Metabolic Surgery in Asia
Wei-Jei Lee, M.D., Ph.D.
Dept. of Surg., Min-Sheng General Hospital, National Taiwan University, Taiwan

Type 2 diabetes mellitus (T2DM) is now a global health priority.

It wasestimated that more than 240 million people in the world are affecting with T2DM
and that number is expected to 360 million by the year 2025.

More than 60% of theworld’s population with diabetes comes from Asia and the incidence of T2DM in Asia
is increasing more rapid than the rest of the world.

In Taiwan, the T2DM incidenceof adult male increased more than double from 4.6% to 9.3% in the past decade.
Unlike in the west, where older population is most affected, the burden of diabetes
in Asian countries is disproportionately high in young to middle-age adults.

For

those early onset T2DM patients, the incidence rate of diabetic nephropathy isalarmingly high, especially in those not well controlled patients.

In Asia, 55%of newly diagnosed end staged renal disease patients are due to T2DM.

How tocontrol this chronic and deliberating disease will be a very important health issue
in Asia.
There are strong evidences that bariatric surgery can cure most of theassociated T2DM morbid obese patients (BMI > 35 Kg/m2).

However, the mechanism fordiabetes remission after gastric bypass remained speculative.

Optimal outcomes fordiabetes remission after metabolic surgery will occur if the mechanism isunderstood and patients best suited to the surgery are selected and those who will
predictably have a poor result are excluded. To be able to make such decisions, weneed a collaborative study from Asia for the Asian.

This information is helpful

for applying gastric bypass surgery as metabolic surgery for type 2 diabetes
treatments in the future.

1

"Asian particularity on Obesity and Metabolic disorder"
The personality of the patients with morbid obesity

Kohji Shirai
Internal Medicine, Sakura Hospital, Toho University, JAPAN.

Bariatric surgery might become indispensable for the therapy of morbid obesity.
Metabolic disorders could be well improved by bariatric surgery. In some cases, weight
reduction relief the insulin therapy in obese type 2 diabetes mellitus. But, following
up term after operation is very important, because actual body weight reduction can beobtained in this term. The trouble in this term seems to be not so few. One is psychologicalunstableness. We had already experienced them during semi-starvation therapy. For example,
depression, refusal diet, trial of suicide, solitary and so on.
To understand the causes for that unstableness, personalities of the patients wereanalyzed using Rorschach test by applying Ender’s methods. In many cases, depression andorganic psychological diseases were concealed. One of conspicuous features was high lambda
style, in which, passive attitude, superficial understanding, apparent obedience wereobserved. Those people were controlled well in the hospital, but, they easily show rebounds
once outside of the hospital. The percentage of high lambda style is increasing as thedegree of obesity.
Before operations of the patients, we had better understand the personality of thepatient, beforehand. Moreover, psychotherapy such as enforcement will improve the benefitof surgery. And, how to understand the personality of the patients need further studies.

Bariatric surgery in Asia. A literature review.

Department of Weight Loss Surgery, Minimally Invasive Surgery Center, Yotsuya Medical
Cube, Tokyo, Japan
Yosuke Seki, Kazunori Kasama, Hideharu Shimizu

Like in Western countries, bariatric and metabolic surgery in Asia has been steadily
gaining popularity although the pace of spread is gradual. The purpose of the present
review is to evaluate the current evidence regarding weight loss, complication rates,
postoperative mortality, and co-morbidity improvement after bariatric surgery for Asians.
Pubmed was searched for citations.

1
Laparoscopic Roux-en-Y Gastric Bypass for Normal Weight Type II Diabetes Mellitus*

Bariatric & Metabolic International Surgry Center, E-Da Hospital, Kaohsiung, Taiwan
Department of General Surgery, E-Da Hospital, Kaohsiung, Taiwan‡
Department of Chemical Engineering, Institute of Biotechnology and Chemical
Engineering, I-Shou University, Kaohsiung, Taiwan
Chih-Kun Huang, MD*†‡, Chi-Hsien Lo, MD*, Jer-Yiing Houng, PhD‡, Yaw-Sen Chen, MD†,
Po-Huang Lee, MD††

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) can dramatically ameliorate
type 2 diabetes mellitus (T2DM) in morbidly obese patients. However, little evidence
supports the effectiveness of LRYGB in normal weight patients.
Methods: After getting E-Da IRB approval, twelve normal weight patients with T2DM
underwent LRYGB. Data, including patient demographics; BMI; co-morbidities; anddetails of diabetes mellitus, including disease duration, family history, medicationuse, and remission were prospectively collected and analyzed.
Results: The mean age of 5 men and 7women was 51 years (range, 35–65 years); mean BMI,
23.6 (range, 22.9–24.7 kg/m2); and mean duration of T2DM onset was 11 years (range, 3–
20 years). Mean operation time was 89 min (range, 46-229). Mean hospitalization was 2days (range, 1-4). There was no mortality. One patient received laparoscopic repair ofPeterson’s defect due to symptoms from internal hernia 6 months later after surgery.
The result of diabetic remission would be reported.
Conclusions: In this preliminary report, LRYGB is safe in normal-BMI Diabetic patients;
result of long-term follow up for diabetic remission is expectable.

