountrydocs.com/sitebuildercontent/sitebuilderpictures/surgeon.jpg

http://images.google.it/imgres?imgurl=http://www.buonissimo.org/images/cereali.jpg&imgrefurl=http://www.buonissimo.org/rubriche/cereali.asp&h=299&w=400&sz=45&tbnid=OmtfgM4ieTbR_M:&tbnh=89&tbnw=120&hl=it&start=1&prev=/images%3Fq%3Dcereali%26svnum%3D10%26hl%3Dit%26lr%3D

Valutazione clinica e strumentale prima della chirurgia

Esami ematochimici Esami ematochimici Inquadramento endocrino-metabolicoInquadramento endocrino-metabolico* e genetico* e genetico Rx torace Rx torace Ecografia addome superiore e inferioreEcografia addome superiore e inferiore Doppler venoso arti inferioriDoppler venoso arti inferiori Emogasanalisi, spirometria, polisonnografiaEmogasanalisi, spirometria, polisonnografia Inquadramento psicologico-nutrizionale (psichiatra e Inquadramento psicologico-nutrizionale (psichiatra e

dietisti)dietisti) Rx baritato (+Trendelenburg per ernia iatale)Rx baritato (+Trendelenburg per ernia iatale) EGDS + biopsia per infezione H. pyloriEGDS + biopsia per infezione H. pylori Consulenza cardio-anestesiologicaConsulenza cardio-anestesiologica



Inquadramento endocrino-Inquadramento endocrino-metabolico e nutrizionalemetabolico e nutrizionale

Indagine alimentare, variabili antropometricheIndagine alimentare, variabili antropometriche Indici nutrizionaliIndici nutrizionali HOMA/ OGTT per glicemia e insulinemiaHOMA/ OGTT per glicemia e insulinemia Pattern ormonali: Pattern ormonali:

– asse ipofisi-surrene/gonadiasse ipofisi-surrene/gonadi– asse ipofisi-tiroideasse ipofisi-tiroide– asse GH /IGF1asse GH /IGF1

Ecografia tiroideaEcografia tiroidea Mineralometria ossea computerizzata “Total body”Mineralometria ossea computerizzata “Total body”



• Palatableness (taste receptors)• Geography• Nutrients availability• Economic situation• Culture • Religion

Is Diet dependent on …?Is Diet dependent on …?

Energy needs Environment Genes (metabolism)

Your Gut Has Taste Receptors

ScienceDaily (Aug. 21, 2007)



http://upload.wikimedia.org/wikipedia/commons/6/6a/Kerala_fisherman.jpg

http://www.sciencedaily.com/videos/2006/0608-why_i_hate_anchovies.htm

Lazar Science 2005 modified by Garruti

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

The Desert’s perfect foodsEt lucem sed aliam reddit…

Normalweight

Overweight

Obese


Indagine alimentare Et lucem sed aliam reddit…

2200

62 99.2 154 41.8

2012% 28% 60%

3X X X

pane, pasta, condimenti, rusticiverdura

Dieta a b.i.g 1200 Kcal/Die Attività fisica (v. piramide attività fisica)


Giovanna MallardiGiovanna Mallardi

Diet & Energy needsNeuronal 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



http://radiographics.rsnajnls.org/content/vol27/issue4/images/large/g07jl07c01a.jpeg

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 volumeAlternatively foods with low energy density provide a larger portion size with a fewer number of calories.



0 1 2 3 4 5 6 7 8

Energy Density of Selected Foods

Energy Density (kcal/g)

LettuceVegetable soup

Skim milkApple

Black beansWhite fish

YogurtVegetable lasagna

Roast chickenWhite bread

PretzelsCheddar cheese

Salad dressingPotato chips

BaconButter

Klein S, et al. Gastroenterology. 2002



HEALTHY PYRAMID FOOD (Harvard Medical School)


http://www.intelihealth.com/IH/ihtIH/WSIHW000/356/34813/308755.html?d=dmtContent

ClassificationGastric restriction

Primarily restrictive and partially malabsorptive

Primarily malabsorptive and partially restrictive

Procedure

Adjustable Gastric Banding

Roux-en-Y Gastric Bypass Sleeve Gastrectomy

Biliopancreatic diversion with duodenal switch

Biliopancreatic diversion

Distal gastric bypass

Current Bariatric Surgical Procedures Et lucem sed aliam reddit…


Restrictive Gastric Surgery

Vertical gastroplasty

Adjustable gastric banding

Intragastric balloon

(BIB)



Laparoscopic Adjustable Gastric Banding

Silicone band placed around upper stomach to create a small pouch. Outlet diameter can be changed by infusing or withdrawing saline from port.

