current status of bariatric surgery in asia - 2013 international...

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)


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


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


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


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


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


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


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


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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