Ileal Interposition for Control of Type-2 Diabetes
Dr Surendra Ugale,
Kirloskar Hospital,
Hyderabad, India
Ileal Interposition is a specific surgery directed to control type -2 diabetes & can be
performed for patients of any weight. We present 48 cases of Ileal Interposition surgeries
for control of type-2 diabetes done since Feb.2008 under clinical protocol after
Institutional Ethics Committee approval.
Selection of patients was done after checking C-Peptide levels and Insulin resistance with
HOMA-IR and excluding any cases of LADA. All procedures were completed laparoscopically with
6 ports, performing 3 transections, 3 anastomosis, closure of all 3 mesenteric gaps and avariable sleeve gastrectomy depending on BMI levels. The ileal segment was 170 cms long withtransections at 30 cms proximal to I-C junction and 20 cms distal to Lig of Trietz to performthe Standard procedure utilizing the hindgut hypothesis mainly. A Diverted option, using
duodeno-jejunal bypass was added for the difficult diabetic situations to also include theforegut hypothesis.
In a follow up of 18 months we have found significant improvement in blood glucose, HbA1c,
triglycerides &microalbuminuria. Results were statistically significant for Blood glucose,
HbA1c, triglycerides & microalbumin at all times upto 24 months. Malabsorption as measured
Vit B12, Ca+2, Iron-- was not observed.
We conclude that Ileal Interposition can be done with safety & is effective in controllingtype -2 diabetes in patients with any BMI, without any malabsorption.

Title: Laparoscopic Sleeve Gastrectomy with Duodenojejunal Bypass for Type 2 diabetes withBMI under 35 kg/m2

Kazunori Kasama MD,FACS. Yosuke Seki MD, Hideharu Shimizu MD,

Abstract:
BackgroundWe introduced laparoscopic sleeve gastrectomy with duodenojejunal bypass (LSGB) forJapanese obese patients with a risk of gastric cancer in 2007. Forty-three patients
underwent LSGB from April 2007 to December 2010. Regarding anti-diabetic effect, theremission rate of Type 2 diabetes (T2DM) was 93%. This result showed that LSGB could achieve
comparable or better remission of T2DM, compared with other bariatric procedures. The
metabolic surgery for patients with BMI lower than 35 kg/m2 is still controversial. We
evaluated the effect of LSGB on T2DM with BMI under 35.
Methods
Seven patients with T2DM underwent LSGB. The preoperative mean BMI and weight were 33.4
±1.5 kg/m2 and 97.4 ±11.0kg, respectively. There were six patients with T2DM and one
patient with IGT. The data on T2DM, lipid profile and blood pressure of the subjects werestudied before and 12 months after surgery.
Results
The mean excess weight loss at 12-month follow up point was 82.7%. The mean fasting plasma
glucose and HbA1c before and 12 months after surgery were 154.7 mg/dl, 8.1% and 128.5 mg/dl,
6.1%. The remission rate of T2DM was 83%. The mean systolic blood pressure and LDL before
and 12 months after surgery were 147.5 mmHg, 158.4 mg/dl and 131.0 mmHg and 140.0 mg/dl.
There was one patient who could not achieve the remission of T2DM with 20- year history
and preoperative insulin required status (more than 100 U/day). The other CVD risk factors
related to T2DM were improved clinically.
Conclusion
This result showed that LSGB for low BMI patients with T2DM could achieve the considerable
remission rate of T2DM and reduce the other CVD risk factors.