Gastric BandConnection tubing

Access port (reservoir)

American Society for Metabolic and Bariatric Surgery, www.asbs.org

LapBandTM

Puglisi 2008



Roux-en-Y gastric bypass Et lucem sed aliam reddit…


http://care.diabetesjournals.org/content/vol31/Supplement_2/images/large/zdc1020867850001.jpeg

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

Biliopancreatic Diversion with Biliopancreatic Diversion with Duodenal SwitchDuodenal Switch

Marceau P. et al. World J Surg 1998;22:947-54



Follow-up (post- LAGB and post-GBP)

0 1 3 6 9 12 15 18 21 24 0 1 3 6 9 12 15 18 21 24 months

EGDS Calibration

Rx ?Rx ?

Cardiologist, Dietitian or Nutritionist, Cardiologist, Dietitian or Nutritionist, Endocrinologist , Pneumologist, PsychiatristEndocrinologist , Pneumologist, Psychiatrist

surgeonsurgeon

……?



Energy Metabolism in mammalsEnergy Metabolism in mammals

Basal Metabolic Rate[Obbligatory Thermogenesis (Th)]

Exercise-induced ThDiet-induced Th

Major effects of

Bariatric Surgery Weight



Indagine alimentare Et lucem sed aliam reddit…

1000

99.2 154 41.8

3015% 28% 57%

3X X X

?

Dieta a b.i.g 1000-1200 Kcal/Die Attività fisica (v. piramide attività fisica)


Maria A. Lucafo’ & Giovanna MallardiMaria A. Lucafo’ & Giovanna Mallardi

X X

Life-style modifications :

Anti-atherogenic Diet



Suggested Energy Deficit based on Initial BMI

Initial BMI

(Kg/m2)

Suggested Energy Intake

(kcal/d)

Approximate Initial Energy Deficit

(kcal/d)

25-29.925-29.9 ?? 500500

30-34.930-34.9 ?? 500500

35-39.935-39.9 ?? 500-1000500-1000

>>4040 ?? 500-1000500-1000

>>50 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



Obrien et al. Ann Intern Med. 2006

Wei

ght L

oss,

%

Baseline

Surgical (LapBand)

Nonsurgical

*VLCD, behavioral modification, and pharmacotherapy

6 mo 12 mo 18 mo 24 mo

Weight Loss after Bariatric Surgery Weight Loss after Bariatric Surgery or Mor Medical edical TTherapyherapy**

BMI between

30 and 35 Kg/m2



MesiMesi WL(Kg)/SEMWL(Kg)/SEM WE(Kg)/SEMWE(Kg)/SEM %EWL/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

Parametri antropometrici dopo BIB

6° mese 18.0/8.0 40.0/5.6 27.0/7.8



Parametri antropometrici dopo LapGB

Mesi WL(Kg)/SEM

WE(Kg)/SEM

%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



% of subjects with low or high compliance

Excess Weight Excess Weight Loss (EWL) and Compliance to (EWL) and Compliance to CComprehensive omprehensive MMedical edical TTherapyherapy* * after Gastric Bandingafter Gastric Banding

lowhigh

low high

Lucafo’ MA, Rotelli MT, De Tullio A. 2008 unpublished

*[life-style modifications (diet, exercise) + pharmacotherapy]

%EWL in subjects with low or high compliance



Procedure ApproximateLoss of Excess

Weight (%)

Laparoscopic gastric banding 45–65

Gastric bypass procedure 55–65

Biliopancreatic diversion (DS) 60–75

Effect of Different Bariatric Surgical Procedures on Weight Loss

Klein et al. Gastroenterology. 2002;123:882-932



Comorbidity outcomes after Bariatric surgery

Comorbidity Improved/Resolved

Diabetes 100%

Coronary artery disease 100%

Hypercolesterolemia 96%

Gastroesophageal reflux d. 96%

Sleep apnea 93%

Hypertension 88%

Osteoarthritis 88%

Hypertriglyceridemia 86%

Depression 55%

Adapted from Schauer et al. Ann Surg 2000

Busetto et al. Obes Surg 2000 10: 569Busetto et al. Obes Surg 2000 10: 569

Pontiroli et al JCEM 2002 87:3555Pontiroli et al JCEM 2002 87:3555

Scopinaro et al. Diabetes Care 2005; 28:2406Scopinaro et al. Diabetes Care 2005; 28:2406

Busetto et al. NMCD 2008; 18:112Busetto et al. NMCD 2008; 18:112



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

Total M FN 20 9 (45%) 11 (55%)Mean age (SD) 40.8 (12.2) 36.4 (11.3) 44.4 (12.3)Range 22-60 22-51 23-60

