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.

Forthose 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 issuein 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.

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"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.

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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 ChemicalEngineering, 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 inAsia. Most experts agreed that Asians are more prone to develop diabetes at lower BMIand 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 positiveoutcomes. 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 USAAn 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 ornational 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% andRYGB increased from 11.1% to 39.0%; whereas, in USA/Canada, AGB increased from 9.0% to44.0% 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 5years (266% increase). Bariatric surgery continues to grow worldwide, but less so than inthe past. The types of procedures are in flux; trends in Europe vs USA/Canada arediametrically opposed.