Metabolic surgery in Korea : Remission of hyperglycemia with modified mini-gastricbypass for the patients with BMI less than 30 kg/m2
Kyung Yul Hur, M.D.
Department of Surgery, Soonchunhyang University College of Medicine, Seoul, Korea
Background: Type 2 Diabetes mellitus (T2DM) has become an epidemic health problem.
Compared to western countries, Asian T2DM occurs in patients with lower body mass index(BMI) due to central obesity and decreased pancreatic β-cell function. The efficacy oflaparoscopic mini-gastric bypass (LMGB) in obese patients with T2DM is proven bynumerous studies. Treatment outcomes of LMGB for non-obese T2DM patients are also
estimated to be excellent. The aim of our pilot study was to evaluate the efficacy andsafety of LMBG in non-obese T2DM patients (BMI < 30 kg/m2).
Methods: Eighty-eight patients underwent LMGB at Soonchunhyang University Hospital from
August 2009 to November 2010. Preoperative data including glycosylated hemoglobin(HbA1c), fasting plasma glucose (FPG), and 2-hour post prandial glucose (2-hr PPG) werecompared with data collected at 1, 3,6 and 12 months postoperatively.
Results: All procedures were completed laparoscopically. Mean age was 47.1 years, mean
BMI was 25.3 kg/m2, mean operative time was 96.2 minutes, and mean postoperative
hospital stay was 4.6 days. Neither mortality nor major complications occurred. Mean
preoperative HbA1c, FPG, 2-hr PPG, and C-peptide level were 9.7%, 222 mg/dl, 343 mg/dl,
and 2.78 ng/ml, respectively. 12months follow-up was possible in13 patients. HbA1c, FPG,
2-hr PPG, and C-peptide level at 12th post-operative month were 6.3%, 124 mg/dl, 194
mg/dl, and 2.18 ng/ml, respectively.
Conclusion: The present preliminary study demonstrated resolution of hyperglycemia in
non-obese T2DM patients (BMI < 30 kg/m2). Although long-term follow-up data are required,
early operative outcomes were satisfactory in terms of glycemic control and safety ofthe procedure.

Metabolic Surgery in Hong Kong

Wilfred Mui
Hong Kong Bariatric and Metabolic InstituteAsians have higher fat content and different indications for bariatric surgery ascompared to western population. In response to DSS in Rome, Asia Consensus Meetings on
Metabolic Surgery, endorsed by the Asia Pacific Bariatric and Metabolic Surgical Society
were held at Trivandrum in India in 2008 and Taipei 2010 to discuss the situation in
Asia. Most experts agreed that Asians are more prone to develop diabetes at lower BMI
and early consensus for the use of metabolic surgery to treat Type II diabetes mellitus
in Asia were laid and stated as the followings:
1.

Bariatric/Gastrointestinal Metabolic surgery should be considered as a treatment
option for obesity in people with Asian ethnicity with a BMI more than 35 kg/m2
with or without co-morbidities.

2.

Bariatric/Gastrointestinal Metabolic surgery should be considered as a treatment
option for obesity in people with Asian ethnicity above a BMI of 30 if they havecentral obesity (waist circumference more than 80 cm in females and more than 90
cm in males) along with-at least two of the additional criteria for metabolic
syndrome: raised triglycerides, reduced HDL cholesterol levels, high bloodpressure and raised fasting plasma glucose levels or Type II diabetes mellitus
patients who are inadequately controlled by life-style and medical therapy.

3.

A surgical approach may also be appropriate as a non-primary procedure alternative
to treat Type II diabetes mellitus patients with BMI >27 and central obesity (waist
circumference more than 80 cm in females and more than 90 cm in males) who are
inadequately controlled by life-style and medical therapy.

Most clinicians and patients in Hong Kong at present are not aware of the optionof surgery for treating Type II diabetes. Increasing evidences demonstrate that
gastrointestinal surgery including current bariatric surgery has a specific andindependent effect on the disease. We have introduced metabolic surgery to treat TypeII diabetes since 2008 in Hong Kong. At the moment, we limit our patients to BMI >27
with poorly controlled DM. Options would be sleeve gastrectomy vs. gastric bypass vs.
sleeve gastrectomy with DJB.