Mean Baseline weight (SD) 132.3 (23.4) 142.4 (26.9) 124 (17.3)Range 100-195 112-195 100-161

Mean Baseline BMI (SD) 45.8 (5.9) 45.6 (6.5) 45.9 (5.8)Range 37.4-58.6 37.4-55.7 38.9-58.6

Arterial hypertension 9 (45%) 3 (33.3%) 6 (54.5%)Hypertryglyceridemia 8 (40%) 5 (55.6%) 3 (27.3%)Smoke 7 (35%) 3 (33.3%) 4 (36.4%)Diabetes 7 (35%) 3 (33.3%) 4 (36.4%)Vascular dis. 5 (25%) 2 (22.2%) 3 (27.3%)Joint diseases 4 (20%) 1 (11.1%) 3 (27.3%)Hypoventilation syndrome 3 (15%) 1 (11.1%) 2 (18.2%)Heart diseases. 3 (15%) 2 (22.2%) 1 (9.1%) Anxiety-depression 3 (15%) 0 (0%) 3 (27.3%)Thyroid dysfunction 2 (10%) 0 (0%) 2 (18.2%)Gallbladder stones 1 (5%) 0 (0%) 1 (9.1%)

Box plot comparing EI 3 PA at baseline and 3 and 6 months after surgery.



AI: aggregation index; EI: elongation index AI: aggregation index; EI: elongation index

T0 T3 T6p-values

T3 vs T0 T6 vs T0AI % 0.74 (0.04) 0.72 (0.05) 0.67 (0.06) 0.013 0.000AI t1/2 1.34 (0.36) 1.38 (0.3) 1.49 (0.29) 0.3447 0.189EI 0.03 Pa 0.042 (0.016) 0.039 (0.016) 0.043 (0.023) 0.32 0.757EI 3 Pa 0.379 (0.065) 0.412 (0.056) 0.449 (0.067) 0.049 0.0001EI 30 Pa 0.584 (0.128) 0.646 (0.043) 0.669 (0.064) 0.11 0.0274

Weight132.305 (23.446)

117.85 (25.775)

109.75 (25.007) 0.0001 0.0001

BMI 45.813 (5.977) 40.813 (6.867) 37.965 (6.792) 0.0001 0.0001

Tot Chol 207.8 (23.305) 196.6 (16.529)185.15

(18.883) 0.0045 0.0001HDL Chol 48.25 (11.201) 50.15 (10.277) 53.5 (8.918) 0.197 0.0048

LDL Chol 132.05 (21.197)128.21

(26.388) 122.2 (23.294) 0.086 0.0042

Tryglicerides 154.75 (51.759)138.85

(38.232) 129.7 (37.542) 0.0161 0.0038Glycaemia 103.7 (15.058) 99.65 (10.937) 97.65 (7.436) 0.16 0.38

Insulin 33.66 (17.155)27.171

(13.507) 24.29 (12.446) 0.001 0.0001

AI: aggregation index; EI: elongation index

THE EFFECTS OF GASTRIC BANDING ON RED BLOOD CELL AGGREGATION & DEFORMABILITY IN MORBID OBESE PATIENTS

Puglisi Francesco et al.

Box plot comparing AI% 3 at baseline and 3 and 6 months after surgery


Bs 3M 6M


BMI DISTRIBUTION IN A COHORT BMI DISTRIBUTION IN A COHORT OF TYPE 2 DIABETIC SUBJECTSOF TYPE 2 DIABETIC SUBJECTS



GARRUTI G., VITA MG, GIAMPETRUZZI F et al. 2008 unpublished

LapGBLIMITILIMITI Anestesia Anestesia (vs Tx medica integrata)(vs Tx medica integrata) Limitato calo ponderale Limitato calo ponderale (vs Tx chirurgica malassorbitiva)(vs Tx chirurgica malassorbitiva) Obbligatorio “counseling” Obbligatorio “counseling” Alimentazione semiliquida per ~ 1 settimana Alimentazione semiliquida per ~ 1 settimana (600 - 800Kcal/die) (vs Terapia medica ed chirurgica malassorbitiva)(600 - 800Kcal/die) (vs Terapia medica ed chirurgica malassorbitiva) Durata del pasto:> 40 min Durata del pasto:> 40 min Intervallo tra cena e bed-time: 2 hIntervallo 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



Complications after Gastric Bypass 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



GBP & Dumping syndromeGastric 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 diarrhea Symptoms dissipate after the patient rests???



