1. Bariatric/ metabolic surgery-Bariatric/ metabolic surgery-
What should patients know?What should patients know?
Torsten Olbers MD, PhDTorsten Olbers MD, PhD

2. Why lose weight?Why lose weight?
Improve health-Improve health- live healthier and longerlive healthier and longer
Quality of lifeQuality of life-- ability to live a normal lifeability to live a normal life

3. What do we want to achieve?
Lower body weightLower body weight Not per seNot per se
Improved QoLImproved QoL YesYes
Reduced morbidityReduced morbidity Yes!Yes!
Cost effective treatmentCost effective treatment Yes!Yes!
Prevent premature deathPrevent premature death YES!YES!

4. Not medicineNot medicine OROR surgery,surgery,
ratherrather
medicinemedicine ANDAND surgerysurgery

5. An important question..An important question..
Do we suggest surgery,Do we suggest surgery,
or is it the patient driving..?or is it the patient driving..?

6. Who can be a surgical candidate?Who can be a surgical candidate?
 BMI >35 kg/m² (BMI >30)BMI >35 kg/m² (BMI >30)
 > 18 y> 18 y
 Previous failure on conventional attemptsPrevious failure on conventional attempts
 No unstable psychiatric diseaseNo unstable psychiatric disease
 No current addiction (alcohol, pills, drugsNo current addiction (alcohol, pills, drugs))

7. Type of operationsType of operations
 Gastric bandGastric band
 Gastric BypassGastric Bypass
 Sleeve gastrectomySleeve gastrectomy

8. Laparoscopic gastric bypass
Olbers, Lönroth et al, Obesity Surgery 2003

10. How does it work?How does it work?
 Less hungerLess hunger
 Faster fullnessFaster fullness
 Changes in food preferenceChanges in food preference
 Altering energy expenditureAltering energy expenditure
Altering in signals regulating food
intake and energy expenditure

11. Gastric bypass vs. SleeveGastric bypass vs. Sleeve
Gastric bypassGastric bypass
 ””Gold standardGold standard””
 Since 70iesSince 70ies
 Long term results- 20yLong term results- 20y
 AllAll ””spare partsspare parts”” left in situleft in situ
 Cures reflux diseaseCures reflux disease
 Some more need forSome more need for
supplementssupplements
SleeveSleeve
 Newcomer (5-10 y)Newcomer (5-10 y)
 No involvement of small bowelNo involvement of small bowel
 AsAs ””majormajor”” surgerysurgery
 ””Spare partsSpare parts”” resectedresected
 Reflux, vomitingReflux, vomiting

12. What to expect in weight loss?What to expect in weight loss?
Short term 33%, long term 25-30% weight lossShort term 33%, long term 25-30% weight loss
Loss of half to all of overweight over one yearLoss of half to all of overweight over one year
>90% have a good long term effect>90% have a good long term effect

13. Sjöström et al NEJM -07
SOS- Swedish Obese Subjects study

14. Sleep apnaeSleep apnae
AsthmaAsthma
NASH, NAFLDNASH, NAFLD
Cardio-vascularCardio-vascular
Type 2 diabetes
Hyperlipidemia
Hypertension
InfertilityInfertility
PCOSPCOS
Osthoarthritis,Osthoarthritis,
pain, mobilitypain, mobility
GallstoneGallstone
CancerCancer
What about health?
StrokeStroke
Psoriasis, RAPsoriasis, RA

15. Could you never eatCould you never eat ””normallynormally”” again?again?
 Can be tough in the beginning (weeks-months)Can be tough in the beginning (weeks-months)
 Changes in sensations around foodChanges in sensations around food
 Not always liking same type of foodsNot always liking same type of foods
 You should be able to eat everything–You should be able to eat everything–
in smaller amountsin smaller amounts

16. Diet before and after surgeryDiet before and after surgery
 Low calorie diet some weeks before surgeryLow calorie diet some weeks before surgery
 Gradually increase in texture over first monthGradually increase in texture over first month

17. Portion sizePortion size
 Varies!Varies!
 After some months- small normal portionAfter some months- small normal portion

18. Eating after gastric bypassEating after gastric bypass
 Chew properlyChew properly
 Regular mealsRegular meals
 Keep the pace slowKeep the pace slow
 Planning!Planning!
 DonDon’’t drink when eatingt drink when eating
 Eat on a small plateEat on a small plate