Experience of diabetes surgery in India

Muffazal Lakdawala

Abstract
Diabetes is believed to be a quintessential medical disease. The notion that surgery iseffective and can lead to a virtual cure is a revolutionary concept that evolved when longterm results of bariatric surgery started coming in. This led to a major shift in the goalof treatment from improving life with diabetes towards curing it. These reports have far
reaching implications for a country like India which is the diabetic capital of the world.
It is postulated that by 2025 there will be 57 million Indians suffering from type 2 diabetes
mellitus. Almost 70% of the diabetics are overweight.
It is a well known fact that Asians have a higher body fat percentage as compared to theirwestern counterparts. Asians are metabolically obese and tend to develop comorbidities
like type 2 diabetes at a much lower weight. Visceral fat as measured by the waist
circumference holds a lot more importance in Asians. In the wake of these observations
1st Asian consensus meeting on metabolic surgery was organized to contend the existing
NIH criteria for defining obesity in the Asian perspective.
Presently laparoscopic roux-en-y gastric bypass (RYGB) and laparoscopic sleeve
gastrectomy (LSG) are the most commonly performed bariatric procedures in India. Indianstudies have shown about 98% resolution of type 2 diabetes after RYGB in morbidly obese.
Recent reports suggest comparable results after LSG albeit it takes longer than after RYGB.
Presently these procedures are being recommended for patients with a BMI of 32 and above
with type 2 diabetes mellitus. It has also been recommended for patients with a BMI of
30 and above in conjunction with waist circumference and presence of comorbidities.
The contention is whether the same results can be simulated in diabetics who are not obese.
Whether metabolic procedures like ileal transposition and duodenojejunal bypass will standthe test of time is yet to be seen. Trials are going on in various parts of the world.
India has the biggest diabetic load and stands to benefit the maximum from any positive
outcomes. There is immense hope riding on this concept as any positive results would prove
to be a boon to the millions of diabetics who can then hope of a pill or insulin free life.

Overview of Metabolic Surgery Worldwide
Karl Miller, MD, FACS, Hallein Clinic, Austria
Henry Buchwald, Department of Surgery, University of Minnesota USA
An email survey was sent to the leadership of the 36 International Federation for theSurgery of Obesity and Metabolic Disorders nations or national groupings, as well as
Denmark, Norway, and Sweden. Responses were tabulated; calculation of relative prevalenceof specific procedures was done by weighted averages. Out of a potential 39, 36 nations or
national groupings responded. In 2008, 344,221 bariatric surgery operations were performed
by 4,680 bariatric surgeons; 220,000 of these operations were performed in USA/Canada by
1,625 surgeons. The most commonly performed procedures were laparoscopic adjustable
gastric banding (AGB; 42.3%), laparoscopic standard Roux-Y gastric bypass (RYGB; 39.7%),
and total sleeve gastrectomies 4.5%. Over 90% of procedures were performed
laparoscopically. Comparing the 5-year trend from 2003 to 2008, all categories ofprocedures, with the exception of biliopancreatic diversion/duodenal switch, increased inabsolute numbers performed. However, the relative percent of all RYGBs decreased from
65.1% to 49.0%; whereas, AGB increased from 24.4% to 42.3%. Markedly, different trends
were found for Europe and USA/Canada: in Europe, AGB decreased from 63.7% to 43.2% and
RYGB increased from 11.1% to 39.0%; whereas, in USA/Canada, AGB increased from 9.0% to
44.0% and RYGB decreased from 85.0% to 51.0%. The absolute growth rate of bariatricsurgery decreased over the past 5 years (135% increase), in comparison to the preceding 5
years (266% increase). Bariatric surgery continues to grow worldwide, but less so than in
the past. The types of procedures are in flux; trends in Europe vs USA/Canada arediametrically opposed.

System of Obesity Surgery: overview
Adelaide Circle of Care, Flinders Private Hospital/Flinders University of South Australia,
South Australia, Australia
Lilian Kow
Obesity is a disease in which fat has accumulated to the point where health is impaired.
It is a rapidly growing problem not only in the western society but also more recently in
the Asia Pacific region.Worldwide, the incidence of morbid obesityhas doubled, and about
300 million people are now considered obese.
Obesity surgery started more than 50 years ago. Tremendous advances have been observed inthis practice of surgery. New techniques, new procedures, minimally invasive access andimprovements in preoperative management have transformed the system of obesity surgery
into a subspecialty of its own. To date,there is no effective diet ordrug therapy
available to treat the morbidly obese.On the other hand, bariatric surgery has been provento be effective, providingmarked and lasting weight loss, ranging from 47.5%to 70.1% ofexcess body weight.These resultsare achieved in relative safety, with operative
mortalityequal or less than that for other major operativeprocedures (about 0.5%).The
weight loss outcome, results in dramatic improvement on the co-morbidconditions of morbid
obesity.
The major medical co-morbid conditions can be divided into thosewhere reversal or
improvement has been proven such as type 2 diabetes, hyperlipidaemia, hypertension,
obstructive sleep apnea,etcand those where reversal or improvementare reasonable andpresumed such as cardiac and peripheral vascular disease, incidence of thrombophlebitis
and pulmonary emboli and various carcinomas.
The ameliorating effects of bariatric surgery are not limited to medical co-morbidities.
Socially, quality of life is vastly improved, as are body image, personal hygiene, andsexual activity.Many of the economic deprivations of the morbidly obese are reversed aftermarked weightloss due to increased employment opportunities advancement potential, and level ofincome.The sum total of these co-morbidity benefits is anincrease in longevity.

