SchauerSurgeryforTDM糖尿病脂肪肝.ppt

1、Role of Bariatric Surgery for Diabetes and Metabolic Disease,Cleveland ClinicBariatric and Metabolic InstituteEndocrinology, Diabetes and Metabolism,Philip R. Schauer, MDProfessor of Surgery, Cleveland Clinic Lerner College of MedicineDirector: Bariatric and Metabolic Institute (BMI)schauepccf.org,P

2、resenter Disclosure,Philip R. Schauer MDBoard Member/Advisory Panel: SurgiquestConsultant: Ethicon, Lilly, Nestle, Novo Nordisk, Quadrant HealthCom, Inc.Research Support: Ethicon, NIHStock/Shareholder: Surgiquest, SEHQC LLC, ReMedyMD,Dr. Schauer does not intend to discuss any off-label use/unapprove

3、d use of drugs or devices,ObesityW,The Diabetes Epidemic: Global Projections, 20102030,IDF. Diabetes Atlas 5th Ed. 2011,Obesity is a Disease,Diabetes Treatment,Lifestyle ModificationDrug TherapySurgery,NHANES data 2007-2010, n = 4,926,Bariatric Surgery Could Potentially Improve Success in Achieving

4、all 3 Targets of Therapy,Diabetes Care 2013,Look AHEAD Study,NEJM June 24, 2013,7kg/10 yrs,HbA1cNo changeAt 10 yrs,Greater, longer sustained wt. loss is necessary to produce clinical benefit,Introducing Surgery as a more effective treatment for T2DM,Bariatric/Metabolic Surgery 2014,55%,35%,8%,2%,Lap

5、aroscopic,Open,Safety of Bariatric Surgery in Obese Patients,Weighing benefits with risk,30-day mortality 0.3%Major morbidity 4.3%ONE TENTH THE RISK OF CORONARY BYPASS SURGERY,Most Common ComplicationsRoux-en-Y Gastric Bypass,Moustarah et al. Current Surgical Therapy 10th Ed. Cameron 2010, Elsevier,

6、73 studies (3 RCTs),Journal of Obesity 2012,NAFLD Stage: Before and After Bariatric Surgery,P =0.001,Score,n,N=70,Results,1st biopsy,2nd biopsy at 8.5 months,Severe steatosis, inflammation, and bridging fibrosis,Mild steatosis, no inflammation, and no fibrosis,What about the effect of surgery on Lon

7、g-term Morbidity/ Mortality,How Durable is the effect of surgery?,Brethauer et al. Ann Surg 2013,SOS JAMA 2012,Look Ahead,Surgery associated with:Reduced all cause mortalityReduced CV events (fatal and nonfatal)Reduced Cancer mortality Reduced microvascular complications,Effect on Long-term Mortalit

8、y Compared to Non-Operated Controls,RCTs Comparing Bariatric Surgery with Medical Therapy for T2DM,Published online March 31, 2014,Funded by Ethicon/NIH,Intensive Medical Therapy,Weight management with diet and lifestyle counseling per ADA clinical care guidelines*Insulin sensitizers, GLP-1 agonists

9、, sulfonylureas and multiple insulin injections utilized to target HbA1c 6%Scheduled visits with nutrition, psychology and endocrinology per protocolFollow-up visits every 3 months through year 2, and every 6 months for remaining follow up,*Standards of medical care in diabetes-2011. Diabetes Care;3

10、4 Suppl 1:S11-61,Bariatric Surgery,Roux-en-Y Gastric Bypass Sleeve Gastrectomy,Kashyap S, Schauer P, Bhatt D; Diabetes Obesity Metabolism 2010 Sep;12(9):833,Baseline Characteristics,Note: Based on analyzed population,Schauer et al. NEJM 2014,Primary and Secondary Endpoints at 36 Months,1 Gastric Byp

11、ass vs Medical Therapy; 2 Sleeve vs Medical Therapy,Schauer et al. NEJM 2014,Change in HbA1c,Change in HbA1c (%),P0.001,P0.001,MedicalSleeve Gastric Bypass,Change in Body Mass Index,Changein BMI (Kg/M2),P=0.006,P0.001,P0.001,MedicalSleeve Gastric Bypass,Change in Diabetes Medications,Schauer et al.

12、NEJM 2014,Cardiovascular Medications atBaseline and Month 36,* P value 0.05 with Medical Therapy group as comparator,Change in Quality of Life Measures,Physical Functioning,Role Limitations,Physical Health Components,Mental Health Components,*,*,* 0.05 * 0.001 (Compared to IMT),*,*,*,%,%,*,*,Summary

13、: QOL Changes,Gastric Bypass: 5/8 domains improvedSleeve Gastrectomy: 2/8 domains improvedIntensive Med Rx: 0/8 domains improved,BMI 950 patients, BMI 25-52) show that surgery results in superior glycemic control compared to medical Rx ( up to 3 year follow-up)CV risk factors improved with surgerySu

14、rgery significantly improves quality of lifeSurgery reduces mortality/CV events (non-RCT, SOS)Perioperative morbidity 5%, mortality 7.0%) and Obesity (BMI 30) should be considered for bariatric surgery,THANK YOU!Role of Bariatric Surgery for Diabetes and Metabolic Disease,Cleveland ClinicBariatric and Metabolic InstituteEndocrinology, Diabetes and Metabolism,Philip R. Schauer, MDProfessor of Surgery, Cleveland Clinic Lerner College of MedicineDirector: Bariatric and Metabolic Institute (BMI)schauepccf.org,