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Chirurgia Metabolica

Il concetto di “chirurgia metabolica” è nato, alcuni anni orsono, partendo da alcune osservazioni cliniche in pazienti diabetici sottoposti ad interventi chirurgici bariatrici e seguiti nel tempo. Da molti anni è noto che la chirurgia bariatrica nel paziente diabetico è efficace nel controllare la malattia e, in molti casi, nel guarirla. I vari interventi hanno gradi di efficacia diversi tra loro, probabilmente in relazione alla grande perdita di peso, alla nuova configurazione anatomica ed al loro meccanismo d’azione. L’aspetto più significativo, sorprendente, che però ha dato il via al nuovo concetto di “chirurgia metabolica” consisteva nel fatto che nel paziente diabetico sottoposto a chirurgia bariatrica si osserva un trend di normalizzazione della glicemia a partire dalla prima settimana post-operatoria, molto prima che il peso subisca variazioni significative (Rubino, Gagner e Gentileschi, Annals of Surgery, 2002). Partendo da questa osservazione molti studiosi hanno cominciato a considerare il possibile meccanismo anti-diabetico della chirurgia bariatrica ipotizzando dei meccanismi d’azione degli interventi chirurgici diversi dalla semplice perdita di peso. Si è quindi iniziato a pensare al concetto non più di chirurgia bariatrica ma metabolica, volta cioè non solo alla correzione dell’obesità ma alla terapia di malattie del metabolismo come il diabete tipo II e quindi proponibile non solo nel paziente gravemente obeso diabetico ma anche nel paziente con obesità moderata e con una forma di diabete resistente alla terapia medica.

metabolicDa allora molti studi clinici e diversi studi sperimentali sono stati condotti in tutto il mondo con risultati sorprendenti. Particolarmente affascinanti per gli studiosi sono gli effetti gastrointestinali, endocrini e fisiologici degli interventi bariatrici che potrebbero essere alla base dell’effetto anti-diabetico della chirurgia metabolica. In sintesi, il miglioramento del controllo dell’omeostasi (l’attitudine propria degli esseri viventi a mantenere intorno a un livello prefissato, il valore di alcuni parametri interni) glucidica, visibile già dopo pochi giorni dall’intervento, non sembrerebbe necessariamente secondaria al calo ponderale ma, piuttosto, correlata al cambiamento della secrezione di specifici peptidi regolatori gastrointestinali e determinata dal rimaneggiamento dell’intestino.

 

Una recente metanalisi ha coinvolto 16 diversi Studi e un totale di 343 pazienti affetti da T2DM (Diabete Mellito di Tipo 2) con BMI <35 kg/m². Questi individui, sottoposti a diversi interventi di chirurgia bariatrica, hanno mostrato una remissione globale della patologia diabetica nell’85% dei casi a ≥6 mesi dall’intervento e una riduzione della HbA1c (emoglobina glicata), al di sotto del 6%, rilevando, altresì, una bassa incidenza di complicazioni associate e  una bassa mortalità perioperatoria (0.29%).

 

La chirurgia bariatrica per il trattamento dell’obesità di grado moderato                                                 La Chirurgia Bariatrica  presenta un vantaggioso rapporto costo-efficacia, specialmente a lungo termine, per il trattamento dell’obesità, di grado moderato.

Un recentissimo studio condotto dalla Southampton Health Technology Assessments Centre (SHTAC) – uno dei principali Centri accademici indipendenti per la valutazione delle tecnologie sanitarie, della salute e dei servizi di ricerca, nel Regno Unito – ha valutato, proficuamente, il rapporto costo-efficacia della chirurgia bariatrica in pazienti con obesità di grado moderato, confrontando il beneficio ed i costi del trattamento chirurgico con Bendaggio Gastrico Laparoscopico (LAGB), rispetto ai trattamenti conservativi per l’obesità. L’analisi condotta ha coinvolto 2 diversi trials clinici ed ha dimostrato una significativa efficacia del LAGB, in termini di perdita di calo ponderale. La riduzione dell’ICER (Incremental Cost – Effectiveness Ratio) a lungo termine dimostra che non esiste un reale costo aggiuntivo dovuto all’intervento chirurgico, poiché questo è bilanciato dalla riduzione dei costi per l’assistenza medica delle patologie obesità-correlate; in particolare la remissione del T2DM (Diabete Mellito di Tipo 2) rappresenta il più grande contributo a detta riduzione.

 

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