Role of incretins in metabolic surgery-induced remission of type 2 diabetes.

Chikashi Shibata, Takeshi Naitoh, Fumie Ikezawa, Hirofumi Imoto, Masayuki Kakyo, Makoto Kinouchi,
Naoki Tanaka, Iwao Sasaki.
Department of Surgery, Tohoku University School of Medicine, Sendai, Japan.

Two hypotheses are proposed as a mechanism for remission of type 2 diabetes (T2DM) in metabolic
surgery; one is foregut hypothesis associated with the exclusion of the duodenojejunum from thenutrient exposure, while another one is hindgut hypothesis associated with the rapid exposure of
the ileum to the bike and nutrients. These hypotheses are tested using rat models of T2DM, including
Goto-Kakizaki rats and obese Zucker rats. Two most representative procedures of metabolic surgery
in rats are ileal interposition (II) and duodenojejunal bypass (DJB). II is considered as a modelfor hindgut hypothesis, whereas DJB as a model for foregut and partly hindgut hypothesis. These
2 procedures improve glucose metabolism, and there are no differences in T2DM remission effects
between 2 procedures. Incretins including GIP and GLP-1 are assumed to play an important role inremission of T2DM in these procedures. Most studies reported that II does not affect fasted plasma
GLP-1 levels but increases those after glucose or meal administration. Effects of II on the fasted
and postprandial plasma GIP levels are still controversial. The effects of DJB on plasma GLP-1 and
GIP levels are also controversial, and mechanisms independent of incretin are assumed in DJB-induced
remission of T2DM. Clinically, ileal interposition with sleeve gastrectomy (II-SG) and ileal
interposition with diverted sleeve gastrectomy (II-DSG) are being attempted. More than 90% of
patients achieved adequate glycemic control (HbA1C<7%). Plasma levels of GLP-1, GIP, and PYY
significantly increased, while plasma levels of ghrelin significantly decreased, after II-SG and
II-DSG in the fasted and postprandial states. These results indicate the important role of incretinsin metabolic surgery-induced remission of T2DM, but mechanisms other than incretins are also likely.

From the Aspect of Mental health

Tetsuya Nakazato
Yotsuya Medical Cube

Morbid obesity is a not only physically but also psycho-socially complicated disease.
It is important to focus on the environment of the patients.

For example, familial

relationships, friendships, work relationships and other relationship.
Surgical treatments for morbid obesity have started in our institution since June 2006.
The objective of the treatment is to improve quality of life (QOL). For improvement of
QOL, physical, psychological, and social supports are important through pre- andpost-treatment. Our multidisciplinary team consists of doctors, nurses, nutritionist, andsocial worker. This multidisciplinary approach is necessary to achieve highly effective
treatment for obesity. To defeat the complexity of obesity, approach from different aspects
is important. The key to success lies in a multidisciplinary team to empower the patients.
As the profession of social worker is to establish interaction between patients and theirenvironments, The roles of the social worker in bariatric surgical team start from thefirst intake of all clients, conducting support groups, making an assessment of
psycho-social problems and counseling.
The term “Mental illness” encompasses a wide variety of problems. The presence of
psychiatric disorders is not an absolute contraindication to weight loss surgery.
The lecture will be regarding behavioral and psychological factors in the assessment andthe treatment of bariatric surgery patients.

From the aspect of Nutrition; Formula diet

Atsuhito Saiki
Center of Diabetes, Endocrine and Metabolism, Toho University Sakura Medical Center

Formula diet is a powdered preparation and is composed of high-protein,low-carbohydrate, low-fat, vitamins and minerals. Formula diet is safe, convenience andeffective in weight loss for treatment of obesity. However, the nutritional efficacy is
not fully explored.
We compared the effects of partial use of formula diet (MicroDiet®; 170kcal/pack,protein 21.5g/pack, fat 2.4g/pack, carbohydrate 16.5g/pack) and conventional subcaloric
diet on weight reduction, body fat distribution and related metabolic variables in obese
patients with type 2 diabetes for 24 weeks. In formula diet group, weight reduction,
visceral fat reduction, decrease in systolic blood pressure, HbA1c, triglyceride andincrease in HDL-C was greater than in conventional diet group. Interestingly, improvements
in visceral fat, HbA1c, triglyceride and HDL-C per reduced body weight were higher informula diet group. These findings have given us a hypothesis that formula diet has specificnutritional effect, which is independent of calorie restriction. To clarify the hypothesis,
we investigated the effects of formula diet on visceral fat, metabolic parameters andadipokines expression in Zucker diabetic fatty rats (low-calorie diet; 56kcal/g,
P:F:C=25:15:60, formula diet (MicroDiet®); 56kcal/g, P:F:C=50:14:36). The changes in bodyweight were not different between groups, however in formula diet group, decrease invisceral fat volume and improvement in triglyceride and HDL-C were greater. Adiponectin,
LPL, PGC-1α and PPARγ mRNA/protein expression in visceral fat tissue were higher informula diet group. On the other hand, formula diet also led to greater reduction of liver
fat content in Zucker rat.
Formula diet may be useful for prevention of malnutrition and long-term weightgain after bariatric surgery. Furthermore, the potent effect on liver fat reduction is
also useful before surgery, because enlarged fatty liver in obesity compromises surgicalaccess to gastroesophageal junction. Pre- and post-operative formula diet may be a key
nutritional option when bariatric surgery is performed.