19. It is not normal with vomiting orIt is not normal with vomiting or
abdominal pain after gastric bypass!abdominal pain after gastric bypass!
If early:If early: suspect complicationsuspect complication
If late:If late: suspect internal herniationsuspect internal herniation

20. SupplementationSupplementation
•• Less food intake initiallyLess food intake initially
•• Impaired uptakeImpaired uptake
 Vitamin BVitamin B1212
 Calcium + Vitamin DCalcium + Vitamin D
 Multi vitamin- andMulti vitamin- and
mineral tabletmineral tablet
 Iron to fertile womenIron to fertile women

21. Healthy choices!Healthy choices!
 VariationVariation
 Prioritize proteinPrioritize protein
 A lot of fruit and vegetablesA lot of fruit and vegetables
 Full corn breadFull corn bread
 Fast food less appealingFast food less appealing

22. DumpingDumping
 Food enters directly to the intestineFood enters directly to the intestine
 Not harmful, just very unpleasant!Not harmful, just very unpleasant!
 Tiredness/weakness, nausea, palpitation,Tiredness/weakness, nausea, palpitation,
cold sweatingcold sweating
 Disappears within 15-30 minDisappears within 15-30 min
– Sweet and fat foodsSweet and fat foods
– Too large amountToo large amount
– Too fastToo fast

23. Normal courseNormal course
 Early mobilisationEarly mobilisation
 Start drinking- often and littleStart drinking- often and little
 First 24 h can be toughFirst 24 h can be tough
 1-2 days in hospital1-2 days in hospital
 3 weeks sick leave3 weeks sick leave
 Physical activity allowed, almost no restrictionPhysical activity allowed, almost no restriction

24. What can go wrong?What can go wrong?
• Complication 1/20Complication 1/20
1-2/100 serious (possibly reoperation)1-2/100 serious (possibly reoperation)
 HaemorrhageHaemorrhage
 LeakageLeakage
 Pulmonary embolismPulmonary embolism
• Complications usually early after surgeryComplications usually early after surgery
• What is the risk of dying? 0,5/ 1000What is the risk of dying? 0,5/ 1000

25. Late complaintsLate complaints
 Feeling cold and tiredFeeling cold and tired
 Modest hair loss after some 3-6 monthsModest hair loss after some 3-6 months
 Risk for vitamin/mineral deficienciesRisk for vitamin/mineral deficiencies
 Excessive skinExcessive skin
 ””HypoglycaemiaHypoglycaemia””
 AlcoholAlcohol
 Abdominal painAbdominal pain

27. Treatment of reactive hypoglycaemiaTreatment of reactive hypoglycaemia
Patti ME. Diabetologia 2005; 48: 2236-2240
Goldfine AB. J Clin Endocrinol Metab 2007; 92: 4678-4685
Kellogg TA. Surg Obes Relat Dis 2008; 4: 492-499
Tack J. Nat Rev Gastroenterol Hepatol. 2009;6: 583-90

28. Bariatric/ metabolic surgeryBariatric/ metabolic surgery
 Do the patient need help with signals?Do the patient need help with signals?
 Reasonable expectationsReasonable expectations
 Be aware about risk of complicationsBe aware about risk of complications
 Weight loss does not resolve all problems..Weight loss does not resolve all problems..

29. Follow upFollow up
 2 months2 months
 6 months6 months
 12 months12 months
 24 months24 months
Thereafter yearly assessments and bloodsThereafter yearly assessments and bloods
Availability for extra visits!Availability for extra visits!

30. Metabolic surgery-Metabolic surgery-
a novel indication?..a novel indication?..

31. Bariatric surgery reduces CV eventsBariatric surgery reduces CV events
Sjöström et al
JAMA 2012

32. ...but only fasting insulin predict benefit (not BMI)...but only fasting insulin predict benefit (not BMI)

33. Bariatric surgery reverses endBariatric surgery reverses end
organ damageorgan damage Mingrone et al Diabetes Care 2011Mingrone et al Diabetes Care 2011

35. Effects of Gastric Bypass Surgery in Patients
With Type 2 Diabetes and Only Mild Obesity
Ricardo V. Cohen, M.D., Jose C. Pinheiro, M.D., Carlos A. Schiavon, M.D.,
João E. Salles, M.D., Bernardo L. Wajchenberg, M.D., David E. Cummings,
M.D.
Diabetes Care
Volume 35: 1420-1428
July, 2012