BraiBrainn

NPYAGRPgalanin

Orexin-Adynorphin

StimulateStimulateα-MSHCRH/UCNGLP-I

CARTNE5-HT

InibitInibit

Central SignalsCentral Signals

Glucose

CCK, GLP-1 Apo-A-IVVagal afferents

Insulin

Ghrelin

Leptin

Cortisol

Peripheral Peripheral signalssignals

Peripheral Peripheral organsorgans

+

+

Gastrointestinaltract

Adiposetissue

FoodIntake

Adrenal glands

External factorsEmotionsFood characteristicsLifestyle behaviorsEnvironmental cues

Regulation of Food IntakeRegulation of Food Intake

Schwartz et al. 2000 Nature



ANP



Adipose Tissue depots are a marvelous source of adipocyte

precursors stem cells

Any surgical procedureAny surgical procedure normalizes hyperglycemianormalizes hyperglycemia restores insulin sensitivityrestores insulin sensitivity prevents progression from IGT to DMprevents progression from IGT to DM reduces mortality from DMreduces mortality from DMGastric bypass and Biliopancreatic diversionGastric bypass and Biliopancreatic diversion restores euglycemia and normal insulin restores euglycemia and normal insulin long before any significant weight losslong before any significant weight loss

Changes in hormones secretion from the GI tract

Bariatric surgery and GlycaemiaBariatric surgery and GlycaemiaEt lucem sed aliam reddit…


Bariatric Surgery in DM2:When?

““Should surgeons treat diabetes in severely obese people ?”Should surgeons treat diabetes in severely obese people ?”

J.H. Pinkney, SjJ.H. Pinkney, Sjööstrströöm C.D., Gale E.A.M. Lancet 2001 357: 1357m C.D., Gale E.A.M. Lancet 2001 357: 1357..



Rubino et al 2004 Ann Surg 240(2): 236–242

Incretins and anti-incretins in DM2Et lucem sed aliam reddit…

Rubino et al. Ann Surg. 2004; 240(2): 236–242

Incretins and anti-incretins in DM2 after GBP


[A] Simple gastro-jejunostomy

Enhanced delivery of nutrients to the hindgut without excluding

nutrient flow through the proximal intestine

No improvement of Diabetes in diabetic GK animals.

[B] DJB creates similar shortcuts of

nutrients as in gastro-jejunostomy

- includes the exclusion of the proximal intestine from the flow

of nutrients- improves glucose tolerance and

fasting glycemia in diabetic GK rats

Exclusion of the duodenum is critical for the effect on diabetes

Duodeno-jejunal bypass (DJB) and Diabetes

Rubino et al. Diab. Care 2008


http://care.diabetesjournals.org/content/vol31/Supplement_2/images/large/zdc1020867850002.jpeg

• 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 GLP-1, a crucial incretin hormone.

Gastric inhibitory polypeptide (GIP), also known as the glucose-dependent insulinotropic peptide

Drucker, D. J. J. Clin. Invest. 2007;117:24-32

Dipeptidyl peptidase IV (DPP4) enzyme that breaks down gut peptides especially GLP-1

DPP-4 Inhibitors or Incretin Enhancers


http://www.diabetesnet.com/diabetes_treatments/glp1.php

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?

IndicationsBMI >40 kg/m2 or BMI 35–39.9 kg/m2 and

life-threatening cardiopulmonary diseases

severe DIABETES

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

Systematic comparative studies with new therapeutic compounds

- CB1 antagonists

- CCK enhancers

- DPP4 inhibitors

- Incretin enhancers

- Glitazones

SurgerySurgeryV. MEMEOF. PUGLISI

P. CAPUANO M. TEDESCHI

M. A. LUCAFO’

PsychiatryPsychiatry L. ZAVOIANNI

Internal Medicine & Internal Medicine & EndocrinologyEndocrinology

F. GIORGINOG.MALLARDI

A. BELLOMO DAMATO F. BRESCIA

G.STEFANELLIG. MALLARDIA. DE TULLIO

Clinical NurtitionClinical NurtitionG. DE PERGOLA

L. MANDOI A. RAFFO

Anesthesia Anesthesia P. CARAVETTA

Acknowledgements

EndoscopyEndoscopyO. CAPUTI IAMBRENGHI

Laboratory of D.E.T.OLaboratory of D.E.T.O..M. T. ROTELLI

CardiologyCardiologyA. VENEZIANI


Internal MedicineInternal MedicineR. GIORGINO


PneumologyPneumology N. PALUMBO

O. RESTA

screening and follow-up in obese subjects bariatric sugery: when? gabriella garruti department of...

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