Francesco Rubino, MD

Associate Professor of SurgeryChief, GI Metabolic Surgery

Diabetes Surgery CenterWeill Cornell Medical College- New York, NY

Covidien :◦ Research grant, Educational Grant

Roche: ◦ Research Grant

NGM Biotech: ◦ Scientific Advisory Board/Consultant

“My daddy is a doctor and he treats diabetes.”

“My daddy is a surgeon and he cures it.”

“The surgeon’s perspective”

“Francesco, why don’t you just give him Metformin?

W.J. PoriesThe physician’s perspective

THE HERETICAL SUGGESTIONTHE HERETICAL SUGGESTION

Nicolaus Copernicus (1473-1543)

Nicolaus Copernicus (1473-1543)

The Heretical Suggestion: A Surgical Treatment for Diabetes

“The Showdown: Surgeons vs Endocrinologists”

“…Rubino's idea boils down to one impolite word used to refer to the excrement of steers.”

…A surgeon’s perspective

Develop practical recommendations for clinicians on patient selection and management

Identify barriers to surgical access

Suggest health policies that ensure equitable access to surgery

Identify priorities for research

Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

Conveners:•Professor George Alberti•Professor John B. Dixon•Professor Francesco Rubino•Professor Paul Zimmet

Attendees:•Professor Stephanie Amiel•Professor Louise A. Baur•Professor Nam H. Cho•Dr. Bruno Geloneze•Professor Jan Willem Greve

• Professor Linong Ji• Dr. Muffazal Lakdawala• Professor Wei-Jei Lee• Professor Pierre Lefebvre• Dr. Carel le Roux• Professor Jean-Claude Mbanya• Professor Gertrude Mingrone• Dr. Philip R. Schauer• Professor Luc Van Gaal• Dr. David Whiting• Professor Bruce M. Wolfe

Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

INDICATIONS TO SURGICAL TREATMENT

Bariatric surgery is an appropriate treatment for people with type 2 diabetes and obesity not achieving recommended treatment targets with medical therapies, especially when there are other major co-morbidities.

Surgery should be considered early in the treatment of diabetes patients, not as a last resort

Surgery should be an accepted option in people who have type 2 diabetes and BMI of 35 or more

Surgery should also be considered as an alternative treatment option in persons with BMI 30 to 35 when diabetes cannot be adequately controlled by optimal medical regimen, especially in the presence of other major cardiovascular disease risk factors

In Asians, and some other ethnicities of increased risk, BMI action points may be lower e.g. BMI 27.5 to 32.5

Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

DiabetesSurgerySummit

Rome2007

CHOICE OF PROCEDURE

The position group considers RYGB, LAGB, BPD/BPD-DS, SG as currently accepted bariatric surgical procedures

Only two are considered acceptable in adolescents: RYGB and LAGB

The position group acknowledges that there are limited medium- or long-term data regarding SG, and there are safety, nutritional and metabolic concerns with BPD/BPD-DS

Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

Apart from conventional procedures now in use new techniques and devices should be explored in research settings only

New bariatric procedures require robust assessment for their efficacy, safety, and durability using similar principles to those for assessing new drug therapies and having regards to the benefits and risks of established therapy

Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

risks and benefits, the importance of compliance, the effects on eating choices and behaviours

Factors to consider when choosing a bariatric procedure in patients with Type 2 diabetes

The duration of Type 2 diabetes and the degree of apparent residual B-cell function

PERIOPERATIVE MANAGEMENT

Surgery should be considered as complementary to medical therapies to reduce micro-vascular and cardiovascular risk

Patients should be assessed and managed by experienced multi-disciplinary teams

Glycaemic control should be optimised peri-operatively and should be closely monitored after surgery

It should be recognised that a prolonged period of normalisation of glycaemic control has benefit for diabetes even if there is eventual relapse

Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

There should be a minimal accepted data set for pre-surgery and follow-up◦ Weight, blood glucose control, assessment for diabetes

complications, laboratory measures and medications etc.

Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

Pre-operative and Follow-Up Data Set

> characteristics of pts population> Pts needs and expectations> Outcomes and definition of success

“Diabetes Surgery” vs “Bariatric Surgery”

◦Indications◦Preoperative diagnostic evaluation◦Choice of Procedure◦Definition of success of treatment◦Assessment of postoperative outcomes◦Type of follow-up◦Complementary therapies◦Definition of “care team”

DEFINITION AND MONITORING OF SUCCESS OF TREATMENT

Develop practical recommendations for clinicians on patient selection and management

Identify barriers to surgical access

Suggest health policies that ensure equitable access to surgery

Identify priorities for research

Bariatric Surgical and Procedural Interventions in the Treatment of Obese Patients with Type 2 Diabetes

Stigma of Obesity

Misperception about risk factors vs disease state

Misconception of “Obesity”

Identification of “Bariatric Surgery” with “Weight Loss Surgery

In the medical community:

“…obesity is a cultural and behavioural problem…”

“…attempt to combat excess of food by cutting out parts of stomachs and intestines Not a rational solution”

Stigma of Obesity

Misperception about risk factors vs disease state

Misconception of “Obesity”

Identification of “Bariatric Surgery” with “Weight Loss Surgery

Risk Factor Disease

Lifestyle Modification complementary

Surgery, Radiotherapy,Chemotherapy

Treatments Considered Rationale

Smoking Cancer

>

Lifestyle Modification

Not-rationale solutions:

(Surgery, Drug Therapy)

Risk Factor DiseaseTreatments Considered Acceptable

Overeating-Sedentary Lifestyle Obesity

>

Stigma of Obesity

Misperception about risk factors vs disease state

Misconception of “Obesity”

Identification of “Bariatric Surgery” with “Weight Loss Surgery

Obesity is an ill-defined condition

Excess weight is symptom of disease, not disease per se

OBESITY

Increased BP

CVD/Death

Obesity without Insulin Resistance (IR) Obesity without Diabetes Normal Weight Individuals with IR Normal Weight Individuals with Diabetes

and MS

◦ Metabolically healthy obese individuals◦ Metabolic syndrome in non-obese individuals

ARCH INTERN MED/VOL 168 (NO. 15), AUG 11/25, 2008

OBESITY

Increased BP

CVD/Death

Stigma of Obesity

Misperception about risk factors vs disease state

Misconception of “Obesity”

Identification of “Bariatric Surgery” with “Weight Loss” Surgery

OBESITY

Increased BP

CVD/Death

BARIATRIC SURGERY

JAMA Jan 2012

JAMA Jan 2012

Baseline Insulin, Not BMI or weight lossPredict CV benefits of surgery

OBESITY

Increased BP

CVD/Death

BARIATRIC SURGERY

Advocacy for obese patients

Define risk factors vs disease state

Re-definition of “Obesity”

From Bariatric to “METABOLIC” and DIABETES SURGERY

Advocacy for obese patients

Define risk factors vs disease state

Re-definition of “Obesity”

From Bariatric to “METABOLIC” and DIABETES SURGERY

Advocacy for obese patients

Define risk factors vs disease state

Re-definition of “Obesity”

From Bariatric to “METABOLIC” and DIABETES SURGERY

Advocacy for obese patients

Define risk factors vs disease state

Re-definition of “Obesity”

From Bariatric to “METABOLIC” and “DIABETES” SURGERY

OBESITY

Increased BP

CVD/Death

METABOLIC SURGERY

Advocacy for obese patients

Define risk factors vs disease state

Re-definition of “Obesity”

From Bariatric to “METABOLIC” and “DIABETES” SURGERY

Recognize the role of GI Tract in the Physiology/Pathophysiology of Metabolic Illnesses

The GI Tract: An Endocrine Organ