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 orimprovement 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 ofthe 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. These2 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 andGIP 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% ofpatients 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 andII-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 ofQOL, 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 ofpsycho-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.