37. Roux-en-Y Gastric Bypass vs Intensive Medical ManagementRoux-en-Y Gastric Bypass vs Intensive Medical Management
for the Control of Type 2 Diabetes, Hypertension, andfor the Control of Type 2 Diabetes, Hypertension, and
Hyperlipidemia: The Diabetes Surgery Study RandomizedHyperlipidemia: The Diabetes Surgery Study Randomized
Clinical TrialClinical Trial
Ikramuddin et al, JAMA 2013Ikramuddin et al, JAMA 2013

38. EOSSEOSS

39. The IDF Position Statement onThe IDF Position Statement on
Bariatric Surgery in obese type 2Bariatric Surgery in obese type 2
diabetes 2011diabetes 2011
Bariatric Surgical and Procedural Interventions in theBariatric Surgical and Procedural Interventions in the
Treatment of Obese Patients with Type 2 DiabetesTreatment of Obese Patients with Type 2 Diabetes

40. Management Algorithm for MetabolicManagement Algorithm for Metabolic
Control in Type 2 DiabetesControl in Type 2 Diabetes
Basal Premixed
Basal Bolus insulin
Sulphonylurea
Acarbose DPP-4 inhibitor/
GLP-1 analogues
Glitazone Insulin
Lifestyle Modification
•diet modification
•weight control
•physical activity
Metformin
Bariatric Surgery
BMI > 30 eligible & BMI > 35
prioritized
*If HbA1c >7.5% despite
optimized conventional
therapy, especially if weight
is increasing, or if other
weight responsive
comorbidities are not
reaching target on
conventional therapy.
Bariatric Surgery
BMI > 35 eligible
BMI > 40 prioritised
Bariatric Surgical and Procedural Interventions in theBariatric Surgical and Procedural Interventions in the
Treatment of Obese Patients with Type 2 DiabetesTreatment of Obese Patients with Type 2 Diabetes

41. Metabolic surgeryMetabolic surgery
- Reconstructions of the GI tract can resolve:Reconstructions of the GI tract can resolve:
- Type 2 diabetes mellitusType 2 diabetes mellitus
- Sleep apnoeaSleep apnoea
- HyperlipidemiaHyperlipidemia
- HypertensionHypertension
- NASH/NAFLDNASH/NAFLD
- Renal impairmentRenal impairment
- AsthmaAsthma
- PsoriasisPsoriasis
- EtcEtc
Which patients benefit most?Which patients benefit most?

42. ConclusionConclusion
 Currently strongest evidence for benefits inCurrently strongest evidence for benefits in
patients having a BMI>35patients having a BMI>35
 No problem justifying surgery for metabolicallyNo problem justifying surgery for metabolically
impaired patients having a BMI<35impaired patients having a BMI<35
 Need of hard endpoint studies: RCTs for T2D-Need of hard endpoint studies: RCTs for T2D-
best medical vs. best medical+ surgerybest medical vs. best medical+ surgery
 Surgery should be regarded as add on therapySurgery should be regarded as add on therapy

43. Future
• Metabolic surgery
• Diabetic surgery
• Tailored surgery/medication- phenotypes
• Studies of the mechanism of action

44. An important question..An important question..
Do we suggest surgery, or doDo we suggest surgery, or do
patients need to claim right topatients need to claim right to
treatment?....treatment?....

45. AcknowledgementsAcknowledgements
 UCD- DublinUCD- Dublin
– Carel le RouxCarel le Roux
 Imperial College LondonImperial College London
– Alex MirasAlex Miras
– Dimitris PournarasDimitris Pournaras
– Sam SchoultzSam Schoultz
 Sahlgrenska AcademySahlgrenska Academy
– Hans LönrothHans Lönroth
– Lars SjöströmLars Sjöström
– Lars FändriksLars Fändriks
– Marlin WerlingMarlin Werling
– Anna LaureniusAnna Laurenius
 University Hospital OsloUniversity Hospital Oslo
– Torgeir SövikTorgeir Sövik
– Eerlend AasheimEerlend Aasheim
– Tom MalaTom Mala
 University of ZurichUniversity of Zurich
– Thomas LutzThomas Lutz
– Marco BueterMarco Bueter

46. ””Metabolic surgery”Metabolic surgery”
Duodeno-jejunal
bypass
Ileal
transposition Endoluminal sleeve