Consensus of Asian Diabetic Surgery Summit (ADSS) and APBSS
Wei-Jei Lee, M.D., Ph.D.
Dept. of Surg., Min-Sheng General Hospital, National Taiwan University, Taiwan

2005 APBSG consensus meeting has modified the indication of bariatricsurgery for Asian people to
1. Obese patients with their BMI over 37
2. Obese patients with their BMI over 32 in the presence of diabetes or other two
significant obesity related co-morbidities.
3. Have been unable to lose or maintain weight loss by dietary or medical measures.
4. Age of patient > 18 years and < 65 years.
*

Under

specialcircumstanceandinconsideration

with

a

pediatrician,bariatric surgery may be used in children under age 18
2010 ADSS meeting in Taipei has proposed the indication of metabolic surgery
for Asian diabetes people
1. Metabolic surgery should be recommended for diabetes patients with their BMI
over 37
2. Metabolic surgery should be considered for diabetes patients with their BMI over
32 and not well controlled (HbA1c > 7.5%) after intensive medical treatment.
3. Metabolic surgery may be considered for diabetes patients with their BMI over 27
with many co-morbidities and not well controlled (HbA1c > 7.5%) after intensive
medical treatment.
4. Age of patient > 18 years and < 70 years, with acceptable surgical risk andwithout end-organ damage.
*The patient should be cared and followed by multi-discipline medical team andpre-operative B-cell function evaluation is indicated1Concensus of Diabetic Surgery Summit (DSS)
Impact on Asian population

Wilfred Mui
Hong Kong Bariatric and Metabolic Institute

Background: The purpose of the Summit, led by Prof. Rubino is to formulate new consensus
for surgical intervention for Type II diabetes mellitus in western population. It createdtremendous impact on Asian population and in response to DSS guidelines, ADSS and ACOMOMS
guidelines were developed specifically for Asian population.
Method: Multidisciplinary voting delegates around the world gathered at Roma in March
2007 for the 1st DSS. During the meeting, available scientific evidence were examinedand discussed by the entire group. Consensus for diabetic surgery for western population
was established.
Results and Conclusions:
1. GI surgery should be considered for the treatment of T2DM in acceptable surgicalcandidates with BMI >35kg/m2 who are inadequately controlled by lifestyle andmedical therapy.
2. A surgical approach may also be appropriate as a non-primary alternative to treat
inadequately controlled T2DM in suitable surgical candidates with mild-to-moderate
obesity (BMI 30–35 kg/m2). RYGB may be an appropriate surgical option for diabetes
treatment in this patient population.
3. Although novel GI surgical techniques (eg, duodenal-jejunal bypass, ileal
interposition, sleeve gastrectomy, endoluminal sleeves) show promising results forthe treatment of T2DM in early clinical studies, they should currently be used onlyin the context of IRB-approved and registered trials.
4. To improve quality of medical evidence, the development of standards for measuring
clinical and physiological outcomes of surgical treatment for T2DM is a highpriority.
5. Randomized controlled trials are strongly encouraged to assess the utility of GI
surgery to treat T2DM.
6. Development of a standard registry/database is a high priority for research in thisarea. In addition to clinical trials, animal studies can provide useful information
about the efficacy and mechanisms of GI metabolic surgery to treat T2DM.

National report of treatment of obesity and metabolic disorder from (India).
Dr. Mahendra Narwaria, MS, FICS.
President, Obesity and Metabolic Surgery Society of India
Asian Indians exhibit unique features of obesity; excess body fat,abdominal adiposity, increased subcutaneous and intra-abdominal fat, anddeposition of fat in ectopic sites (liver, muscle, etc.). Obesity is a major driver for
the widely prevalent metabolic syndrome and type 2 diabetes mellitus (T2DM) in
Asian Indians in India and those residing in other countries. Based on
percentage body fat and morbidity data, limits of normal BMI are narrower andlower in Asian Indians than in white Caucasians. A consensus statement, waspublished for revised guidelines for diagnosis of obesity, abdominal obesity, themetabolic syndrome, physical activity, and drug therapy and bariatric surgery forobesity in Asian Indians after consultations with experts from various regions ofIndia belonging to the various medical disciplines representing reputed medical
institutions, hospitals, government funded research institutions, and policy
making bodies.
According to National Family and health Survey (NFHS), approximately
7.1% of Indian population is under obesity risk. Almost 65% of adult urban
Indian are –either over weight, obese or have abdominal obesity. The highest
incidence is observed in North western (Punjab) part of India (M: F- 30.3/37.5%),
followed by South (M: F-24.3/34%) and North east (M: F-17.3/21%).
With an estimated 50.8 million people living with diabetes, India has theworld’s largest diabetes population, followed by china with 43.2 million. The
prevalence of type II DM in adult population ranges from 9% to 16%, with 14.2 %of male and17.5 of female.
The Obesity and Metabolic Surgery Society of India was established in 2001.
The indication for surgery is generally in accordance with guidelines using the
WHO standard for obesity on Asia, i.e. BMI >37.5/32.5 with co-morbidities. There
are few no of bariatric and metabolic surgeries carried out outside the standard
guidelines for obesity surgery but they are mainly as part of some clinical trials.
There are about 80 surgeons (certified general, GI surgeons with training
and experience) performing bariatric surgery regularly in India, carrying out
2000 procedures per year.
There are 5 high volume centres and few of them applied for centre of
excellence (ICE) certification from ASMBS.OSSI is jointly working with SRC todevelop centre of excellence in India. Cost of bariatric treatment depends uponthe types and location of the operative procedure. We accept and operate theinternational patients.
Refrences:

IDF-Diabetes Atlas, 4th edition, Oct 2009.



G. Vijaykumar et.al; JAPI, Aug 2009, Vol-57.



A. Mishra, P.Chowbey, BM Makkar, NK Vikram et.al; JAPI, Feb 2009.

Consensus of OSSANZ National Report from Australia
President, Obesity Surgery Society of Australia and New Zealand
Lilian Kow
The OSSANZ Bariatric Surgical Standards (OBSS) was developed to ensure that all surgeons
who undertake to perform Bariatric Surgery within any Health Service (Public or Private)
are properly credentialed and have the scope of providing a quality bariatric surgicalservice in accordance with both their level of skill and experience and the capability of
the Health Service.The following are the recommended OSSANZ Bariatric Surgical Standards
for defining the scope of clinical practice for Bariatric Surgery.
An Australian standard has been developed to guide the process of credentialing anddefining the scope of clinical practice (www.safetyandquality.org).
These recommendations have been developed to ensure the delivery of high quality bariatricservice within any Health Service. It is recommended that these OBSS assists Credentialing
Committees of Health Services to ensure their bariatric surgeons are performing operationscommensurate with their skill and are also providing a quality bariatric service to theirpatients as defined below.
These OBSS apply to all surgeons who are practicing or considering bariatric surgery. They
are guidelines recommended for Credentialing Committees of Health Services in thecertification and recertification of bariatric surgeons in Australia and New Zealand.
For surgeon members, the process of their application for clinical practice of bariatricsurgery (operation specific) within any Health Service should be of the following 3
categories:

1.

Provisional Bariatric Surgical Accreditation

Provisional Bariatric Surgical is the first step for surgeons with FRACS or equivalent,
who wish to become fully accredited Bariatric Surgeons in any Health Service. This is theagreed step to be taken when undergoing and completing training in bariatric surgery, andmentoring of cases, before being accredited as Bariatric Surgeon for a specific bariatricprocedure:
a.
b.
c.
d.

e.
2.

Nominated by 2 surgeons experienced in Bariatric Surgery.
Successful completion of, and proof of, approved Bariatric Surgery Training or
a Bariatric Course.
Documentation of minimum of 3 mentored cases by another Bariatric Surgeon,with written approval by the mentor.
The surgeon may then proceed to documenting 20 bariatric cases, (Logbook)which is to be forwarded to, and to be approved, by the Credentialing
committee.
Agree to contribute to the OSSANZ Bariatric Registry.

Full Bariatric Surgical Accreditation
Bariatric Surgical Service is applied for after fulfilling the requirements of
the Provisional Bariatric Surgical Accreditation.
a.

Has fulfilled the criteria of Provisional Bariatric Surgeon andreceived the necessary written approvals.

b.

c.
d.
e.

3.

Maintains and updates clinical skills and bariatric knowledge which
includes one bariatric surgical meeting (national or international)
yearly.
Continues to contribute to the ongoing OSSANZ Bariatric Registry andfollow-up.
Maintains surgical skills by at least 20 bariatric operations annually.
Reviewed/renewed triennium.

Grandfather Clause
Surgeons already performing Bariatric surgery will need to provide the following
when applying for recertification as Bariatric Surgeons by their Health Service
a.
b.
c.
d.
e.

Fully qualified and recognized General Surgeon
Evidence of successful completion of a Bariatric Course or Training
Evidence/experience and explanation of Bariatric Training
Name of 2 referees – experienced in Bariatric Surgery.
Evidence of having performed 100 Bariatric Cases and complication rate

JSSO Consensus Statement 2010

Chairman of the JSSO guideline committee, Isao Kawamura

JSSO, as a body member of IFSO, had been formulating its guidelines for about 3 years in order to enact
them.

These were completed and released as Statement 2010 in 2010.

The basis of the guidelines wasestablished by complying with the IFSO guidelines 2008, in consideration of the state of affairs inJapan and characteristics of obesity patients. However it also takes account of the flexibility tohandle future revision if necessary.

The first feature of JSSO is the fact that surgeons should havean idea the treatment of morbidily obese patients lasts a lifetime, does not end with surgical treatmentonly. Those are compared to lines and points. In other words, the treatment of morbid obesity needs
multidisciplinary treatment with a team which includes physicians, psychiatrists, dieticians,
counselors and so on.

Surgical indications characterize the second feature of JSSO. Indications forbariatric surgery is applied for the patients with BMI ≧35, because the criterion of Japanese obesity
is defined by BMI≧25.

We have defined the indication for metabolic surgery by BMI≧32 and havepositioned it as clinical study.

It obliges a through follow-up for the patients under the rigid

registration system. Our report mainly consists of these details.

ACMOMS I

Muffazal Lakdawala

Abstract
Background: The Asian consensus guidelines were the outcome of a two day deliberation that wasorganized in Trivandrum, India on the 9th and 10th August 2009.
Methods: Asian Consensus Meeting on Metabolic Surgery (ACMOMS) was the first ever meeting of its
kind in Asia where 52 professionals involved in the field of bariatric surgery, metabolic surgery,diabetes, and medical research from countries across Asia and the GCC met at Trivandrum, India
to vote for and create a new set of guidelines for the Asian phenotype, which were different fromthe NIH guidelines set for bariatric surgery. The aim was to set culturally, geographically, andgenetically relevant standards for the management of obesity and metabolic syndrome.
Results: It is known that Asians have higher adiposity for a given level of obesity, and this isvisceral obesity as compared to other populations. Currently, worldover guidelines set by NIH in
1991 are being followed for bariatric surgery. Surgeons believe that NIH guidelines need to berevisited and modified. It is in light of these observations that the genesis of ACMOMS took place.
At ACMOMS, it was recommended that the NIH guidelines are not suitable for Asians, and the BMI
guidelines should be lowered for indication of surgery. Waist or waist–hip ratio must gainsignificance as compared to BMI alone for Asians. The recommendations were as under:•

Bariatric/Gastrointestinal Metabolic surgery should be considered as a treatment option
for obesity in people with Asian ethnicity with a BMI more than 35 kg/m2 with or without
co-morbidities.

•

Bariatric/Gastrointestinal Metabolic surgery should be considered as atreatment option

for obesity in people with Asian ethnicity above a BMI of 32 kg/m2 with co-morbidities.
•

Bariatric/Gastrointestinal Metabolic surgery should be considered as a treatment option
for obesity in people with Asian ethnicity above a BMI of 30 kg/m2 if they have central
obesity (waist circumference more than 80 cm in females and more than 90 cm in males) alongwith at least two of the additional criteria for metabolic syndrome: raised triglycerides,
reduced HDL cholesterol levels, increased LDL levels, high blood pressure and raised fasting
plasma glucose level.

•

Any surgery done on diabetic patients with a BMI less than 30 kg/m2 should be strictly done
only under study protocol with an informed consent from the patient. The nature of thesesurgeries should be considered as yet purely experimental only as part of research projects
with prior approval from the ethics committee.

Conclusions: The collective recommendations were submitted as a report to the executive committee
for approval. These guidelines have now been accepted by the Asia Pacific Metabolic and BariatricSurgery Society (APMBSS) and IFSO Asia Pacific Chapter and have been published in the journal of
Obesity surgery.